Hypertensive Disorders in Pregnancy Flashcards
When is HTN recognized to be considered gestational HTN?
After 20 wks gestation
Evaluation of chronic HTN in pregnancy
Monitor for maternal end-organ damage — CBC, glucose, CMP, 24 hr urine collection for total protein, EKG
Assess for fetal well being with initial US for accurate dating, screening US’s, growth US’s monthly after 28 wks; antepartum fetal testing to begin between 32-34 wks
Management of mild chronic HTN in pregnancy
Initiate antihypertensive if reach threshold value
Prenatal visits every 2-4 wks until 34-36 wks, then weekly
Antepartum fetal monitoring
Delivery between 39-40 weeks
Management of severe chronic HTN in pregnancy
Antihypertensive therapy — may include methyldopa, labetolol, nifedipine
Close prenatal monitoring for medication dosage change
With associated renal disease — 24 hr urine collection every trimester
Observe for signs of developing superimposed preeclampsia
Antepartum fetal surveillance w/ growth US every 3-4 wks, nonstress tests and/or biophysical profiles
Delivery after 38 wks gestation
What common class of antihypertensives must be avoided in pregnancy to avoid damage to fetal kidneys?
ACE inhibitors
Gestational HTN = hypertension without any features of _______; occurs after 20weeks gestation or within 48-72 hrs of delivery and resolves by 12 wks postpartum
Preeclampsia
Signs/symptoms of preeclampsia
Signs: HTN, proteinuria, edema
Sxs: scotoma, blurred vision, epigastric and/or RUQ pain, HA
Risk factors for preeclampsia
Age <20 and >35 Primigravid Multiple gestation Hydatiform mole Diabetes Thyroid disease Chronic HTN Renal disease Collagen vascular disease Antiphospholipid syndrome Prior hx of preeclampsia
How might preeclampsia affect the brain, heart, and lungs?
Brain: cerebral edema; possibly fibrinoid necrosis, thrombosis, microinfarcts, and petechial hemorrhages
Heart: absence of normal intravascular volume expansion (third spacing), reduction in circulating blood volume
Lungs: noncardiogenic pulmonary edema
How might preeclampsia affect the liver, kidneys, and eyes?
Liver — swelling (stretching of glisson’s capsule results in RUQ pain)
Kidneys — swelling of glomerular capillary endothelial cells, narrowing of capillary lumen
Eyes — retinal vasospasm, retinal edema
Preeclampsia may be classified as either mild (preeclampsia without severe features), or severe (preeclampsia with severe features).
What are the criteria for mild preeclampsia?
BP >140/90 but less than 160/110
Proteinuria >300 mg/24hr urine, but less than 5g/24hr urine, or a single specimen urine protein:creatinine ratio of 0.3 mg/dL
Asymptomatic
Preeclampsia may be classified as either mild (preeclampsia without severe features), or severe (preeclampsia with severe features).
What are the criteria for severe preeclampsia?
BP systolic >160 or diastolic >110 (2 occasions, 4 hrs apart)
Proteinuria of at least 5g/24hr or 3+ protein on 2 random urine dips at least 4 hrs apart
Oliguria
Symptomatic — cerebral or visual disturbance, pulmonary edema, epigastric or RUQ pain, elevated liver enzymes, thrombocytopenia
Exam findings in pt with preeclampsia
Brisk reflexes
Clonus
Edema
Lab findings in pt with preeclampsia
Increased H/H, lactate dehydrogenase, transaminases, and uric acid
Thrombocytopenia (low platelets)
Management of mild preeclampsia (preeclampsia without severe features) in pt less than 37 weeks gestation
Modified bed rest
Once (BPP) or twice (NST) weekly antepartum testing
Fetal growth US every 3-4 wks
Office visits and lab eval
Possibly hospitalization
Management of mild preeclampsia (preeclampsia without severe features) between 37-40 wks gestation
If favorable cervix — induction
If unfavorable cervix — use a cervical ripening agent to begin induction
Management of severe preeclampsia (preeclampsia with severe features)
Immediate hospitalization
Delivery if greater than 34 wks
Management of BP with anti-hypertensives: hydralazine, labetolol, nifedipine
If less than 37 weeks, administer corticosteroids and work towards delivery as long as pt and fetus are stable
Preferred method of delivery for pts with preeclampsia
Vaginal delivery
[use cervical ripening agents and pitocin as necessary]
Intrapartum management of preeclampsia may include _________ administration for seizure prophylaxis. Pain management is similar to a normal vaginal delivery, unless pt is ______ in which case they may not be able to receive an epidural
Magnesium sulfate; thrombocytopenic
Management for eclampsia
Protect the airway
Magnesium sulfate is first line tx
May need lorazepam if persistent seizures
Not an indication for cesarean delivery but fetus may need some in-utero resuscitation time
What is HELLP syndrome and what is it an indication for?
Hemolysis, Elevated Liver enzymes, and Low Platelets
Indication for immediate delivery!
What drug may be utilized during pregnancy to prevent preeclampsia if they have certain risk factors (hx of preeclampsia, multifetal gestation, chronic HTN, etc.)?
Aspirin
