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CP2 OBS > Hypertensive Disorders in Pregnancy > Flashcards

Hypertensive Disorders in Pregnancy Flashcards

1
Q

When does blood pressure fall to a minimum level during pregnancy?

when does it go back to ‘normal’

A

2nd trimester - by about 30/15mmHg because of reduced vascular resistance

By term, blood pressure rises again to pre-pregnant levels

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2
Q

What is the cause of hypertension due to pre-eclampsia?

A

increase in systemic vascular resistance

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3
Q

Excretion of what substance is increased in normal pregnancy?

A

protein (still less than 0.3g/24 hours in the absence of renal disease)

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4
Q

What is pregnancy induced hypertension?

A

When the blood pressure rises above 140/90mmHg after 20 weeks

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5
Q

What are the causes of pregnancy induced hypertension?

A

Pre-eclampsia or transint hypertension

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6
Q

What is pre-eclampsia?

A

Pre-eclampsia refers to new high blood pressure (hypertension) in pregnancy with end-organ dysfunction, notably with proteinuria (protein in the urine). It occurs after 20 weeks gestation

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7
Q

What is the difference between pre-eclampsia and gestational hypertension?

A

Gestational hypertension - new hypertension presenting after 20 weeks without proteinuria

HOWEVER, occasionally, proteinuria is absent in pre-eclampsia, particularly in early pregnancy

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8
Q

What is pre-existing hypertension

A

When blood pressure is >140/90mmHg before pregnancy or before 20 weeks gestation, or the woman is already on hypertentive treatment

May be primary hypertension or secondary to renal or other disease - may also be pre-existing proteinuria because of renal disease

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9
Q

What is pre-eclampsia?

A

Multisystem syndrome that usually manifests as new hypertension after 20 weeks with significant proteinuria

specific to pregnancy, of placental origin and cured only be delivery

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10
Q

What are the effects of pre-eclampsia?

A

Blood vessel endothelial cell damage leads to vasospasm, increased capillary permeability and clotting dysfunction - both the foetus and mother are a risk

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11
Q

What are the two phenotypes of pre-eclampsia?

A

Early onset - that which causes complications before 34 weeks: typically the foetus is growth restricted

Late onset - manifest at any later gestation - not usually associated with growth restriction, although fetal death and damage may occur

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12
Q

What is the first step in the pathophysiology of pre-eclampsia?

A

Poor placenta perfusion

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13
Q

What happens in normal pregnancy to allow adequate placenta perfusion?

A

Trophoblastic invasion of spiral arterioles leads to vasodilation of vessel walls to allow adequate placenta perfusion

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14
Q

How is pre-eclampsia caused?

A

Pre-eclampsia is caused by high vascular resistance in the spiral arteries and poor perfusion of the placenta. This causes oxidative stress in the placenta, and the release of inflammatory chemicals into the systemic circulation, leading to systemic inflammation and impaired endothelial function in the blood vessels.

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15
Q

What is pre-eclampsia as opposed to severe pre-eclampsia?

A

Pre-eclampsia - new hypertension presenting after 20 weeks with significant proteinuria

severe pre-eclampsia - pre-eclampsia with severe hypertension and/or with symptoms and/or biochemical and/or haematological impairment

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16
Q

What are the classifications of hypertension?

A

Mild - 140/90 - 149/99mmHg
Moderate - 150/100 - 159/109mmHg
Severe >160/110mmHg

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17
Q

What are the classifications of pre-eclampsia?

A

mild/moderate: pre-eclampsia without severe HTN and no symptoms and no biochemical or haematological impairment

Severe- pre-eclampsia with severe HTN and/or with symptoms, biochemical or haematological impairment

Early: <34 weeks
Late >34 weeks

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18
Q

Describe the epidemiology of pre-eclampsia?

A

Affects 6% of nulliparous women

less common in multiparous women unless additional risk factors are present

15% recurrence risk
this is up to 50% if there has been severe pre-eclampsia before 28 weeks

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19
Q

What are the predisposing factors for pre-eclampsia?

A 
High-risk factors are:
Pre-existing hypertension
Previous hypertension in pregnancy
Existing autoimmune conditions (e.g. systemic lupus erythematosus)
Diabetes
Chronic kidney disease
Moderate-risk factors are:
Older than 40
BMI > 35
More than 10 years since previous pregnancy
Multiple pregnancy
First pregnancy
Family history of pre-eclampsia

Women are offered aspirin from 12 weeks gestation until birth if they have one high-risk factor or more than one moderate-risk factors.

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20
Q

What are the clinical features of pre-eclampsia?

A 
Headache
Visual disturbance or blurriness
Nausea and vomiting
Upper abdominal or epigastric pain (this is due to liver swelling)
Oedema
Reduced urine output
Brisk reflexes

Hypertension = usually the first sign - massive oedema is also found in pre-eclampsia, not postural or of sudden onset

presence of epigastric tenderness is suggestive of impending complications

urine dipstick testing for protein should be considered part of clinical exam

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21
Q

What do the following indicate:

trace

Dipstick 1+ for protein

Dipstick >2+ for protein

PCR >30mg/nmol

24h collection >0.3g/24h

A

trace - seldom significant

1+ - possible significant proteinuria: quantify

> 2+ - significant proteinuria likely: quantify

PCR >30mg/nmol: confirmed significant proteinuria

24h collection: confirmed significant proteinuria

22
Q

What are the maternal complications of pre-eclampsia?

A

ECLAMPSIA

CV haemorrhage

Fluid overload

Renal failure

Liver failure - rupture/ HELPP

PE - give enoxaparin

DIC - prevent

placental abruption

23
Q

What is eclampsia?

A

grand mal seizure resulting from cerebrovascular vasospasm - mortality can result from hypoxia and concomitant complications of severe disease

Treatment: magnesium sulphate and intensive surveillance for other complications

24
Q

What Is the cause of cerebrovascular haemorrhage?

A

failure of cerebral blood flow auto regulation at MABP >140mmHG

25
Q

What liver and coagulation problems result from pre-ecalmpsia?

A

HELLP syndrome
Haemolysis
Elevated Liver enzymes
Low Platelets

DIC, liver failure and liver rupture may also occur

treatment Is supportive and includes magnesium sulphate prophylaxis against eclampsia - liver infarction or subscapsular haemorrhage may occur

26
Q

How is renal failure identified?

A

careful fluid balance monitoring and creatine measurement

Haemodialysis is required in severe cases

27
Q

What is pulmonary oedema as a result of pre-eclampsia treated with?

A

oxygen and furosemide and assisted ventilation may be required - ARDS may develop

28
Q

What are the fetal effects of pre-eclampsia?

A

perinatal mortality and morbidity of the foetus = increased

5% stillbirths
10% preterm deliveries accounted for by pre-eclampsia

growth restriction (early onset)

at term - affects foetal growth less, but is still associated with increased morbidity and mortality

at all gestations, there is an increased risk of placental abruption

29
Q

What investigations should be done for pre-eclampsia?

A

if bed stick urinalysis is +ve, the protein is quantified - 24hr urine or PCR is used

30mg/nmol or 0.3g/24hr protein excretion - proteinuria may be absent in early disease and testing for proteinuria is repeated

Blood tests - elevation of uric acid. HB often high and rapid fall in platelets due to aggregation on damaged endothelium - impending HELLP

Rise IN LFTs (ALT) - impending liver damage
LDH levels rise

Renal function mildly impaired - rising creatinine

USS

30
Q

What is the most common screening test for early prediction?

A

uterine artery Doppler at 20 weeks - sensitivity for PE at any stage in pregnancy is about 40% for a 5% screen-positive rate

31
Q

What is the screening test for late prediction of PE?

A

placental growth factor (PlGF) testing on one occasion during pregnancy in women suspected of having pre-eclampsia.

Placental growth factor is a protein released by the placenta that functions to stimulate the development of new blood vessels. In pre-eclampsia, the levels of PlGF are low.

32
Q

What is the prevention of pre-eclampsia?

A

low-dose aspirin (75mg) before 16 weeks (evening) reduces the risk of pre-eclampsia and is now NICE recommended.

High dose vitamin D with Ca2+ supplementation might also be effective

33
Q

What is the management of pre-eclampsia?

A

Assessment - day assessment
sFlt-1:PIGF ratio

pts without proteinuria and with mild/moderate hypertension are usually managed as outpatients - BP and urinalysis repeated 2/week - USS 2-4 weeks unless suggestive of foetal compromise

Admission

Drugs

34
Q

What are the indications for admission with pre-eclampsia?

A

Necessary with severe HTN and presence of proteinuria - if hypertension absent but proteinuria, they should be admitted

Assessment using sFlt-1:PIGF assay may determine which women are most at risk and should be admitted

35
Q

What drugs are used in pre-eclampsia?

A

Labetolol is first-line as an antihypertensive
Nifedipine (modified-release) is commonly used second-line
Methyldopa is used third-line (needs to be stopped within two days of birth)

Intravenous hydralazine may be used as an antihypertensive in critical care in severe pre-eclampsia or eclampsia

IV magnesium sulphate is given during labour and in the 24 hours afterwards to prevent seizures
Fluid restriction is used during labour in severe pre-eclampsia or eclampsia, to avoid fluid overload

Steroids if delivery before 36 weeks

36
Q

What are the indications of antihypertensives?

Which drugs are used?

A

Given if BP reaches 150/100mmHg - labetalol maintenance is recommended

Oral nifedipine for initial control with IV labetalol as 2nd line with severe hypertension

aim for BP is 140/90

37
Q

What Is magnesium sulphate used for in pre-eclampsia?

A

used in both treatment and prevention - IV loading dose followed by IV infusion

increased cerebral perfusion so treats underlying pathology of eclampsia

toxicity is severe, resulting respiratory depression, hypotension, loss of patellar reflex

38
Q

What are steroids used for in pre-eclampsia?

A

promote foetal pulmonary maturity if the gestation is <34 weeks

39
Q

At what gestation should women with pre-eclampsia be delivered?

A

36 weeks

40
Q

At what gestation should women with gestational hypertension be delivered?

A

40 weeks as usual , as long as foetal compromise is monitored

41
Q

What are the indications for C-section in PE?

A

Before 34 weeks
If severe growth restriction
abnormal CTG

42
Q

What things need to be given in labour for PE?

A

Induction - prostaglandin
anti-hypertensives
maternal pushing avoided in 2nd stage if BP is 160/110

oxytocin instead of ergometrine - 3rd stage as latter can increase BP

43
Q

What is the postnatal care for PE?

A

Enalapril (first-line)
Nifedipine or amlodipine (first-line in black African or Caribbean patients)
Labetolol or atenolol (third-line)

44
Q

What is pre-existing hypertension in pregnancy?

A

When BP is already treated or exceeds 140/90 before 20 weeks

45
Q

Who is pre-existing hypertension more common in?

A

Older women
Obese women
Positive FH
Developed HTN on COCp

46
Q

What is secondary HTN commonly associated with?

A 
Obesity
Diabetes
Renal disease - ADPKD, renal artery stenosis or chronic pyelonephritis
PCC
Cushing's syndrome 
Cardiac disease
Coarctation of the aorta
47
Q

What investigations are done for pre-existing HTN?

A

Renal function assessed and renal USS performed

PCC excluded

quantification of any proteinuria and uric acid level allow comparison in later pregnancy

48
Q

Why are ACE-i not used in preganancy?

A

Teratogenic and affect foetal urine production

49
Q

What drugs are normally used to treat maternal HTN in pregnancy?

A

Labetalol

Nifedipine

50
Q

Why might treatment not be needed in 2nd trimester?

A

Physiological fall in BP

51
Q

What other measures are put in place for pre-existing maternal HTN?

A

low dose aspirin advised - 75mg
screening using uterine artery doppler and additional antenatal visits are usual

Delivery: 38-40 weeks

CP2 OBS (20 decks)

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