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Obstetrics > Hypertensive Disorders in Pregnancy > Flashcards

Hypertensive Disorders in Pregnancy Flashcards

1
Q

what are the normal blood pressure changes in pregnancy

A

Blood pressure usually falls by 30mmHg in systolic and 15mmHg in diastolic in the 2nd trimester due to reduced vascular resistance

Hypertension may be a sign of pre-eclampsia due to increased systemic vascular resistance

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2
Q

What is a normal amount of protein excretion in pregnancy

A

Protein excretion is normal in pregnancy, but in the absence of renal disease it is <0.3g/24hr

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3
Q

what is the diagnostic criteria for pregnancy induced hypertension

A

> 140/90 after 20 weeks (before that it is considered preexisting)

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4
Q

how do you differentiate between pregnancy induced hypertension and preeclampsia

A

pre-eclampsia generally has proteinuria whereas in the absence of renal disease pregnancy induced hypertension doesn’t - however this isn’t true 100% of the time

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5
Q

what is the only definitive cure for pre-eclampsia

A

delivery of the baby

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6
Q

what is the recurrence risk of pre-eclampsia

A

15% , rising to 50% if there is severe pre-eclampsia before 28 weeks

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7
Q

what are the two phenotypes for preeclampsia

A

early onset - complications occurs <34 weeks, foetus often growth restricted

late onset - manifests at a later gestation, no foetal growth restriction however foetal death and damage may occur

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8
Q

how do you classify hypertension in pre-eclampsia

A

Mild = 140-149/90-99

Moderate = 150-159/100-109

Severe = >160/110

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9
Q

how do you classify pre-eclampsia

A

early (<34 weeks, IUGR) or late (>34 weeks, no IUGR)

mild-moderate pre-eclampsia = no severe HTN, symptoms or biological/haematological impairment

severe = Severe hypertension +/- symptoms/biological/haemotological impairment

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10
Q

what is the pathophysiology of pre-eclampsia

A

1st step – poor placental perfusion

In normal pregnancy, trophoblast invasion of spiral arterioles (branches of the ovarian/uterine artery) leads to vasodilation of vessel walls to allow adequate placenta perfusion

In early onset PE this is incomplete causing oxidative stress, which is detected as high resistance flow in uterine arteries In late onset PE as growth of a normal placenta reaches its limits, intervillous perfusion may reduce because terminals become overcrowded causing oxidative stress

2nd step

Both mechanisms produce oxidative stress, causing the placenta to oversecrete proteins that regulate angiogenic balance

This can be detected by an increased sFlt-1 (similar to VEGF) and reduced PIGF (placental growth factor) levels in the maternal blood

Widespread endothelial damage follows, causing vasoconstriction, increased vascular permeability and clotting dysfunction – causing the clinical manifestations

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11
Q

what are risk factors for pre-eclampsia

A

Nulliparity

Family history

Previous history of PE

Long interpregnancy interval

Obesity

Extremes of maternal age (>40)

Disorders characterised by microvascular disease

Pregnancies with a large placenta

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12
Q

what are examples of disease characterised by microvascular disease

A

Chronic hypertension

Chronic renal disease

Sickle cell disease

Diabetes

Autoimmune disease

Antiphospholipid syndrome

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13
Q

what pregnancies are associated with a large placenta

A

Twins

Foetal hydrops

Molar pregnancy

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14
Q

what are clinical features of pre-eclampsia

A

Asymptomatic

Headache

Drowsiness

Visual disturbance

Nausea-vomiting

Epigastric pain (later stage)

Hypertension (often 1st sign)

Presence of epigastric tenderness is suggestive of impending complications

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15
Q

what are the maternal complications of pre-eclampsia

A

Eclampsia

Cerebrovascular haemorrhage

liver/coagulation problems - HELLP syndrome/DIC/liver failure

Renal Failure

Pulmonary Oedema

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16
Q

what is eclampsia

A

Grand mal seizure resulting from cerebrovascular vasospasm

Mortality may occur from hypoxia

17
Q

what is the treatment/prophylaxis for eclampsia

A

Magnesium Sulphate and intensive surveillance

18
Q

What is HELLP syndrome

A

Haemolysis
Elevated liver enxymes
Low platelets

19
Q

what are the foetal complciations of pre-eclampsia

A

Perinatal mortality and morbidity of the foetus are increased, pre-eclampsia accounts for about 5% of still births and 10% of preterm deliveries

Early onset mainly has the issue of growth restriction, preterm delivery is often required, although spontaneous preterm labour is also more common

At term, pre-eclampsia affects foetal growth less, but it is still associated with increased morbidity and mortality, as at all gestations there is an increased risk of placental abruption

20
Q

how should you investigate ?pre-eclampsia

A

Urine dipstick -For protein

+ve = quantification for P:Cr and total 24hr protiein
>30mg/nmol for P:Cr or >0.3g/24hr total protein is abnormal

Bloods 
Elevated uric acid  
High Hb 
Rapid fall in platelets  
Indicates HELLP  
DIC 
Rise in LFTs (Raised ALT is most indicative)
Raised lactate  
Renal function will be impaired

USS
Estimated foetal weight at early gestations to assess foetal growth
Umbilical artery doppler is also used to estimated foetal wellbeing

Cardiotocography

21
Q

what are early predictors of pre-eclampsia

A

Uterine artery doppler at 20 weeks - about 40% sensitive

22
Q

what are late haemotological predictors of pre-eclampsia

A

Ratio of SFlt-1:PIGF in maternal blood later in pregnancy

Especially those with mild hypertension

23
Q

what medical prevention for pre-eclampsia is recommended

A

Low dose aspirin (75mg) before 16 weeks reduces the risk of pre-eclampsia – NICE recommended

High dose vitamin D with calcium supplementation might also be effective

24
Q

how do you manage pre-eclampsia

A

Women with new hypertension >140/90 are assessed in day assessment unit

SFlt-1:PIGF ratio assays determine who is at higher risk

Patients without proteinuria and with mild/moderate hypertension are usually managed as outpatients with BP/urinalysis repeated 2 per week

USS 2-4 weeks unless suggestive of foetal compromise

25
Q

what is the admission criteria for pre-eclampsia

A

Necessary with severe hypertension and presence of proeinuria

If HTN is absent but there is significant proteinuria they should be admitted

SFlt-1:PIGFassay may determine which women are most at risk and should be admitted

26
Q

what hypertensive medication is recommended for pre-eclampsia

A

Labetalol maintenance (alternatives = nifedipine/hydralazine)

IV if acute

27
Q

what medication is given for eclampsia

A

Magnesium Sulfate

IV loading dose followed by IV infusion

28
Q

how should you manage a severe deterioration in pre-eclampsia

A

IV labetalol

Magnesium sulfate

Steroids if baby is <34 weeks

Delivery ASAP

29
Q

when is hypertensive therapy given in pre-eclampsia

A

> 150/100 (moderate)

30
Q

when should a woman with pre-eclampsia deliver by

A

36 weeks

31
Q

when is maternal pushing discouraged in labour

A

if they are hypertensive >160/100

32
Q

how do you treat pre-eclampsia post birth

A

BP is highest 3-4 days after birth

1st line – beta blocker

2nd line – nefedipine + Ace-I

Tx may be needed for severeal weeks

33
Q

what patient population is pre-existing hypertension common in during pregnancy

A

Obesity

Diabete s

Renal disease

Phaecytochroma

Cushings

Cardiac disease

Coarctation

34
Q

in pre-existing hypertension in pregnancy, what medication is recommended

A

ACE-is should be removed as theyre teratogenic

labetalol 1st line

nifedipine 2nd line

meds may not be required in 2nd trimester due to drop in BP

35
Q

what extra management is required in patients with pre-existing hypertension

A 
low dose aspirin 
uterine doppler scanning 
exta visits (consultant care)

Obstetrics (16 decks)

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