Hypertensive Disorders in Pregnancy Flashcards by Zachary Harbin

What are some maternal risks for hypertensive disorders during pregnancy?

MI
Death
Cerebral vascular accident
Pulmonary edema
Renal and liver failure
Retinal ischemia and injury
Preeclampsia and eclampsia

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What are some fetal complications with hypertensive disorders during pregnancy?

Fetal growth restriction
Preterm birth
Placental abruption
Stillbirth
Neonatal death
Congenital anomalies

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What is chronic hypertension defined as?

Present before or recognized during first half of pregnancy

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What is gestational hypertension defined as?

Recognized after 20 weeks gestation

- Or within 48-72 hours after delivery

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What is preeclampsia hypertension defined as?

Occurs after 20 weeks and coexists with proteinuria

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What is eclampsia hypertension defined as?

New onset seizure activity associated with preeclampsia

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What is superimposed preeclampsia/eclampsia?

Transposed onto chronic hypertension

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What are some possible causes of chronic hypertension?

Idiopathic
Vascular disorders
Endocrine disorders
Renal disorders
Connective tissue disorders

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What are some vascular disorders that cause of chronic hypertension?

Reno-vascular

- Aortic coarctation

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What are some endocrine disorders that cause of chronic hypertension?

Diabetes

- Hyperthyroidism

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What are some renal disorders that cause of chronic hypertension?

Diabetic nephropathy

- Chronic renal failure

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What is a connective tissue disorders that cause chronic hypertension?

Systemic lupus erythematosus

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How do you take a BP?

After a patient has rested for at least 10 minutes and is seated with legs uncrossed and back supported
Use an appropriate sized cuff

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What evaluation is done during assessment of chronic hypertension?

Rule out underlying disorders
Assess for maternal end-organ damage (CBC, CMP, 24 hour urine collection for total protein, EKG
Assess for fetal well being

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What is being look at when assessing for fetal well being during chronic hypertension evaluation?

Initial ultrasound for accurate dating
Screening ultrasound
Growth ultrasounds monthly after 28 weeks gestation
Antepartum fetal testing to begin between 32-34 weeks gestation

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What is the management for mild chronic hypertension?

Begin aspirin therapy 81 mg daily at 12 weeks till delivery
Initiate antihypertensives if reach threshold value
Prenatal visits every 2-4 weeks until 34-36 weeks gestation then weekly
Antepartum fetal monitoring
Delivery between 38-39+6 weeks gestation

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What is the management for severe chronic hypertension?

Antihypertensive therapy (methyldopa, labetalol, nifedipine)
Avoid ACE inhibitors and ARBs due to increased risk of malformations
Close prenatal monitoring for medication dosage changes
With associated renal disease- 24 hour urine collection every trimester
Observation for signs of developing superimposed preeclampsia
Antepartum fetal surveillance

When does gestational hypertension resolve?

By 12 weeks postpartum

How is the diagnosis of preeclampsia made?

Hypertension
Proteinuria
Edema

What are some symptoms of preeclampsia?

Scotoma
Blurred vision
Epigastric and/or RUQ pain
Headache

What are some risk factors for preeclampsia?

Age (<20 and >35)
Nulliparity
Multiple gestation
Hydatidiform mole
Diabetes
Obesity
Chronic hypertension
Renal disease
Collagen vascular disease
Antiphospholipid syndrome
Prior history of preeclampsia
Assisted reproductive technology
Interpregnancy interval >7 years
Obstructive sleep apnea

What happens in the brain during preeclampsia?

Cerebral edema

- Possibly fibrinoid necrosis, thrombosis, microinfarcts and petechial hemorrhages

What happens in the heart during preeclampsia?

Absence of normal intravascular volume expansion

- Reduction in circulating blood volume

What happens in the lungs during preeclampsia?

Noncardiogenic pulmonary edema
Changes in colloid osmotic pressure, capillary endothelial integrity and intravascular hydrostatic vessels (leaking vessels)

What happens in the liver during preeclampsia?

- Sinusoidal fibrin deposition in the periportal areas with surrounding hemorrhage and portal capillary thrombi - Stretching of glisson's capsule results in RUQ pain

What happens in the kidneys during preeclampsia?

- Swelling and enlargement of glomerular capillary endothelial cells - Narrowing of the capillary lumen

What happens in the eyes during preeclampsia?

- Rential vasospasm | - Rential edema

What does mild preeclampsia look like?

- BP >140/90 but less than 160/110 at least 4 hours apart - Proteinuria >300 mg/24 hours or a single specimen urine protein:creatinine ration of 0.3mg/dL or a urine dipstick of +2 - Asymptomatic

What does severe preeclampsia look like?

- BP systolic >160 or diastolic >110 - Oliguria (less than 500 ml in 24 hrs) - Renal insufficiency - Liver enzymes twice the normal limits or epigastric pain refractory to treatment - Thrombocytopenia - Pulmonary edema - New onset headache - Symptomatic

What is done during a preeclampsia evaluation?

- Get complete history | - Address physical symptoms like headache, RUQ pain, N/V, vaginal bleeding, vision changes

What does the PE look like in preeclampsia?

- Brisk reflexes - Clonus - Edema

What laboratory findings are seen in preeclampsia?

- Increased Hct, lactate dehydrogenase, AST/ALT, and uric acid - Thrombocytopenia

What is the management of preeclampsia without severe features at less than 37 weeks?

- Once (BPP) or twice (NST) weekly antepartum testing - Fetal growth ultrasound every 3-4 weeks - Office visits and laboratory evaluation - Possibly hospitalization

What is the management of preeclampsia without severe features between 37-40 weeks?

- Begin induction at time of diagnosis at this gestational age - If favorable cervix - induction - If unfavorable cervix - use cervical ripening agent to begin induction

What is the management of preeclampsia with severe features?

- Immediate hospitalization - Delivery if greater than 34 weeks - Management of BP with anti-hypertensives (labetalol, nifedipine, hydralazine) - If less than 37 weeks, administer corticosteroids and work towards delivery as long as patient and fetus are stable

What is the intrapartum management of preeclampsia?

- Vaginal delivery is preferred - Use cervical ripening agents and pitocin if necessary - Magnesium sulfate administration for seizure prophylaxis - Pain management as with any delivery unless thrombocytopenic then may not be able to receive an regional anesthesia

What is the loading dose and maintenance dose for magnesium sulfate?

- 4 gm bolus for loading | - 2gm/hr for maintenance

What is the therapeutic value for magnesium sulfate?

- Between 5-9 mg/dL

What is done in eclampsia?

- Protect the airway - Magnesium sulfate administration is first line treatment - May need lorazepam if persistent - Not an indication for cesarean delivery but fetus may need some in-utero resuscitation time

What is HELLP syndrome?

- Hemolysis - Elevated liver enzymes - Low platelets

What labs are seen in HELLP syndrome?

- LDH greater than 600 IU/L - AST/ALT twice the upper limit of normal - Platelets less than 100,000

What is done in HELLP syndrome?

- Immediate delivery