Hypertensive Disorders in Pregnancy Flashcards
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
What are some fetal complications with hypertensive disorders during pregnancy?
- Fetal growth restriction
- Preterm birth
- Placental abruption
- Stillbirth
- Neonatal death
- Congenital anomalies
What is chronic hypertension defined as?
- Present before or recognized during first half of pregnancy
What is gestational hypertension defined as?
- Recognized after 20 weeks gestation
- Or within 48-72 hours after delivery
What is preeclampsia hypertension defined as?
- Occurs after 20 weeks and coexists with proteinuria
What is eclampsia hypertension defined as?
- New onset seizure activity associated with preeclampsia
What is superimposed preeclampsia/eclampsia?
- Transposed onto chronic hypertension
What are some possible causes of chronic hypertension?
- Idiopathic
- Vascular disorders
- Endocrine disorders
- Renal disorders
- Connective tissue disorders
What are some vascular disorders that cause of chronic hypertension?
- Reno-vascular
- Aortic coarctation
What are some endocrine disorders that cause of chronic hypertension?
- Diabetes
- Hyperthyroidism
What are some renal disorders that cause of chronic hypertension?
- Diabetic nephropathy
- Chronic renal failure
What is a connective tissue disorders that cause chronic hypertension?
- Systemic lupus erythematosus
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
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
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
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
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
