Hypertensive Disorders of Preg Flashcards
What defines hypertension in pregnancy?
Systolic BP =/> 140 mmHg and/or
Diastolic BP =/> 90 mmHg
BP usually falls in pregnancy
25% of women who develop HTN = eventual diagnosis w/ pre-eclampsia
Chronic HTN = monitor every 2 weeks until 30 wks, then weekly till delivery
What is the maternal risk of untreated HTN in pregnancy?
Accelerated HTN, esp in 3rd tri
superimposed pre-eclampsia
maternal morbidity
Inc life-time CV risk
What is the foetal risk of untreated HTN in pregnancy?
Intrauterine growth restriction
Foetal death
Outline the classification of HTN in pregnancy
Chronic HTN = present/detected <20 wks
Gestational HTN = new onset HTN, >20wks, no additional pre-eclampsia
Pre-eclampsia-eclampsia = new onset HTN >20 wks, + systemic symptoms
Pre-eclampsia superimposed on chronic HTN = new onset of proteinuria, sudden worsening of HTN or proteinuria >20 wks
Explain mild chronic HTN in pregnancy (characteristics)
No evidence of end organ damage
W/draw HTN in 1st trimester, dec ADRs on foetus
Physiological fall in BP
Outline treatment moderate-severe chronic HTN in preg
Continue anti-HTN therapy
Change to appropriate anti-HTN
What is gestational HTN?
New onset HTN after 20 weeks, adverse preg outcomes
Normalisation of BP w/in 2 months
Risk of recurrence in subsequent preg
What is the target (BP) goal for gestational HTN?
Systolic reduction to = 140-160 mmHg
Diastolic reduction = 90-100mmHg
Stricter BP control = foetal growth restriction –> placental hypoperfusion
What HTN drugs should be avoided in gestational HTN?
ACEi = teratogenic in 1st tri
ARB = teratogenic in 1st tri
Diuretics = avoid
Beta blockers = avoid
CCB = avoid
What HTN drugs are safe in gestational HTN?
Labetalol
Oxprenolol
Methyldopa
Hydralazine = usually added to prazosin if therapy inadequate
Prazosin
What are the 1st line anti-HTN for gestational hypertension?
Methyldopa
Labetalol
oxprenalol
What are the 2nd line anti-HTN for gestational hypertension?
hydralazine
nifedipine
prazosin
clonidine
How is gestational HTN managed after 20 wks?
Same as <20wks
Add hydralazine if BP not controlled OR controlled release nifedipine
Close monitoring, 25% progress to pre-eclampsia
gestational HTN should resolve w/in 3 months PP, patient weaned off drugs
Monitor for pre-eclampsia = worsening HTN, new/worsening proteinuria
What is pre-eclampsia? (define, aetiology
Multi-system disorders characterised by one or more organ systems and/or foetus
Aetiology:
- immunological factors
- genetic factors
- placental factors = abnormal placental formation, release of systemic vasoactive compounds
- maternal vascular disease
- diet
*Outline risk factors of pre-eclampsia
Antiphospholipid syndrome
Pre-existing pre-eclampsia/diabetes, DM, nulliparity, multiple pregnancies
Renal disease, chronic HTN
Chronic autoimmune disease
<18 yrs of age, >40 yrs of age
> 10 yrs since last preg
BP >130/80 mmHg
*What are features of pre-eclampsia
Proteinuria = protein:creatinine ration >30g/mol
Renal = serum or plasma creatinine >90 micromol or oliguria
haematological = haemolysis, thrombocytopenia, raised bilirubin, dec haptglobulin
Hepatic = raise serum transaminases, severe upper right quadrant pain, epigastric pain
pulmonary oedema
uteroplacental = foetal growth restriction, placental abruption
neurological = severe headache, visual disturbances, hyperreflexia, convulsions, stroke
Outline some symptoms/referral points of suspected of pre-eclampsia
Elevated BP, severe headache
Excessive N/V, vomiting blood, swelling of feet and hands
smaller amounts/no urine or blood in urine
rapid heart beat, dizziness, ringing/buzzing in ears
double/blurred vision
drowsiness, abdominal pain
What are maternal complications of pre-eclampsia?
HELLP syndrome
placental abruption
acute renal failure
liver rupture
intracerebral haemorrhage
eclampsia
inc. risk of CVD
What is HELLP syndrome?
Haemolysis, Elevated liver enzymes, Low Platelet count
Minimal BP elevation and renal dysfunction. exhibit severe liver disease
Life-threatening
What are the early sx of HELLP?
epigastric pain (heartburn) or upper right quadrant pain
malaise
N/V
What is eclampsia? (warning signs/sx, what is)
Complication of preg-induced HTN = new-onset seizures (early preg, early PP -24 hrs)
Warning signs/SX:
- headache, visual disturbances, epigastric pain, HTN, proteinuria
- unpredictable seizures
What are foetal complications of pre-eclampsia?
Ischaemic encephalopathy
Intrauterine growth restriction
foetal death, due to placental insufficiency
What are neonatal complications of pre-eclampsia?
preterm birth plus hypoxic and neurological injury
perinatal death
What are complications of children born from pre-eclampsia?
Inc risk of stroke, CHD, metabolic syndrome
possible autism link, developmental delay
How is mild pre-eclampsia managed?
monitored in outpatient setting
How is moderate pre-eclampsia managed?
admission to antenatal ward w/ planned induction at 37 wks
How is severe pre-eclampsia managed?
requires delivery, regardless of gestation
Outline the pharmacological treatment of pre-eclampsia
anti-HTN = hydralazine, nifedipine, labetolol, or diazoxide) –> monitoring, IV fluids to prevent hypotension
IV magnesium sulfate = seizure prevention –> block glutamate receptor, prevent post-hypoxic brain injury
Outline the postpartum management of pre-eclampsia
Resolved after birth, monitor 4 hrly = pulse, BP, RR, temp, O2
Avoid NSAIDs = effect HTN, renal function, platelet function
BP and urinalysis = normal by 6wk PP
Outline pre-eclampsia prophylaxis
Primary prevention based on risk factor
Aspirin = from 12 wks onward for high risk patient, reduce stillbirth, neonatal, foetal death
Calcium = women of moderate to high risk of pre-eclampsia, if dietary intake low –> reduce risk
