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Obstetrics > Hypertensive disorders of pregnancy > Flashcards

Hypertensive disorders of pregnancy Flashcards

1
Q

How do you prevent seizures in PET?

A

IV Mg
4g IV over 20 minutes via controlled infusion device.

1g per hour IV for 24 hours after birt

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2
Q

What can you give if seizures occur while preparing Mg SO4-?

A

Diazepam 5-10mg IV at a rate of 2-5mg/min (max dose 10mg)
Clonazepam 1-2 mg IV over 2-5 mins
Midazolam 5-10mg IV over 2-5 mins or IM

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3
Q

What can you give if seizures reoccur while receiving MgSO4-?

A

MgSO4- 2g IV over 5 minutes (may be repeated after 2 minutes)
Diazepam 5-10mg IV at a rate of 2-5mg/min (max dose 10mg)
Midazolam 5-10mg IV over 2-5 minutes or IM
Clonazepam 1-2mg IV over 2-5 minutes

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4
Q

How would you alter the dose of MgSO4- with impaired renal function?

A

Reduce maintenance dose to 0.5mg/hr

Consider serum monitoring.

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5
Q

How would you monitor a women with PET who is receiving MgSO4-?

A

BP, pulse every 5 minutes until stable then every 30 minutes.
RR and patellar reflexes hourly
Temp Q2H
Continuous CTG monitoring if > 24 weeks (interpret with caution if < 28 weeks)
Measure urine output hourly via IDC
Strict fluid blaance monitoring
Serum Mg if toxicity suspected.

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6
Q

What is the serum therapeutic Mg level?

A

1.7-3.5mmol/L

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7
Q

When would you consider stopping Mg infusion (in the case of PET?)

A

UO < 80ml in 4 hours
Deep tendon reflexes are absent or
RR < 12 breaths/min

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8
Q

What is the antidote to MgSO4-?

A

10% calcium gluconate 10ml IV over 5 minutes

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9
Q

What are RFs for PET in pregnancy?

A 
Previous PET
FHx of PET
Inter-pregnancy interval > 10 year
Nulliparity 
Pre-existing medical conditions:
  - APLS
  - Pre-existing diabetes
  - Chronic HTN
  -Chronic autoimmune disease 
BMI > 35 kg/m
Age > 40
Multiple pregnancy
Elevated BP at booking
Gestational trophoblastic disease
Fetal triploidy
  -
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10
Q

A women has PET. What are the indications for birth?

A 
Non-reassuring fetal status
Severe fetal growth restriction
>/= 37 weeks
Eclampsia
Placental abruption
Acute pulmonary oedema
Uncontrollable HTN
Deteriorating platelet count
Deteriorating liver and/or renal function
Persistent neurological symptoms
Persistent epigastric pain, nausea or vomiting.
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11
Q

A G1P0 at K34 has a sBP >/= 140 and/or dBP >/= 90 during her pregnancy. What investigations do you request?

A 
Concerned for PET. 
Maternal invx:
- Urine dipstick for proteinuria
- spot urine PCR: if >/= 2 + or recurrent 1+  on dipstick
FBC
Urea, creatinine electrolytes and urate
LFT including LDH.

Fetal Ax:

  • CTG
  • USS for fetal growth & wellbeing
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12
Q

A G1P0 at K34 has a sBP >/= 140 and/or dBP >/= 90 during her pregnancy. What mng would you initiate?

A 
Definitely commence antihypertenisve if:
sBP >/= 160 and/or dBP >/=100
Consider if sBP >/= 140 and or dBP >/= 90.
Antihypertensive choice (initial dose):
- *methyldopa 125-250mg BD
- * Labetalol 100mg BD
- *^Oxprenolol 40-80mg BD
- " Hydralazine 25mg BD
- " Nifedipine (SR) 20-30mg daily
-"Prazosin 0.5mg BD
- " Clonidine 50-150 microg BD
" 2nd line drugs
^not QH approved.
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13
Q

A women has HTN in pregnancy. When would you consider admission?

A

Fetal WB is of concern
sBP >/= 140mmHg OR
dBP > 90 OR
symptoms of PET, or proteinuria or abnormal bloods.

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14
Q

Define gestational HTN?

A

New onset HTN arising after 20 weeks gestation.
No additional features of PET
Resolves w/i 3 months PP.

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15
Q

Define PET?

A

A multisystem disorder characterised by HTN and involvement of one or more other organ systems and/or the fetus

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16
Q

Define PET superimposed on chronic HTN?

A

Where a woman with pre-existing HTN develops systemic features of PET after 20 weeks gestation.

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17
Q

How do you dx PET?

A 
HTN  arising after 20 weeks gestation confirmed on 2 or more occasions and accompanied by one or more of hte organ/systems below:  
- Proteinuria  (random PCR >/= 30mg/mmol
- Renal: serum or plasma creatinine >/= 90micromol/L OR oliguria. 
- Haematological:
  - Thrombocytopenia (plts < 100)
  - Haemolysis: schistocytes or red cell fragments onblood film raised BR, raised LDH, decreased haptoglobin.
  - DIC
Liver: 
  - raised transaminaises
  - severe epigastric or RUQ  pain
Neurological: 
  - Severe headache
  - Severe visual disturbances (photopsia, scotomata, cortical blindness, retinal spasm)
  - hyperreflexia with sustained clonus
  - convulsions (eclampsia)
  - Stroke. 
Pulmonary:
  - Pulmonary oedema
Uteroplacental
  - Fetal growth restriction

NB: pre-existing HTN is a strong RF for the development of PET . Proteinuria is common but not mandatory to make dx.

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18
Q

How do you diagnosis SGA?

Ranzcog

A

SFW that measures < 10th percentile on US. This dx does not necessarily imply pathological growth abnormalities, and may simply describe a fetus at the lower end of the normal range.

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19
Q

You are reviewing a women in antenatal clinic. She has a history of PET and placental insufficiency. What mng would you recommend?

RANZCOG

A

Low dose aspirin.
LShould be recommended to women iwht a PHx of placental insufficiency syndromes including IUGR and PET. It should be initiated beetween 12 and 16 weeks’ gestation and continued until 36 weeks.

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20
Q

The presence of two or more risk factors would lead you to recommend initiating low dose aspirin in a women (from between 12 and 16 weeks -> 36 weeks).
(or from 16 -37 weeks or birth of baby as per QH).

A

Pre-gestational HTN, obesity, maternal age > 40 years, h/o ART, pre-gestational diabetes mellitus (type I or II), multiple gestation, previous H/O placental abruption, and previous history of placental infarction.

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21
Q

What advice would you give to women at high risk of hypertensive disorders of pregnancy regarding the S&S of PET?

A

Symptoms:

  • Severe headache
  • Problems wiht vision (e.g. blurring or flashing before teh eyes)
  • Severe pain just below the ribs on the right side
  • vomiting
  • Sudden swelling of the face, hands or feeet.
22
Q

What initial invx would you request for a women with new onset HTN after 20 weeks?

A 
Urinary dipstick for proteinuria. 
PCR
FBC 
Urea, creatinine, electrolytes and urate
LFT including LDH
If thrombocytopenia or a falling Hb, invx for DIC and/or haemolysis including:
- coags 
- Blood film
- LDH
- fibrinogen
- haemolytic studies

If severe/early onset PET consider invx fo rassociated conditions (e.g. SLE, APLS, chronic renal disease).

Fetal assessment:
- CTG if > 24 weeks
USS to ax: fetal growth, AFV or DVP, UA flow (doppler) and follow-up to assess fetal growth velocity.

23
Q

What adverse outcomes are associated with HTN for the mother and baby?

A

Maternal:
Cerebral haemorrhage, posterior reversible encepahlopathy syndrome and hypertensive encephalopathy.
Obstetric:
placental abruption, DIC< hepatic failure and acute renal failure.
Neonatal: prematurity, SGA, admission to intensive care nursery.

24
Q

What are the suggested BP targets in PET?

A

dBP < 90

sBP < 140

25
Q

When would you consider initiating BP medication in a women with moderate HTN in pregnancy?

A

sBP 140-160
dBP 90-100
Associated S&S of PET

26
Q

Which first line antihypertensives are recommended for PET in pregnancy?

A 
Methyl dopa
  - Start: 125-250mg BD
  - Up to 500mg QID
  - MD 2g
Labetalol
  - Start 100mg BD
  - up to 200 - 400mg QID
  - MD 2.4g
27
Q

What are 2nd line antihypertensives for HTN/PET in pregnancy?

A

Hydralazine:

  • Start: 25mg BD
  • Up to 25-100mg BD
  • MD 200mg

Nifedipine (SR)

  • Start: 20 -30mg OD
  • Up to 60-120mg OD
  • MD: 120mg

Nifedipine (IR)

  • start: 10-20mg BD
  • Up to 40mg BD
  • MD 80mg

Prazosin:

  • Start 0.5mg BD
  • Up to 1mg TDS
  • MD 20mg??

Clonidine

  • Start: 50-150mcg BD
  • Up to 150-300mcg BD
  • MD 600mcg
28
Q

What medication can you use for tx of acute severe HTN?

A

Nifedipine
Labetalol
Hydralazine
Diazoxide

29
Q

What are the doses of nifedipine for acute tx of severe HTN?

A

PO Nifedipine 10-20mg IR.

  • Onset 30-45minutes
  • Repeat after 45 mins
  • MD 80mg.

IV Labetalol 20mg bolus over 2 minutes (SAS)

  • Repeat with 40-80mg.
  • Onset 5 minutes
  • Repeat every 10 minutes.
Labetalol infusion (SAS) 20-160mg/hour
  - titrate to BP response to a MD of 300mg.

IV hydralazine bolus

  • 5-10mg (5mg if fetal compromise), give over 3-10minutes.
  • Onset 20mins
  • repeat every 10minutes
  • MD 30mg

Hydralazine infusion 10-20mg/hour - titrate to BP response, follow hydralazine infusion.

Diazoxide.

30
Q

What are signs of severe PET?

A

Severe HTN, headache, epigastric pain, oliguria or nausea and vomiting are ominous signs - require urgent admission .

31
Q

What are the indications for MgSO4- (3)

A
  1. Eclampsia
  2. Severe PET, defined in the Magpie Trial as:
    - sBP >/= 170mmHg or dBP >/= 110 and at least 3+ proteinuria OR
    - sBP >/= 150mmHg or dBP >/= 100 on two occasionas and at least 2+ proteinuria in the presence of at least two signs or symptoms of “imminent eclampsia”
  3. PET with a least one sign of CNS irritability
32
Q

Define HELLP syndrome?

A

A variant of PET
Haemolysis
Elevated Liver enzymes
Low Platelets

Elements include:

  • Thrombocytopenia (common)
  • Haemolysis (rare) and
  • elevated liver enzymes (common)
33
Q

What investigations would indicate severe PET disease? (3)

A
  1. Plts count < 100
  2. Elevated transaminases
  3. Microangiopathic haemolytic anaemia with fragments /schistocytes on blood film
34
Q

How would you manage HELLP?

A

liaise with obs phsyician, physician haematologist and anaethetist.
If greater than 34 weeks and/or condition deteriorating, plan birth.
Mg sulfate may be indicated.
Consider plt transfusion if:
- Thrombocytopenia presents a hazard to operative birth OR
There is significant bleeding PP attributable to preeclamptic thrombocytopenia

35
Q

Define eclampsia?

A

the occurrence of one or more seizures superimposed on PET.

36
Q

Goals in treating eclampsia? (4)

A

terminate the seizure
Prevent recurrence
Control HNT
prevent maternal and fetal hypoxia

37
Q

Define imminent eclampsia as per the Magpie trial.

A

At least two of the following symptoms:

  • Frontal headache
  • Visual disturbance
  • Altered level of consciousness
  • Hyperreflexia
  • Epigastric tenderness.
38
Q

A women is having an eclamptic seizure while initiating MgSO4. What else can you administer?

A

Diazepam 5-10mg IV at 2-5mg/min (max dose 10mg)
OR
Midazolam 5-10mg IVover 2-5 minutes or IM
Clonazepam 1-2mg IV over 2-5 minutes.

Aim BP < 160/100mgHg

39
Q

A woman has gestational HTN. When would you consider admission to hospital?

A
  • Concern for fetal wellbeing and/or

- sBP >/= 140 or dBP >/=90 or S&S of PET are present.

40
Q

A women is admitted for surveillance with PET. What routine mng would you implement? (7)

A
  1. BP Q4H
  2. CTG daily from 28 weeks.
  3. Daily ward urine analysis if proteinuria not previously confirmed.
  4. Maintain accurate fluid balance record.
  5. Daily review by obs
  6. Normal diet
  7. Consider VTE
41
Q

An antenatal women has gestational HTN. HOw often would you undertake urinalysis for protein, order bloods to screen for PET and USS to ax fetus?

A

(QH guideline)
Urinalysis for proteinuria - 1-2 per week
PET bloods - weekly.
US fetus: at dx and Q2-4 weekly.

42
Q

According to US parameters, define oligohydramnios?

A

AFI 5cm or less

DVP 2cm or less.

43
Q

What are signs and investigations that may indicate fetal compromise?

A

Decreased FMs
Abnormal FHR tracing (e.g. decreased variability)
AFI 5cm or less
DVP 2 cm or less
Oligohydramnios associated with adverse perinatal outcomes.
Asymmetrical intrauterine fetal growth.
UA doppler: increased resistance, absent or reversed end diastolic flow
Ductus venosus doppler: absent or reversed “a” wave
Middle cerebral artery doppler:
- Cerebral redistribution (decreased resistance or ‘brain sparing effect’)
- Paraodoxically the flow can revert back to a high resistance pattern when the pathology has not yet resolved - v poor prognostic sign.

44
Q

Indications for birth with PET (12)?

A 
Non-reassuring fetal status
Severe FGR
Gestational age greater than or equal to 37 weeks
Eclampsia
Placental abruption.
APO
Inability to control HTN despite adequate antihypertensive therapy.
Deteriorating platelet count
Deteriorating liver function
Deteriorating renal function
Persistent neurological symptoms
Persistent epigastric pain, nausea or vomiting with abnormal LFT.
45
Q

A women with PET is going for a CS. Which type of anaesthetic would you prefer and why?

A

Spinal: quicker onset than epidural and avoids hypertension associated with intubation for GA.

46
Q

What are the risks of expectant mng with HELLP syndrome?

A

6.3% incidence of matenral death and an increased risk of placental abruption.
Plan birth as soon as feasible.

47
Q

In which time period is de novo postpartum HTN most likely to occur?

A

occurs most commonly days 3-6

48
Q

What % of PET occurs in the postpartum period and it what time frame postpartum?

A

44% of eclampsia occurs in the postpartum period, usually in the first 48 hours after birth.

49
Q

Why should you cease methyldopa in the postpartum period?

A

It is associated with clinical depression.

50
Q

Why should you avoid NSAIDS in the postpartum period ?

A

risk of worsenign HTN and renal impairment, esp in volume depleted women.

51
Q

Name antihypertensives that are safe with breastfeeding and can be used postpartum.

A 
Nifedipine
Enalapril
Captopril
Metoprolol
Atenolol 
Labetalol.
52
Q

What d/c advice would you give to a women who has had PET?

A

f/u with GP in 6 weeks to ensure resolution of pregnancy related changes and ascertain the need for ongoin care.
Provide advice re future preg risk reduction (e.g. aspirin) and mgn.
If on ACEi, needs contraception.

Obstetrics (14 decks)

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