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Obs and Gynae > Hypertensive disorders of pregnancy > Flashcards

Hypertensive disorders of pregnancy Flashcards

1
Q

Normal BP during pregnancy

A

Systolic < 140 mmHg
Diastolic < 90 mmHg

*both the systolic and diastolic pressure falls during the second trimester and increase toward the end of pregnancy
*mild rise in BP in third trimester can be normal

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2
Q

Hypertension during pregnancy

A

Diastolic > 90 mmHg AND/ OR
Systolic > 140 mmHg

*high BP in pregnancy = often accompanied by proteinuria

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3
Q

Borderline Hypertension in pregnancy

A

Systolic 135-139 mmHg AND
Diastolic 85-89 mmHg

*always repeat BP after 30 minutes

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4
Q

Proteinuria in pregnancy

A
  • > 3g protein in 24hr specimen
    +1 protein urine dipstick

Causes
1. UTI
2. Renal disease
3. Contamination of urine by vaginal discharge or leucorrhoea

*second sample must be collected: Midstream specimen urine (MSU)

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5
Q

Classification of high BP in pregnancy

A
  1. Started before or after 20th w of GA
  2. Proteinuria present or not

Different forms:
1. Pre-eclampsia (gestational proteinuric hypertension)
2. Gestational hypertension
3. Chronic hypertension
4. Chronic hypertension with superimposed pre-eclampsia
5. Eclampsia

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6
Q

Pre-eclampsia

A
  1. Hypertension +
  2. Proteinuria +
  3. Develop in 2nd half of pregnancy

*may be present during pregnancy, labour, or puerperium

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7
Q

Gestational hypertension

A
  1. No proteinuria
  2. Develop in 2nd half of pregnancy

*if proteinuria develops -> pre-eclampsia

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8
Q

Chronic hypertension

A
  1. Hypertension +/-
  2. Proteinuria
  3. Present during 1st half of pregnancy

*usually a hx of hypertension

*without proteinuria - usually essential hypertension
*with proteinuria - chronic renal disease

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9
Q

Chronic hypertension superimposed on pre-eclampsia

A
  1. Hypertension
  2. Presenting in 1st half of pregnancy
    +
  3. Proteinuria
  4. Develop in 2nd half of pregnancy
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10
Q

Eclampsia

A
  1. Complication of pre-eclampsia
  2. Presenting with convulsions during
    - Pregnancy
    - Labour
    - First 7 days puerperium
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11
Q

Maternal complications of pre-eclampsia

A
  1. Intracerebral haemorrhage
  2. Pulmonary oedema
  3. Eclampsia
  4. HELLP Syndrome
  5. Rupture of liver
  6. Renal failure

*1 & 2 important causes of maternal deaths
*1-3 most common
*HELLP Syndrome
- Haemolysis
- Elevated Liver enzymes
- Low Platelet count

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12
Q

Intracerebral haemorrhage

A

Highest risk
1. Diastolic > 110 mmHg +/ or
2. Systolic > 160 mmHg

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13
Q

Perinatal death due to pre-eclampsia

A
  1. Preterm delivery required due to maternal deterioration or foetal distress
  2. Abruptio placentae more common = intrauterine death
  3. Decreased placental blood flow
    - Intrauterine growth restriction
    - Foetal death
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14
Q

Grading of pre-eclampsia

A
  1. Diastolic and Systolic BP
  2. Grade of proteinuria
  3. Signs and symptoms of severe features
  4. Labs indication renal disease or clotting deficiency
  5. Presence of convulsions

Severity grades
1. Pre-eclampsia
2. Pre-eclampsia with signs of severe disease
(Symptoms of severe disease, abnormal lab tests indicating severe disease)
3. Eclampsia

*Pre-eclampsia
1. diastolic 90-109 mmHg
2. systolic 140-159 mmHg
3. Proteinuria

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15
Q

Pre-eclampsia with severe signs of disease

A
  1. Diastolic > 110 mmHg +/ or
  2. Systolic > 160 mmHg +
  3. Two or more occasions +
  4. 4 hours apart
  5. Diastolic > 120 mmHg +/ or
  6. Systolic > 170 mmHg +
  7. One occasion

*Symptoms of severe disease
- indicate high risk of developing eclampsia
- dx does not depend on degree of hypertension or proteinuria
- dx is made if only one symptom is present irrespective of BP

*Abnormal lab tests indicating severe disease
- SCr > 90 mmol/l
- ALT/ AST > 40 iu/l
- Platelet count < 100,000/ microliter

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16
Q

Grading of pre-eclampsia

A
  1. If doubt about grade, place them in the more severe grade
  2. Px improving on bed rest should be kept in initial grade given on assessment + given management accordingly
17
Q

Symptoms and signs of pre-eclampsia with severe disease

A

Symptoms:
1. Severe headache
2. Visual disturbance/ flashes of light in front of eyes
3. Blindness
4. Dyspnoea
5. Altered mental status
6. Upper abdominal pain
- Epigaatrium +/ or
- Liver

Signs:
1. Tenderness over liver
2. Increased tendon reflexes
- knee reflexes
- tonus
3. Pulmonary oedema
4. Ascites

18
Q

Pxs at risk of pre-eclampsia

A
  1. Primigravida
  2. Chronic hypertensive
  3. > 34 years
  4. Multiple pregnancy
  5. Diabetics
  6. Previous history of pre-eclampsia (esp if late 2nd or early 3rd trimester)
  7. Pxs who develop generalised oedema, especially facial.

*educate these pxs & advise them to contact the hospital if symptoms or signs appear

19
Q

Antenatal care of px at increased risk of pre-eclampsia

A

*Pxs with history of pre-eclampsia and chronic hypertension
1. 150mg aspirin (1/2 Disprin)
- Daily
- from 14 w GA
2. 1g Calcium
- Daily
- 2x 500g
*take 4 hours apart from Fe tablets (decrease Fe absorption)

20
Q

Px with generalised oedema + normotensive + no proteinuria

A
  1. Bed rest
  2. Contact clinic/ hosp if symptoms of imminent eclampsia
  3. Weekly follow up at antenatal clinic
  4. Monitor foetal movements
21
Q

Management of pre-eclampsia

A
  1. Admit to hospital
    *may be level 1 facility with facilities for c/s
  2. Methyldopa (Aldomet) must be prescribed
    *high doses (500mg 8hrly)

*ALL pxs must be admitted to hospital, irrespective of BP

22
Q

Delivery of pre-eclampsia baby

A
  1. GA > 34 weeks
  2. Induce labour on the day of dx
    - Surgical induction if favourable cervix
    - Refer to level 2 for ripening of unfavourable cervix (misoprostol - cytotec or prostaglandin e2 gel is given) and then surgical induction

*monitor px closely for an hour after administering miso/ e2 - overstimulation can cause foetal distress

23
Q

Special investigations pre-exlampsia

A
  1. MSU
    - send for MC&S
    - examine to exclude UTI
  2. Platelets <100,000 - refer to lvl 2
  3. SCr for renal function
  4. US for eGA and foetal weight
  5. Umbilical artery Doppler - placental function
24
Q

Management of pre-eclampsia with severe features

A
  1. Prevent eclampsia: Magnesium sulphate
  2. Prevent intracerebral haemorrhage: Decrease BP with
    - dihydralizine (Nepresol)
    - nifedipine capsules (Adalat)
  3. Prevent pulmonary oedema: Slow IV fluid administration
    - < 80 ml/ hr
25
Q

Steps for managing pre-eclampsia with severe features

A
  1. IV
    - Plasmalyte B /
    - Ringers Lactate
    - AND magnesium sulphate
    *4g slowly IV over 10 minutes - add 8 ml 50% magnesium sulphate to 12ml sterile water
    *5g (10 ml 50% magnesium sulphate) by deep IM into each bottock
    *total magnesium sulphate = 14g

*200ml IV rapid over 1/2 hr, then <80 ml/hr

  1. Foley catheter - urinary output
  2. Measure BP again
    - diastolic > 110 mmHg +/ or
    - systolic > 160 mmHg
    = oral nifedipine (Adalat) or
    = dihydralizine (Nepresol)
    *10 mg nifedipine po OR 5 mg dihydralizine IV slowly
    *take BP every 5 mins for 30 mins
    *BP drops - Balsol/ Ringer’s rapidly till BP normal
    *diastolic >110 and systolic >160 after 30 mins - repeat 10mg Nifedipine
    *Can repeat Nifedipine every 30 mins until 50mg
    *diastolic >110 and systolic >160 after 30 mins - mix 25mg dihydralizine with 10 ml sterile water.
    *bolus doses 2ml (5mg) are given slowly IV.
    *can repeat in 30 mins up to 3 times

*labetalol (Trandate) 20mg IV substitute dihydralizine - another 40mg if no drop after 10 mins.

  1. Transfer px to lvl 2 or lvl 3 hospital
26
Q

Magnesium sulphate

A
  1. Maintenance dose until 24hrs after delivery
  2. 5g IM every 4 hrs
    • 1ml 1% lignocaine

*Side-effects
1. Respiratory depression
2. Cardiac depression
3. Patellar reflex - absent or reduced indicated overdose
4. Only give follow up if patellar reflex present when urinary output <30 ml/hr

*if overdosed:
1. intubate and ventilate
2. ventilate with bag and face mask
3. external vardiac massage
4. 10ml 10% calcium gluconate slowly IV (antidote)

Obs and Gynae (1 decks)

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