Hypertensive Disorders of Pregnancy Flashcards
Risk (%) of Pre-eclampsia /w chronic hypertension
and if BP increases <34 weeks
10-20%
and
35%
Definition of gestation hypertension
onset >20 weeks
Definition of pre-existing hypertension
onset pre preg or <20 weeks
can be essential or secondary
hypertension is defined as:
and
severe hypertension is defined as:
> 90 diastolic on 2 measurements avg (systolic unreliable, false +ves)
and
> = 160 / 110 (either)
Pre-eclampsia definition
new hypertension with 1 or more:
- new proteinuria
- an adverse condition or severe complication
OR pre-existing hypertension with
- new or worse proteinuria
- adverse / severe complication
- or resistant hypertension (3+ drugs)
OR gestational hypertension plus:
- new or worse proteinuria
- a severe complication
severe pre-eclampsia definition
/w 1 or more severe complication
eclampsia definition
seizures without another cause in pre-eclampsia
adverse clinical conditions of pre-eclampsia
headache (ischemia/edema), vision change (occ cortical ischemia), abdo pain (liver), chest pain, dyspnea (edema), N/V, abruption, abnormal labs
fetal: oligo, IUGR, FD, absent or reversed UA doppler, redistribution of MCA, DV abnormalities
severe complications
eclampsia, PRLE sydrome, cortical blindness, retina detach, GCS <13, stroke/tia, severe uncontrolled HTN, O2 desat, pulm edema, MI, platelets <50, transfusion, AKI, dialysis, hepatic rupture/haematoma, INR >2 (no DIC or warfarin)
fetal: abruption + compromise, stillbirth, reversed DV wave
How to dx proteinuria
suspect: dipstick 1+
300mg/day (24hr) or 30mg/mmol creatinine in 1 test
ACR accuracy unknown in preg, normal prot:creatinine= 17-57 mmol/L
severe proteinuria = 3-5g/day
pre-eclampsia comorbidities
any HTN
DM (not GDM)
cerebrovasc disease
renal parenchymal or vasc disease
What BP are you at risk for stroke?
> =160mmg systolic
leading causes of death in pre-eclampsia
stroke, pulmonary edema
investigations for pre-eclampsia: maternal
Hg (hemoconc or hemolysis), WBC + diff (neutrophil), platelets, blood film (microangiopathy/frags), INR + PTT (for DIC), fibrinogen, creatinine, uric acid (higher), glucose (low in fat liver), AST, ALT, LDH, albumin, bilirubin (hemolysis=unconj, or liver dysfunction=conj), urinalysis, proteinuria (dipstick, spot, 24hr)
investigations for pre-eclampsia: fetal
FM counts, NST, BPP, deepest fluid pocket, US for growth, UA doppler (increase resistance, absent or reversed end diastolic)
RFs for pre-eclampsia
multiples
Prev hx or fam hx
APA syndrome
thrombophilia
HTN or renal disease DM obesity BP already >130/80 Fam Hx early CVD
age >40 >10 years since last preg, or <2 years IVF ethnicity: nordic, black, SouthA, PI low SES
infection in preg
gest trophoblastic disease
non-smoker
cocaine or meth
in 3rd trimester: HTN, abnormal MSS or UA doppler, CO>7.4L/min, uric acid high
Hints that HTN is chronic
retinal change on fundoscopy cardiac enlargement (CXR or ECG) renal disease metabolic syndrome prev hx of PIH persists beyond 6wks PP
etiology of pre-eclampsia
trophoblast invasion uteroplacental mismatch vasc endothelial damage endothelial cell activation cardiovasc maladaptation coag abnormalities immune genetic dietary def or excesses
prevention in low-risk women
Ca supplement if low dietary intake
normal stuff: no EtOH, exercise, folate, smoking cessation
non-specific but help other complications:
- prostaglandin precursors (fish oil)
- Mg or Zn
NOT recommended:
- salt restriction
- caloric restriction
- ASA
- Vit C, E, thiazide diuretics
prevention in high risk women
Ca
ASA 75-100mg, pre-preg or at conception, must start <16wks, stop at 35-36wks (or delivery soon)
may help: avoid inter-preg weight gain, rest in 3rd trim, reduce stress
NOT recommended: caloric restriction, weight maintenance in obese, antihypertensives to prevent, vit C or E
antihypertensives: don’t prevent pre-eclampsia, but decrease incidence of severe HTN in those /w mild
Who to hospitalize
severe HTN (160/110) or severe pre-eclampsia = inpatient
non severe: consider day unit or home care
bedrest NOT helpful (rest may be)
Treatment of HTN
severe: target under 160/110
meds:
labetalol:
20mg IV
then 20-80mg q30min
OR 1-2mg/min
(max 300mg, then go PO).
Avoid if asthma or CHF. Caution neonatal brady.
nifedipine:
5-10mg caps PO q30min
10mg PA tab q45min (max 80mg/d)
hyrdalazine: 5mg IV, then 5-10mg IV q30min OR 0.5-10mg/hr, max = 20mg IV (or 30IM)
FHR monitor until stable
can combine nifedipine /w MgSO4
Non-severe hypertension treatment
140/90-160/110
target <155/105
if comorbidities <140/90
meds:
methyldopa
250-550mg po BID-QID, max = 2g/day
labetalol
100-400mg po bid-tid
max = 1200mg/day
nifedipine
PA 10-20mg bid-tid, max=180mg/d
XL 20-60mg po OD, max=120mg/d
When to use steroids
pre-eclampsia <34 weeks
gestational HTN <34 weeks if delivery may be <7 days away
Note steroids –> low HR variability for 4 days
Labour and Delivery notes
who can get epidural?
early epidural
can do spinal or epi if pts >75 (even /w ASA), if on LMWH 12 hrs after prophylactic or 24hrs if therapeutic dose
NO IV fluid bolus before anaesthesia/analgesia
minimize fluids, even if oliguria
no dopamine or furosemide
What other thing need tx in pre-eclampsia?
N/V, abdo pain, seizure prophylaxis, MgSO overdose, fetal monitoring, BP
tx of RUQ/epigastric pain
morphine 2-4mg IV
antacid
seizure prophylaxis
MgSO4 if
- eclampsia
- severe pre-eclampsia
- consider in non-severe
dose: 4g IV, then 1-2g/hr IV
continue until 24hrs post-partum
MgSO4 overdose
observe for toxicity:
- weakness, resp paralysis, somnolence, heart block
- high risk: renal failure, oliguria, CCBs
tx:
- stop infusion
- 10% Calcium gluconate 10ml IV over 3 mins
treatment of eclampsia
- don’t shorten initial convulsion
- prevent injury/aspiration
- maintain O2
- avoid polypharmacy
HELLP syndrome tx
- corticosteroids if pts <50
- consider transfusion if pts <50, falling rapidly, or coagulopathy/excessive bleeding
- strongly consider if VD and <20
- recommended if CS and <20
who to transfer if resources limited
- stable (BP, fetal status reassuring)
- discuss /w patient + receiver
- give anti-HTN + MgSO if indicated
Cure of HTN in preg
delivery
- stabilize mom 1st
- delay only for fetal maturity or transfer if condition allows
- progressive dx, don;t wait if severe of fetal compromise
who can get expectant management in pre-eclampsia
<34wks, may do expectant management, if stable. Consider transfer to centre that can care for premie
34-36wks - no evidence
37wks - deliver
postpartum management
follow BP
restart anti-HTNs
severe: target <160/110
treat if non-severe esp /w comorbidities
safe in BFing: nifedipine XL, labetalol, methyldopa, captopril, enalapril
ensure end-organ issue resolved
pre-conception in patients /w HTN
optimize health
switch to anti-hypertensives safe in preg
methyldopa, labetalol, CCBs ok in 1st trimester
may not need to replace anti-HTNs
