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Finals - Obstetrics and Gynaecology > Hypertensive disorders of pregnancy > Flashcards

Hypertensive disorders of pregnancy Flashcards

1
Q

What the the epidemiology of hypersensitive disorders in pregnancy

A

7-10% of pregnancies:
70% are maternal new onset/gestational
30% are chronic HTN
Eclampsia - 0.05%

Risks:
20% of maternal deaths
10% of preterm births

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2
Q

What are some risk factors for HTN in pregnancy?

A 
Primigravidity
Young female - 3x risk
Black - 2x risk 
Multifoetal pregnancies 
Renal disease 
Collagen vascular disease
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3
Q

How is HTN classified?

A

Gestational - during pregnancy only

Preeclampsia-eclampsia

Chronic HTN

Preeclampsia superimposed on chronic HTN or renal disease

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4
Q

What is gestational HT?

A

New onset HTN after 20th week
Systolic >140
Diastolic >90
No or little proteinuria

25% of these develop preeclampsia

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5
Q

What is preeclampsia-eclampsia?

A

New onset HTN after 20th week

Increased BP (same as gestational - >140/>90) + proteinuria (1+ on dipstick, confirmed using protein:creatinine ratio >30 mg/mmol as a threshold for significant proteinuria)

Oedema not part of definition (though is an associated sign)

Eclampsia - preeclampsia + generalised tonic clonic seizures

Can occur up to 6wks after delivery

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6
Q

What is chronic HTN?

A

Before pregnancy

Before 20wks gestation

Extends from before pregnancy and is not resolved post partum

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7
Q

What is superimposition of HTN?

A

A. Gestational HTN increase + no proteinuria @ <20wks with new proteinuria after 20wks

B. Gestational HTN increase and proteinuria @ <20wks with sudden increase in proteinuria + elevated BP from previously well controlled + thrombocytopenia + AST/ALT derangement

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8
Q

How do you diagnose preeclampsia-eclampsia?

A

Gestational HTN

+

Proteinuria - 1+ on urine dip or >3mg/mmol on protein:creatinine

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9
Q

How do you measure BP?

A

Sitting zbak MORE

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10
Q

How is preeclampsia-eclampsia risk classified by severity?

A 
High risk factors:
HTN disease in previous pregnancy 
Chronic HTN 
Chronic kidney disease 
Autoimmune disease e.g. SLE or antiphospholipid syndrome 
T1/T2DM
Moderate risk factors:
First pregnancy 
>40yrs old
Pregnancy interval >10yrs
BMI >35
FHx preeclampsia 
Multiple pregnancy

Early onset - <34 wks - MORE SEVERE usually

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11
Q

What are the clinical criteria for severe preeclampsia?

A 
Presentation: (HHPPPV)
Headache
Hyperreflexia/clonus 
Papilloedema
Pain - RUQ, epigastric 
Pulmonary oedema
Visual disturbance - floaters, flashing lights 
Investigations:
HTN - usually >170/110mmHg
Proteinuria +1 or more on dipstick 
Platelets - <100*10^6
Abnormal LTF’s or HELLP syndrome
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12
Q

What is the pathophysiology of preeclampsia-eclampsia? How does this manifest clinically?

A

Exact mechanism uncertain

Spiral arteries become fibrous and narrowed rather than dilating massively to become vascular sinuses/uteroplacental arteries that deliver large quantities of blood to foetus like they would in normal pregnancy, less blood gets to the placenta - hypoperfused placenta leads to production of inflammatory cytokines (intrauterine growth restriction, foetal death) - dysfunction of maternal endothelial cells in circulation - vasoconstriction = HTN

Deceased renal blood flow - reduced GFR = raised uric acid levels + proteinuria + hypocalciuria + impaired Na excretion and suppression of RAAS = compounds HTN

Maternal activation of coagulation system - thrombocytopenia, low antithrombin III, higher fibronectin

Maternal liver derangement - HELLP syndrome - Haemolysis, Elevated ALT and AST, Low Platelets

Other possible symptoms - epigastric pain, hepatic swelling/infalmmation, stretch of liver capsule, oedema, rapid weight gain

Maternal CNS involvement - migraine-like headache, visual disturbance, scotoma, cortical blindness, eclampsia/generalised TC seizures

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13
Q

What are the maternal complications of preeclampsia?

A 
Eclampsia 
Emergency C-section 
Haemorrhage (stroke)
HELLP syndrome - haemolysis, elevated liver enzymes, low platelets
Pulmonary oedema 
Liver and renal failure 
DIC
Placental abruption
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14
Q

What are the foetal complications of preeclampsia?

A

Interuterine growth restriction leading to small for gestational age

Haemorrhage

Preterm delivery (+ problems of prematurity), ICU admission

Cardiac failure

Stillbirth

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15
Q

How does preeclampsia present?

A

Mostly unremarkable - will simply pick up HTN and proteinuria

Symptomatic = becoming severe:

Signs:
Raised BP
Proteinuria
Brisk/hyperactive reflexes (though common in pregnancy)
Ankle clonus - neuromuscular irritability that raises concern
Retinal vasospasm or oedema
Right upper quadrant tenderness

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16
Q

What are the lab tests and findings in preeclampsia?

A

HELLP work up:

FBC - Hb low
Serum uric acid - high (because impaired renal function)
U+E - elevated creatinine, 
LFTs - elevated AST/ALT  
Platelets - low in severe

Can also do urine dip - 1+ proteins

IS THIS CARD CORRECT?

17
Q

How is preeclampsia managed?

A

New onset: hospital for assessment; if mild gestational HTN, can manage at home with regular review

Prophylactic aspirin - started at booking visit at 12wks, 75mg OD and continuing to delivery if any one of the following:
HTN disorder in prev pregnancy
CKD
Autoimmune disease - SLE, antiphospholipid
SLIDES

Labetalol PO is first line in treating the HTN throughout pregnancy; nifedipine if asthmatic and contraindicated

If suspect preterm delivery is likely give dexamethasone (lung development) magnesium sulphate (CP risk reduction)

Monitor urine output - restrict to 80mls/hr

Mg SO4 - if indicated e.g. hyperreflexia - prevents eclampsia

Delivery is the only ‘cure’ - always beneficial for mother, but may not be beneficial for baby if means being born seriously premature - so manage maternal problems best as possible in this instance to allow foetal maturation and cervical ripening

18
Q

What is a favourable Vs unfavorable cervix?

A

Soft, opening, approaching readiness for delivery

Can use prostaglandins to ‘ripen’ the cervix

19
Q

Why would we give anticonvulsants in pregnancy?

A

To prevent recurrent seizures in women with eclampsia

Consider in: women with severe preeclampsia where birth is planned within 24hrs or with 1+ symptoms - ongoing severe headache, N+V, epigastric pain, progressively deteriorating bloods etc

Only drug: Magnesium sulphate IV 4g/5mins then 1g/hr/24hrs

SE: Caution in renal failure as Mg is renally excreted and thus can lead to hypermagnesia - paralysis including respiratory depression, slurred speech, diplopia; flushing

20
Q

What are the indications for delivering in preeclampsia?

A

Maternal:
Gestational age >38wks
Platelets <100,000cells/mm3
Progressive deterioration in liver and renal function
Persistent severe headaches, vomiting, visual changes, nausea, epigastric pain or vomiting
Suspected premature separation of placenta from uterus (abruptio placentae)

Foetal:
Severe growth restriction
Oligohydramnios - deficiency of amniotic fluid

Vaginal delivery is best, labour induction (within 24hrs), may get hydralazine/labetalol go keep BP down during delivery

21
Q

What follow up is necessary in preeclampsia?

A

Counselling for future pregnancies:

Risk of recurrence is high before 30wks, if there’s a new father and in black people

22
Q

What are some risk factors for developing preeclampsia?

A

First pregnancy
Multiple foetuses
Mother >35yrs

Hx - HTN, renal disease, diabetes; F/Hx - preeclampsia

Smoking might weirdly be protective - fewer smokers get preeclampsia..

23
Q

How do you treat acute severe HTN in pregnancy?

A

> 160 systolic and/or >105 diastolic

IV hydralazine (vasodilator; SE - hypotension, angina) and labetalol (alpha and beta blocker; SE - severe bradyc. - give atropine)

Avoid in: asthma, congestive heart failure

24
Q

What is HELLP syndrome?

A

Pregnancy complication associated with:
Haemolysis, Elevated Liver enzymes, Low Platelets

Usually begins in 3rd trimester, associated with preeclampsia-eclampsia

Presents with:
Fatigue, oedema, headache, RUQ pain, nosebleed, seizure

Dx:
Anaemia, High AST and LDH, low platelets

25
Q

How do you manage eclampsia?

A

IV MGSO4 4gms over 5 mins then 1g/hr for 24hrs SLIDES

Finals - Obstetrics and Gynaecology (27 decks)

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