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Obstetrics > Hypertensive Disorders of Pregnancy > Flashcards

Hypertensive Disorders of Pregnancy Flashcards

1
Q

What blood pressures define hypertension?

A

SBP>140

DBP>90

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2
Q

What is the difference between chronic hypertension and gestational hypertension?

A

Chronic hypertension is hypertension that develops before 20 weeks gestation/was already present before pregnancy

Gestational hypertension develops after 20 weeks. Pre-eclampsia is gestational HTN with proteinuria, organ dysfunction or uteroplacental insufficiency

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3
Q

What blood pressure should be targeted when managing hypertension in pregnancy?

A

135/85 or below

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4
Q

How does pre-eclampsia differ from gestational hypertension?

A

Pre-eclampsia is HTN with proteinuria

Gestational HTN does not have proteinuria

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5
Q

What should women with pre-existing HTN be told if they become pregnant regarding their medication?

A

ACEi/ARBs/Thiazide diuretics should be stopped as they increase the risk of congenital abnormalities. Alternative medications should be used if a woman is hypertensive during pregnancy

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6
Q

What is the first line medication for the management of HTN during pregnancy?

A

Labetalol

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7
Q

What should be used if labetalol is not suitable?

A

Nifedipine

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8
Q

What medication might be considered if Labetalol or Nifedipine cannot be used?

A

Methyldopa

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9
Q

If a woman is started on antihypertensive medications during pregnancy what blood pressure should be targeted?

A

135/85

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10
Q

When should methyldopa be considered in the management of HTN in pregnancy?

A

When both labetalol and nifedipine are not suitable

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11
Q

How does labetalol work?

A

It is a beta blocker

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12
Q

What is the fetus at increased risk of if beta blockers are taken during pregnancy?

A

Small for Gestational Age/IUGR

Bradycardia

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13
Q

How does Nifedipine work?

A

It is a calcium channel blocker of the dihydropyridine class.

Note- compared to other types of calcium channel blockers DHPs have are more selective to calcium channels of the vasculature (not the heart like others). Amlodipine is another example of a DHP calcium channel blocker more selective for the vasculature. Whereas Verapamil is a calcium channel blocker more selective to the heart, this is a class IV antiarrhythmic.

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14
Q

What should be given from 12 weeks for women with HTN during pregnancy?

A

75-150 mg Aspirin daily

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15
Q

When should aspirin be offered to pregnant women with HTN?

A

From 12 weeks onward. This is 75-150mg.

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16
Q

What is PIGF?

A

Placental Growth Factor

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17
Q

Why might PIGF levels be checked?

A

It investigates for patients with placental dysfunction and those at risk of pre-eclampsia

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18
Q

When should PIGF testing be offered to women with chronic HTN in pregnancy?

A

Between 20 and 35 weeks.

This tests for placental dysfunction and those at risk of developing preeclampsia. It alone cannot be used to diagnose preeclampsia. Check this.

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19
Q

How often should blood pressure be measured for women with chronic HTN in pregnancy?

A

If HTN is uncontrolled weekly appointments should be made to measure the blood pressure and check urine for proteins.

If HTN is well controlled antenatal appointments should be every 2-4 weeks to check BP and urine.

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20
Q

What should be done postnatally for women with chronic HTN in pregnancy?

A

BP checked daily for the first two days after birth
At least once between days 3-5
Review appointment with GP/Specialist 2 weeks later. Further review at 6-8 weeks.

If still hypertensive treatment should be started aiming to keep blood pressure below 140/90.

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21
Q

Can methyldopa be continued after a women with HTN has given birth?

A

No it should be stopped within 2 days and changed to a different antihypertensive according to NICE

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22
Q

If a woman is hypertensive during pregnancy how do you differentiate between chronic HTN and gestational HTN?

A

If present before 20 weeks gestation- Chronic HTN

If develops after 20 weeks gestation- Gestational HTN

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23
Q

Above what BP should a woman who is hypertensive during pregnancy be admitted to hospital?

A

160/110 or above should be admitted to hospital for blood pressure to be monitored every 15-30 minutes until it falls below 160/110. This is severe HTN

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24
Q

What pressure would indicate severe HTN?

A

160/110 or above- this requires admission for BP monitoring every 15-30 minutes.

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25
Q

When should treatment for HTN be offered in pregnant women?

A

As soon as the BP is above 140/90

Labetalol first
Nifedipine
Methyldopa is above not suitable

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26
Q

What should be monitored in a woman who develops gestational hypertension?

A

Blood Pressure- 1-2 times weekly

Urine Dip- Proteins checked 1-2 times weekly

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27
Q

For a pregnant woman admitted with gestational HTN that is severe (>160/110) what should be monitored?

A

BP every 15-30 minutes
Urine dip daily
FBC, LFTs, Creatinine at presentation and weekly
Fetal USS at diagnosis and if normal repeat every 2 weeks
CTG at diagnosis and repeat if indicated
Fetal heart should be auscultated at every appointment

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28
Q

After a woman who developed gestational diabetes has given birth when should her BP be checked?

A

Daily for the first two days
Once between day 3 and 5
Review in 2 weeks and 6-8 weeks with GP

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29
Q

How does pre-eclampsia differ from gestational HTN?

A

HTN >140/90 + Proteinuria

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30
Q

If blood pressure goes above what level should a pregnant woman be admitted?

A

> 160/110

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31
Q

What is the pathology underlying pre-eclampsia?

A

Abnormal spiral arteries form that are not the normal high diameter with high flow. This causes reduced blood flow to the placenta, termed uteroplacental insufficiency. In response the placental releases cytokines which cause endothelial dysfunction including vasoconstriction and vasospasm. This causes rises in blood pressure and partnered with vasospasm can cause organ dysfunction.

32
Q

Why do platelets become depleted in pre-eclampsia?

A

A DIC process underpins this. There is endothelial dysfunction and thrombi form within the vessels, thrombus formation depletes platelets

33
Q

Why is there haemolysis in HELLP syndrome?

A

Endothelial dysfunction leads to thrombus formation, red cells collide with thrombi leading to intra-vascular haemolysis.

34
Q

Why does proteinuria occur in pre-eclampsia?

A

Hypertension and vasospasm processes cause renal injury, damage to the glomeruli allows for proteins to enter the urine.

35
Q

Why are patients with pre-eclampsia at risk of developing oedema? Where can oedema form?

A

HTN and loss of proteins reduces the oncotic pressure. Oedema can form peripherally, pulmonary or cerebral oedema. It is the cerebral oedema that leads to the seizures of eclampsia

36
Q

When does pre-eclampsia become eclampsia?

A

If seizures develop

37
Q

What does HELLP syndrome stand for?

A 
Haemolysis
Elevated
Liver enzymes
Low 
Platelets
38
Q

What tools can be used to assess risk in patients with Pre-eclampsia?

A

Full PIERS

PREP-S (Upto 34 weeks)

39
Q

What features should prompt admission for patients with pre-eclampsia?

A

BP> 160/110
HELLP Syndrome
Signs of eclampsia, pulmonary oedema, fetal compromise or anything else concerning

40
Q

What is used to treat pre-eclampsia?

A

Labetalol
Nifedipine
Hydralazine
Methyldopa if above two not suitable

41
Q

What is the target BP in women with pre-eclampsia who are taking antihypertensives?

A

135/85

42
Q

What initial investigations should be done for a woman with suspected pre-eclampsia?

A

Blood Pressure

Urine Dip

43
Q

What further urine test should be done if a urine dip is positive for protein?

A

If a urine dip is 1+ positive for protein P:CR or A:CR should be checked

44
Q

What P:CR level is diagnostic of proteinuria?

A

> 30mg/mmol

45
Q

What A:CR level is diagnostic of proteinuria?

A

> 8mg/mmol

46
Q

How often should BP be measured for a lady with pre-eclampsia?

A

Every 48 hours if BP is between 140-159

Note if it is above 160/110 admission to hospital is required where it should be checked every 15-30 minutes until it falls below 160/110.

47
Q

If a woman is admitted with BP above 160/110 how often should her BP be measured during pregnancy?

A

Every 15-30 minutes until it falls below 160/110. After this is should be checked at least 4 times daily as an inpatient.

48
Q

What monitoring is required for a woman with pre-eclampsia?

A 
BP
Bloods- FBC, U&Es, Creatinine, LFTs
Fetal USS- if normal every 2 weeks
CTG- if normal every 2 weeks
Fetal Heart Auscultation- every antenatal appointment

Note- Proteinuria quantification does not need to be done repeatedly unless new signs/sx or diagnostic uncertainty

49
Q

What are some symptoms of preeclampsia?

A 
Headaches- frontal + bilateral
Blurred vision
Flashes in vision
Swelling of feet, hands, face
SOB
RUQ Pain- Hepatic Injury
50
Q

What are some signs of preeclampsia?

A

Brisk tendon reflexes
Raised BP
Pitting oedema
Bibasal Crackles- Pulmonary oedema

51
Q

What are some complications of preeclampsia?

A 
IUGR/SGA
Microaneurysms
Cerebral Oedema
Pulmonary Oedema
Seizures- Eclampsia
HELLP Syndrome
Placental ischemia and Abruption
52
Q

What features might indicate that an early birth is required in patients with preeclampsia?

A

Inability to control maternal BP
Pulmonary oedema with low O2 Sats
HELLP
Neurological features, such as intractable headache or eclampsia
Placental abruption
Or any other severe clinical picture, this is only decided by a senior obstetrician

53
Q

If an early birth is planned what should be given and why?

A

Magnesium sulphate- it is neuroprotective

Corticosteroids- to encourage fetal lung maturation

54
Q

Why is it important to monitor women with pre-eclampsia after they have given birth?

A

A large amount of the seizures of eclampsia occur after the woman has given birth

BP should be monitored at least 4 times daily whilst an inpatient and at least once between days 3 and 5.

55
Q

Does anti-hypertensive medication for preeclampsia need to continue after birth?

A

Yes it should be continued for at least 6 weeks but reduce if BP falls below 130/80

Unless it is methyldopa which should be stopped within 2 days of birth and a different anti-hypertensive used.

56
Q

What features indicate it is safe to discharge a woman with preeclampsia after birth?

A

No symptoms of pre-eclampsia
Blood pressure with or without treatment less than 150/100
Blood results stable or improving

Basically an improving picture or stable without severe HTN

Should be reviewed at 2 weeks and again at 6-8 weeks

57
Q

When should women with pre-eclampsia who have given birth be reviewed after discharge?

A

At two weeks and again at 6-8 weeks

58
Q

How often should women with gestational HTN undergo fetal USS?

A

At diagnosis and repeat every 2-4 weeks if normal or when clinically indicated

59
Q

How often should women with chronic HTN undergo fetal USS?

A

At 28, 32 and 36 weeks

60
Q

When should the CTG be repeated in women with pre-eclampsia or severe gestational HTN?

A

CTG should be done at diagnosis

Repeat if a change in fetal movement, vaginal bleeding, abdo pain or a deterioration in maternal condition

61
Q

What should be given if the woman has had an eclamptic fit?

A

Magnesium sulphate IV

62
Q

When is magnesium sulfate indicated?

A 
Eclamptic fit
Ongoing or recurring severe headache
N+V
Epigastric pain
Severe Hypertension
Features of HELLP
63
Q

What is the loading dose of magnesium sulphate?

A

4g IV over 10 to 15 minutes

64
Q

What is the maintenance dose of magnesium sulphate?

A

1g per hour

65
Q

After starting magnesium sulfate what should be done if the woman has a eclamptic fit?

A

2-4g should be given IV over 5-15 minutes

66
Q

What should you advise women needing anti-hypertensive medication in the post natal period?

A

Very small amounts pass into the breast milk and so it is thought to be safe. Advice to monitor for drowsiness, lethargy, pallour, cold peripheries or poor feeding if these develop seek medical attention

67
Q

What antihypertensive agent should be offered in the postnatal period? What patient group is the exception to this?

A

Enalapril

Unless afro-carribean- give nifedipine or amlodipine if previously successful with this

68
Q

What antihypertensive agent should be given to black or afro caribbean women in the postnatal period?

A

Nifedipine

Amlodipine if previous success with this

69
Q

What should be added if the initial antihypertensive agent used in the postnatal period is unsuccessful?

A

Labetalol or atenolol

Or may be used in isolation

70
Q

What antihypertensives should be avoided in breastfeeding mums postnatally?

A

Diuretics

ARBs

71
Q

What is the overall risk of recurrence of hypertensive disorders in future pregnancy?

A

1 in 5

Women should be advised on the risk of recurrence

72
Q

What risks should women who have had a hypertensive disease in pregnancy about for the future?

A

Risk of recurrence in future pregnancy
Risk of CV disease, Stroke, MI, HTN etc

Therefore important to educate about reduced risk- loose weight, exercise, stop smoking, diet…

73
Q

What are some risk factors for pre-eclampsia?

A 
Chronic HTN
Gestational HTN
BMI>35
Age>40
FHx of Pre-eclampsia
Previous pregnancies with hypertensive disorders
Pregnancy interval >10 years
Multiple fetuses
AI Disease- SLE, Anti-Phospholipid, Thrombophilia
74
Q

Outline the management for eclampsia

A

This is an obstetric emergency

Initial ABC Approach and get senior help
Continuously monitor maternal saturations and BP
Magnesium Sulfate 4g IV loading dose and 1g/hr after

75
Q

What are some of the features of magnesium toxicity?

A

Respiratory depression
Loss of tendon reflexes
Decreased urine output due to renal toxicity

76
Q

What should be given in the event of magnesium sulfate toxicity?

A

Calcium Gluconate IV (1g/10ml)

Obstetrics (2 decks)

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