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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
When should treatment for HTN be offered in pregnant women?
As soon as the BP is above 140/90 Labetalol first Nifedipine Methyldopa is above not suitable
26
What should be monitored in a woman who develops gestational hypertension?
Blood Pressure- 1-2 times weekly | Urine Dip- Proteins checked 1-2 times weekly
27
For a pregnant woman admitted with gestational HTN that is severe (>160/110) what should be monitored?
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
28
After a woman who developed gestational diabetes has given birth when should her BP be checked?
Daily for the first two days Once between day 3 and 5 Review in 2 weeks and 6-8 weeks with GP
29
How does pre-eclampsia differ from gestational HTN?
HTN >140/90 + Proteinuria
30
If blood pressure goes above what level should a pregnant woman be admitted?
>160/110
31
What is the pathology underlying pre-eclampsia?
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
Why do platelets become depleted in pre-eclampsia?
A DIC process underpins this. There is endothelial dysfunction and thrombi form within the vessels, thrombus formation depletes platelets
33
Why is there haemolysis in HELLP syndrome?
Endothelial dysfunction leads to thrombus formation, red cells collide with thrombi leading to intra-vascular haemolysis.
34
Why does proteinuria occur in pre-eclampsia?
Hypertension and vasospasm processes cause renal injury, damage to the glomeruli allows for proteins to enter the urine.
35
Why are patients with pre-eclampsia at risk of developing oedema? Where can oedema form?
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
When does pre-eclampsia become eclampsia?
If seizures develop
37
What does HELLP syndrome stand for?
``` Haemolysis Elevated Liver enzymes Low Platelets ```
38
What tools can be used to assess risk in patients with Pre-eclampsia?
Full PIERS | PREP-S (Upto 34 weeks)
39
What features should prompt admission for patients with pre-eclampsia?
BP> 160/110 HELLP Syndrome Signs of eclampsia, pulmonary oedema, fetal compromise or anything else concerning
40
What is used to treat pre-eclampsia?
Labetalol Nifedipine Hydralazine Methyldopa if above two not suitable
41
What is the target BP in women with pre-eclampsia who are taking antihypertensives?
135/85
42
What initial investigations should be done for a woman with suspected pre-eclampsia?
Blood Pressure | Urine Dip
43
What further urine test should be done if a urine dip is positive for protein?
If a urine dip is 1+ positive for protein P:CR or A:CR should be checked
44
What P:CR level is diagnostic of proteinuria?
>30mg/mmol
45
What A:CR level is diagnostic of proteinuria?
>8mg/mmol
46
How often should BP be measured for a lady with pre-eclampsia?
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
If a woman is admitted with BP above 160/110 how often should her BP be measured during pregnancy?
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
What monitoring is required for a woman with pre-eclampsia?
``` 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
What are some symptoms of preeclampsia?
``` Headaches- frontal + bilateral Blurred vision Flashes in vision Swelling of feet, hands, face SOB RUQ Pain- Hepatic Injury ```
50
What are some signs of preeclampsia?
Brisk tendon reflexes Raised BP Pitting oedema Bibasal Crackles- Pulmonary oedema
51
What are some complications of preeclampsia?
``` IUGR/SGA Microaneurysms Cerebral Oedema Pulmonary Oedema Seizures- Eclampsia HELLP Syndrome Placental ischemia and Abruption ```
52
What features might indicate that an early birth is required in patients with preeclampsia?
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
If an early birth is planned what should be given and why?
Magnesium sulphate- it is neuroprotective | Corticosteroids- to encourage fetal lung maturation
54
Why is it important to monitor women with pre-eclampsia after they have given birth?
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
Does anti-hypertensive medication for preeclampsia need to continue after birth?
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
What features indicate it is safe to discharge a woman with preeclampsia after birth?
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
When should women with pre-eclampsia who have given birth be reviewed after discharge?
At two weeks and again at 6-8 weeks
58
How often should women with gestational HTN undergo fetal USS?
At diagnosis and repeat every 2-4 weeks if normal or when clinically indicated
59
How often should women with chronic HTN undergo fetal USS?
At 28, 32 and 36 weeks
60
When should the CTG be repeated in women with pre-eclampsia or severe gestational HTN?
CTG should be done at diagnosis | Repeat if a change in fetal movement, vaginal bleeding, abdo pain or a deterioration in maternal condition
61
What should be given if the woman has had an eclamptic fit?
Magnesium sulphate IV
62
When is magnesium sulfate indicated?
``` Eclamptic fit Ongoing or recurring severe headache N+V Epigastric pain Severe Hypertension Features of HELLP ```
63
What is the loading dose of magnesium sulphate?
4g IV over 10 to 15 minutes
64
What is the maintenance dose of magnesium sulphate?
1g per hour
65
After starting magnesium sulfate what should be done if the woman has a eclamptic fit?
2-4g should be given IV over 5-15 minutes
66
What should you advise women needing anti-hypertensive medication in the post natal period?
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
What antihypertensive agent should be offered in the postnatal period? What patient group is the exception to this?
Enalapril Unless afro-carribean- give nifedipine or amlodipine if previously successful with this
68
What antihypertensive agent should be given to black or afro caribbean women in the postnatal period?
Nifedipine | Amlodipine if previous success with this
69
What should be added if the initial antihypertensive agent used in the postnatal period is unsuccessful?
Labetalol or atenolol Or may be used in isolation
70
What antihypertensives should be avoided in breastfeeding mums postnatally?
Diuretics | ARBs
71
What is the overall risk of recurrence of hypertensive disorders in future pregnancy?
1 in 5 Women should be advised on the risk of recurrence
72
What risks should women who have had a hypertensive disease in pregnancy about for the future?
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
What are some risk factors for pre-eclampsia?
``` 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
Outline the management for eclampsia
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
What are some of the features of magnesium toxicity?
Respiratory depression Loss of tendon reflexes Decreased urine output due to renal toxicity
76
What should be given in the event of magnesium sulfate toxicity?
Calcium Gluconate IV (1g/10ml)

Obstetrics (2 decks)

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