Hypertensive states with pregnancy Flashcards
What are the types of hypertensive disorders during pregnancy?
- gestational hypertension -> hypertension occurring in the second trimester & resolves after delivery
- pre-eclampsia -> hypertension + proteinuria without/with edema
- eclampsia -> hypertension + proteinuria + seizures
- chronic hypertension -> antedating pregnancy or detected before 20 weeks & persistent after 12 weeks potpartum
- pre-eclampsia superimposed on chronic hypertension
What are the classifications of pre-eclampsia?
MILD
- BP: 140/90 mmhg or more
- Proteinuria: >300mg/24hrs
SEVERE
- BP: 160/110 mmhg
- proteinuria: >5gm/24hrs
How is pre-eclampsia characterized?
reduced organ perfusion secondary to vasospasm & endothelial activation
What are the risk factors for pre-eclampsia?
1- extremes of maternal age
2- primigravida
3- long birth intervals
4- black races
5- positive family history
6- multifetal pregnancy
7- maternal malnutrition
8- overweight mother
9- systemic illness
10- + past history of pregnancy induced hypertension
11- ART procedures
12- immunological diseases
13- fetal sex (more in males)
14- paternal factor
What is the recurrence rate for pregnancy induced hypertension?
20%
What is the anatomical pathology in the placenta in case of pre-eclampsia?
Early
- failure of trophoblastic invasion of spiral arteries
Late
- acute atherosis: due to accumulation of macrophages -> narrowing lumen -> placenta ischemia
- placental infarction -> insufficiency -> IUGR -> IUFD
What is the anatomical pathology in the kidney in case of pre-eclampsia?
Glomerular endotheliosis with hypertrophy of intra-capillary cells -> decreased GFR
What is the anatomical pathology in the liver in case of pre-eclampsia?
- periportal hemorrhage & necrosis
- subcapsular hemorrhage & necrosis
- severe: rupture of liver
increased liver enzymes
What is the anatomical pathology in the CNS in case of pre-eclampsia?
- vasospasm
- cerebral edema
- peticheal hemorrhages & thrombi
- infarction or hemorrhage
What is the clinical picture of pre-eclampsia?
ASYMPTOMATIC -> early mild
SYMPTOMATIC -> late, severe, complicated
- persistent headache
- epigastric & right upper abdominal pain
- persistent vomiting
- visual disturbances
- edema of limbs
What are the signs of pre-eclampsia upon clinical examination?
1- Hypertension
- BP 140/90 or >
- rise of 30mmHg systolic
- rise of 15mmHg diastolic
on 2 or more occasions 6 hours apart
- resolves within 6 weeks after delivery
2- Proteinuria
- urine collection for 24hrs shows > 300mg
3- Edema
- occult: abnormal rate of weight gain
- clinical: in non-dependent areas (hands & feet)
What are the complications of Pre-eclampsia on the mother?
1- HELLP syndrome -> hemolysis, elevated liver enzymes, low platelet count
2- Eclampsia
3- Acute renal failure -> acute tubular necrosis or bilateral renal cortical stenosis
4- Abruptio placentae
5- cardiac failure
6- acute pulmonary edema
7- intra-cranial hemorrhage
8- hepatic rupture
9- DIC
10- retinal detachement & cortical blindness
What are the fetal complication of pre-eclampsia?
- IUGR
- IUFD
- prematurity (iatrogenic)
What are the investigations done for pre-eclampsia?
1- urine analysis -> proteinuria, specific gravity, casts
2- serum uric acid -> hyperuricemia early (n = 3-5.5)
3- kidney functions -> blood urea & creatinine
4- liver functions -> HELLP syndrome
5- hematology -> elevated hematocrit, hemolysis
6- coagulation profile
7- fundus examination
How do we investigate the fetal wellbeing in pre-eclampsia?
1- fetal kick count (after 28 weeks)
2- Non-stress test
3- Ultrasound -> fetal weight, amniotic fluid index, biophysical profile
4- doppler ultrasound of umbilical blood flow: early diastolic notch & decreased end blood flow
How do we prevent pre-eclampsia in pregnancy?
low dose aspirin 75 - 80mg daily
in high risk patients
How are mild cases of pre-eclampsia treated?
- mature fetus (>37 weeks) -> deliver
- preterm -> achieve fetal maturity
1- antenatal visits twice a week
2- rest in left lateral position
3- ample proteins
4- salt restriction
5- antihypertensives: a-methyl dopa, labetalol, nifedipine (keep BP 135/85 mmHg)
6- low dose aspirin 75-81mg
7- MgSO4 at 24-34 weeks for neuroprotection
8- corticosteroids at 24-34 weeks for lung maturity
What should be done at every prenatal visit for mother with mild pre-eclampsia?
Close maternal monitoring
- ask about warning symptoms
- BP, body weight, urine output, hyper-reflexia
- lab assessment: proteinuria, uric acid, liver functions
Close fetal monitoring
- kick count
- non-stress test
- ultrasound
- umbilical artery duplex
if there is any deterioration -> termination of pregnancy
How is severe pre-eclampsia managed?
Severe PE without complications -> treat like mild but antenatal visits 3 times a week & higher doses of
- oral hypertensives: labetalol, nifedipine, a-methyl dopa
- corticosteroids
- MgSO4
Severe PE with complications -> immediate delivery
1- hospitalization
2- antihypertensives -> parenteral HYDRALAZINE (5mg IV then 5mg every 20 minutes)
-> Labetalol: 10-20-30-40-80mg IV repeated every 20 mins
3- Prophylactic magnesium sulfate (MgSo4): inital dose 4g IV then 1g/hr for 24 hours
4- antepartum corticosteroids
give proper epidural analgesia then
5- if cervix is not ripe -> C section
6- if cervix is ripe -> prostaglandins, AROM, oxytocin -> vaginal delivery
close observation after delivery
What are the characteristics of an Eclamptic fit?
1- Premonitory stage -> 1/2 min: twitches of face & hands, rolling up of eyes
2- Tonic stage -> 1/2 min: generalized tonic spasm -> opisthotonus -> no respiration -> cyanosis
3- Clonic (dome) stage -> 1/2 - 1 min: tongue may be bitten & breathing is stertorous
4- Coma stage -> patient may recover or fit again
How is eclampsia managed?
1- General measures
- patient kept in a dark quite room
- patient lies on her left side with head down
- free patent air & O2 given by mask
- urinary catheter inserted to record volume
2- Control fits
- magnesium sulfate: loading dose 4gm IV over 20min then maintenance dose 1gm/hr for 24hrs (desired level is 4-7mEq/L)
- diazepam: IV 5-10mg
3- Control BP -> hydralazine or labetalol parentral
4- immediate delivery -> after controlling fits & BP
5- MgSO4 should be continued for 24hrs after delivery to guard against postpartum fits
What are the precautions for magnesium sulfate use?
Before giving next dose, check:
1- urine output: not less than 30ml/hr
2- respiratory rate: not less than 16/min
3- patellar reflex must be present
respiratory & cardiac arrest indicate toxicity
- treat with antidote: Calcium gluconate 1gm (10%) 10ml IV slowly over 3-5 mins
