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MRCOG Part 2 > Maternal Medicine - Hypertensive disease in pregnancy > Flashcards

Maternal Medicine - Hypertensive disease in pregnancy Flashcards

1
Q

What is the International Society of Hypertension in Pregnancy definition of pre-eclampsia?

A

Gestational hypertension of at least 140/90 mmHg on two separate occasions ≥4 hours apart accompanied by significant proteinuria of at least 300 mg in a 24-hour collection of urine, arising de novo after the 20th week of gestation in a previously normotensive woman and resolving completely by the 6th postpartum week.

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2
Q

Pre-eclampsia complicates what percentage of pregnancies?

A

2-8%

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3
Q

Pre-eclampsia causes what % of direct maternal deaths in the UK?

A

15%

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4
Q

How many women worldwide die of pre-eclampsia each year according to WHO?

A

70,000

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5
Q

What is the incidence of eclampsia?

A

2.5/10,000

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6
Q

What happens to placental growth factor in pregnnacy?

A

Increases, then decreases

Lower levels seen in pre-eclampsia

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7
Q

How many stillbirths without congenital abnormality occurred in mothers with pre-eclampsia?

A

5%

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8
Q

How many women in their first pregnancy will give birth below 34/40 as a result of pre-eclampsia?

A

1 in 250 (0.4%)

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9
Q

How many preterm births are from hypertensive disorders?

A

8-10%

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10
Q

How many pre-term and term births <10th centile are to women with pre-eclampsia?

A

20-25% preterm

14-19% term

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11
Q

What are the ‘high risk’ factors for pre-eclampsia?

A 
Hypertensive disease in previous pregnancy
CKD
Autoimmune disease (e.g. SLE, APS)
T1 or T2 diabetes
Chronic hypertension
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12
Q

What BP limit should be aimed for in chronic hypertension?

And with evidence of target-organ damage?

A

150/100 (diastolic not lower than 80)

140/90

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13
Q

When should all women with pre-eclampsia have a medical review postnally?

A

6-8/52

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14
Q

What is the risk of developing gestational hypertension following a pregnancy complicated by pre-eclampsia?

A

13-53% (1 in 8 to 1 in 2)

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15
Q

What is the risk of developing PET following a pregnancy complicated by PET?

A

16% (1 in 6)

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16
Q

What is the risk of developing PET following a pregnancy complicated by severe PET, HELLP or eclampsia leading to birth <34/40?

A

25%

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17
Q

What is the risk of developing PET following a pregnancy complicated by PET leading to birth <28/40?

A

55%

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18
Q

What are the moderate risk factors for PET?

A 
First pregnancy
Age >40
Pregnancy interval >10 years
FHx PET
BMI => 35 at booking
Multiple pregnancy
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19
Q

When should women with chronic hypertension/gestational hypertension be delivered?

A

Not before 37/40 if BP < 160/110, with or without antihypertensive treatment

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20
Q

What is the PN follow up for women with chronic hypertension?

A

BP measurement:
OD first 2/7, at least once D3-5, then as clinically indicated if antihypertensive changed

Review treatment 2/52 after delivery; aim BP <140/90

Review at 6-8/52

21
Q

How are women with mild gestational hypertension managed?

A

Not admitted/treated
BP once a week
Test proteinuria each visit
Routine antenatal bloods

If high risk/<32/40 - BP and urine twice weekly

22
Q

How are women with moderate gestational hypertension managed?

A 
Not admitted
Commence labetalol (aim <150/80-100)
BP twice weekly
Proteinuria test each visit
Test bloods - no further unless proteinuria develops
23
Q

How are women with severe gestational hypertension managed?

A 
Admit until BP =<159/109
Labetalol (aim <150/80-100)
BP QDS
Daily proteinuria test
Bloods at presentation, then weekly

Once discharged - BP and urine twice weekly, blood tests weekly

24
Q

What is the postnatal follow up for women with gestational hypertension?

A

BP measurement:
OD first 2/7, at least once D3-5, then as clinically indicated if antihypertensive changed

Consider reducing Rx if <140/90; reduce if <130/80
Start treatment if >149/99

Medical review at 2/52 if still on treatment

Review at 6-8/52 - if still on treatment refer for speciaslist assessment of their hypertension

25
Q

How are women with mild pre-eclampsia managed?

A

Admit but don’t treat
BP QDS
Don’t repeat proteinuria test
Twice weeklly bloods

26
Q

How are women with moderate pre-eclampsia managed?

A 
Admit
Commence labetalol (aim <150/80-100)
BP QDS
Don't repeat proteinuria test
Bloods three times a week
27
Q

How are women with severe pre-eclampsia managed?

A 
Admit
Commence labetalol (aim <150/80-100)
BP >QDS as indicated
Don't repeat proteinuria test
Bloods three times a week
28
Q

When should pregnancies complicated by PET deliver?

A

Not <34/40 unless severe refractory or maternal/fetal indications

34-36+6 depending on maternal/fetal condition, availability of NICU, risk factors

Within 24-48 hours if mild-moderate >37+0

29
Q

What is the postnatal follow up for women with pre-eclampsia if not on antihypertensives?

A

BP measurement:
QDS while inpatient
At least once D3-5, then alternate days if abnormal until normal

Start antihypertensives if BP =>150/100

Medical review 6-8/52

30
Q

What is the postnatal follow up for women with pre-eclampsia if taking antihypertensives?

A

Consider reducing Rx if <140/90; reduce if <130/80
Start treatment if >149/99

Transfer to community care if no symptoms, BP<=149/99, bloods stable/improving

Medical review at 2/52 and 6-8/52

31
Q

When should PET/proteinuria bloods be repeated postnatally?

A

48-72 hours post delivery - if normal don’t repeat
If abnormal repeat as indicated, and at 6-8/52

Proteinuria - if 1+ at 6-8/52, review kidney function at 3/12 and consider renal referral

32
Q

What is the ultrasound regime for chronic hypertension?

A

28-30, then 32-34 - if normal no further USS unless clinically indicated

33
Q

What is the ultrasound regime for mild-moderate gestational hypertension?

A

Only if diagnosed <34/40

34
Q

What is the CTG/ultrasound regime for severe gestational hypertension or pre-eclampsia?

A

CTG at diagnosis then 2/52 USS

Repeat CTG if change FMs, bleeding, abdo pain, maternal condition detriorates

35
Q

Which women are high risk for pre-eclampsia and what is the ultrasound regime?

A 
Previous:
Severe PET
PET needing birth <34/40
PET with SGA <10th centile
IUD
abruption

Scan 4/52 from 28-30/52 (or 2/52 earlier than previous onset if <28/40)

36
Q

What is the rate of recurrence in previous gestational hypertension?

A

16-47% (1 in 6 to 1 in 2)

37
Q

What is the rate of PET in previous gestational hypertension?

A

2-7% (1 in 50 to 1 in 14)

38
Q

Which ACE inhibitors may be used when breastfeeding?

A

Enalapril (not in prem); captopril if informed consent

39
Q

Which b-blockers may be used when breastfeeding?

A

labetalol, atenolol, metoprolol

40
Q

What should be considered concurrently with 1st dose of IV hydralazine antenatally?

A

500ml crystalloid

41
Q

What is the dose of MgSO4?

A

4g loading dose over 5min followed by 1g/hr over 24hrs

Repeat doses of 2-4g over 5 mins if recurrent seizures

42
Q

What signs/symptoms indicate severe PET when there is mild/moderate hypertension?

A 
Severe headache
Visual disturbance
Epigastric pain/vomiting
Papilloedema
Clonus >=3
Liver tenderness
HELLP
Plt <100
Abnormal LFTs >70
43
Q

What % of women who developed PET <32/40 will have an abnormal thrombophilia screen?

44
Q

Which biochemical markers are altered in pregnancies affected by pre-eclampsia?

A 
Decreased VEGF (proangiogenic factor)
Increased sFlt1 (antiangiogenic factor)
45
Q

What risk factors require that a woman should take aspirin in pregnancy

A

Major: 1 risk factor requires aspirin:

  1. Chronic hypertension
  2. Hypertensive disease in previous pregnancy
  3. Autoimmune disease eg lupus/ APS
  4. Diabetes
  5. Chronic kidney disease

Minor: 2 or more of

  1. First pregnancy
  2. Bmi over 35
  3. Age over 40
  4. Pregnancy interval over 10 yrs
  5. FHx pre eclampsia
  6. Multiple pregnancy
46
Q

By what % does aspirin reduce the risk of developing PET in women at risk of the condition?

A

17%

NNT = 19

47
Q

What are the placental biomarkers implicated in PET?

A

*PLGF (Placental Like Growth Factor - pro-angiogenic)
*PAPP-A (Pregnancy associated plasma protein)
sFLT-1 (soluble FMS-like tyrosine kinase - antiangiogenic)
sENG (soluble endoglin - antiangiogenic)

48
Q

What is the NNT with low dose aspirin for women with a moderate risk factor for PET to prevent one case?

49
Q

What is the NNT with MgSO4 in PET to prevent one seizure?

MRCOG Part 2 (97 decks)

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