Module 2 Flashcards
hypertension in pregnancy is defined as
BP above 140/90
chronic hypertension is
all hypertension before pregnancy occured
Renal hypertension complicates…
kidney disease of any kind. Sodium retention by the kidney leading to water retention and an increased blood volume is usually a factor
Phaeochromocytoma
adrenal gland tumour secreting the dopamine hormones adrenaline/noradrenaline
Coarctation of the aorta
narrowing of the aorta more common for patients with congenital heart disease
Cushings syndrome
excess of glucocorticoid hormones
Conns syndrome
excess of aldosterone hormone causing sodium retention and associated hypokalaemia
in 1st trimester of pregnancy, what happens to BP
marked vasodilation causes a drop in systemic vascular resistance which sees BP fall in all women – exaggerated effect in hypertensive women
complications of hypertension in pregnancy
Fetal growth restriction poor placentation – NICE advocates USS at 28-30 weeks and 32-34 weeks to indentify and monitor SGA
Placental abruption - 1% of pregnancies – smoking aids significantly to this risk
Severe hypertension - acute pharmacological management – labetalol, hydralazine, nifedipine
Super-imposed pre-eclampsia high risk, significant protein 300mg suggestive of preeclampsia – Uric acid raised
chronic hypertension - non-pregnancy treatment and care
- Majority of women with proven hypertension will be on one or more anti-hypertensive drugs – ACE inhibitor (enalapril or lisinopril) or an angiotensin receptor blocker (losartan or irbesartan) beta-blocker (atenolol)
- Low dose aspirin (75mg)
chronic hypertension - pre-conception issues and care
Referred to consultant OB so risks can be discussed and meds can be changed to labetalol or nifedipine , advised on lifestyle factors
medical management and care in pregnancy for hypertension
- Blood pressure meds reduced or stopped in first 20 weeks
- Labetalol – combined alpha and beta-blocker – first line – avoided in asthmatics
- Nifedipine – calcium-channel blocker (short and long acting)
- Methyldopa – centrally active
midwifery management and care - hypertension
- Antenatal visits
- SFH measurement
- BP
- Urine dipstick
- Ask about symptoms of preeclampsia
Medical management and care (labour issues) hypertension
- IOL from 37 weeks
- Usual meds
- Avoidance of syntometrine or ergometrine for 3rd stage
- CTG
- Consider epidural to aid BP
midwifery care labour hypertension
hourly BP
oxytocin 3rd stage
medical management postnatal hypertension
- No known adverse affects of anti-hypertensives on breast-fed babies
- Methyldopa changed to pre-pregnancy meds
- Review at 2 weeks of meds
midwifery management postnatal hypertension
- Target BP 140/90
- Daily BP checks day 1 and 2
- Encourage compliance with meds
- Contraceptive advice and lifestyle factors
preeclampsia
Pregnancy specific syndrome characterised by variable degrees of placental dysfunction and a maternal response featuring systemic inflammation and by the development of new hypertension and protein
risk factors of preeclampsia
- AMA
- Primip
- Hypertension
- Family history
- Previous hx
complications of preeclampsia
- Fetal (growth restriction, prematurity, placental abruption, intrauterine death)
- Mother (renal and liver failure, intracerebral bleeds, eclampsia, HELLP syndrome (haemolysis, elevated liver enzymes, low platelets), disseminated intravascular coagulation, liver rupture and death
pre-conception issues and care for preeclampsia
aspirin (75mg) from 12 weeks
medical management and care pregnancy preeclampsia
- Inpatient care
- BP should be treated with first-line oral labetalol if more than 150/100
- FBC, U&E, LFTs should be measured 2-3 times a week
- USS for growth, AFI and umbilical artery doppler
- TED stockings
midwifery management pregnancy preeclampsia
- Measure BP accurately
- Measure protein
- If any symptoms, transfer care to doctors and get opinions
- Psychological support
labour medical management preeclampsia
- Corticosteroids for fetal lung maturation
- Blood tests
- Delivery
- Avoid syntometrine or ergo
- BP closely observed
- CTG
- FBC , U&E and LFTs if not performed in last 2-3 days
- Continue antihypertensives
midwifery care preeclampsia labour
- Hourly BP
- Call for urgent help if review
- Do not limit second stage unless needed
- Oxytocin
- Prepare for preterm delivery
medical management postnatal preeclampsia
- Close observation of BP
- Obstetric review
- Repeat bloods 48-72 hours after if indicated
- Start antihypertensives if never medicated
- Continue meds – reduce once under 130/80
midwifery care postnatal preeclampsia
- BP check 4 times daily
- BP once 3-5 days
- Refer for medical care if BP >150/100
gestational hypertension
- Describes new hypertension in 2nd half of pregnancy in absence of protein
- 10% of women
severe preeclampsia and eclampsia
- Systolic BP >160mmHg or diastolic >110mmHg 2 times with protein and other clinical features
severe preeclampsia symptoms
- Severe headache
- Visual disturbances
- Epigastric pain
- Liver tenderness
- Clonus
- Papilloedema
- Platelet count <100
- Abnormal liver function
- HELLP syndrome
eclampsia
- One or more generalised convulsions on the background of pre-eclampsia
- Fatality rate 1.8% up to 35% of women suffer major complication
medical management and care antenatal severe preeclampsia and eclampsia
- BP high – urgent intervention
- IV administration of labetalol or hydralazine often becomes necessary and use follow local guidelines
- Fluid restriction is advised to reduce fluid overload
- Restriction – evidence of postpartum diuresis
- IV mag sulph – halves risk of eclampsia – 24 hr prior to delivery
- 4g slow IV 5 min – 1g/hr for 24 hr
- Continue after 24 hrs post birth or 24 hrs post seizure
- Recurrent seizures – 2-4g bolus or increase infusion
- Magnesium toxicity – reduced urine output, loss of deep tendon reflexes, decreased resps
- Diazepam and thiopentone can be used (rare)
midwifery care severe preeclampsia and eclampsia
- One-on-one care HDU, hourly output, reflexes, resp, BP
- Well documented fluid balance
- IV infusions
- six 12 hrly blood tests
postnatal cares preeclampsia and eclampsia
- 24-48 hr HDU
- Debrief
- 4 days inpatient , baby SCN
- BF support
HELLP syndrome
- Haemolysis (RBC rupture – drop in HB level)
- Elevated liver enzymes (raised alanine transaminase (ALT) or aspartate transaminase (AST) liver damage
- Low platelets (cell fragments involved in clotting process)
- Multi-system disorder characterised by activation of the coagulation system leading to increased deposition of the protein fibrin throughout the body
- Can occur postnatally
differential diagnoses - HELLP syndrome
- Acute fatty liver – nausea, vomiting
- Haemolytic uraemic syndrome-thrombotic thrombocytopenic pupura – haemolytic anaemia, low platelets, renal failure, severe headache
- Exacerbation of systemic lupus erythematosus (SLE) chronic inflammatory disease affecting multiple organs
complications - HELLP syndrome
- Disseminated intravascular coagulation
- Placental abruption
- Acute renal failure
- Pulmonary oedema
- Liver haematoma and rupture
cardiovascular disease
diseases of the heart and blood vessels
examples of CV disease
ischaemic heart disease
stroke
hypertensive heart disease
aortic aneurysms
atrial fibrillation
congenital heart disease
endocarditis
peripheral artery disease
rheumatic heart disease
-acquired
-caused by rheumatic fever
-Group A strep
-developing countries (ATSI)
cardiomyopathy
- inflamed, enlarged and weakened heart muscle
- hereditary
- viral infection/bacterial
- fungal or parastitic infection
- ischaemia
other valve, atrial and ventricular defects
- marfan syndrome (inherited disorder that affects connective tissue)
- Eisenmengers syndrome
- Down syndrome
- Brugada syndrome
- Wolff-parkinson white syndrome
effect on pregnancy - CV disease
- 4% affected
- most common cause of indirect maternal death in developed world
- pre-conception counselling
- accurate assessment
- collaborative team
treatment CV diseases
minimise complications
- Pharmacology – antihypertensives, diuretics
- Rest
- Optimum delivery method
- Appropriate anaesthesia
- Appropriate management PP
renal changes
- Changes to the renal system
- Higher renal plasma flow
- Higher GFR (glomerular filtration rate – how well your kidneys filter blood)
- Higher kidney size
- UTI rates higher
- Overt proteinuria
congenital renal disease
- Primary defects of the kidney tissue (parenchymal disease) *
- Obstruction of the urinary tract (hydronephrosis with obstruction)
- Hydronephrosis without obstruction
- Cystic diseases
- Metabolic diseases *
- Syndromes
acute renal disease
- Infection : e. coli
- Hemolytic uremic syndrome
- Nephrotic syndrome
- Poisioning
chronic renal disease
- Diabetes
- Hypertension
- Glomerulonephritis
- Cancer
- Medicine
measuring renal function
- Dipstick
- 24 hr collection – protein/creatine ratio
- Haematological creatinine
