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My MRCOG Part 2 > NICE Hypertension in Pregnancy > Flashcards

NICE Hypertension in Pregnancy Flashcards

1
Q

What proportion of UK population has HTN?

A

10-15%

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2
Q

Define HTN in pregnancy.

A

BP >140/90 x2 readings.

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3
Q

Define oedema in pregnancy.

A

Pitting oedema
Weight gain 2.3kg in 1 week.

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4
Q

Can aspirin be bought OTC in pregnancy?

A

No as it is used off licence in pregnancy.

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5
Q

When is aspirin taken in pregnancy and what dose?

A

75-150mg
12 weeks until delivery.

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6
Q

What are the high risk factors for developing HTN in pregnancy?
(i.e. if one risk present, give Aspirin)

A

HTN in previous pregnancy (PET or HTN).
CKD.
Autoimmune disease (SLE, APLS).
Type 1 or 2 Diabeties.
Chronic HTN.

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7
Q

What are the moderate risk factors for developing HTN in pregnancy?
(i.e. if 2 present then give Aspirin).

A

P0
Age 40+
BMI >35
Family history PET
Multi-foetal pregnancy.

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8
Q

What should be used to test for protinuria in pregnancy?

A

An automated reagent-strip reading device for dipstick screening.

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9
Q

If dipstick is positive for protein, what should be used to further investigate?

A

Albumin: creatinine ratio
(+ve if >8mg/mmol)

PCR
(Significant if >30mg/mmol)

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10
Q

When should urine sample be taken to screen for protinuria?

A

Any time EXCEPT first morning wee.

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11
Q

Women with chronic HTN who are on ACE-i or ARBs, what should happen to these medications when fall pregnant?

A

Increased risk of congenital abnormality.
STOP ACE-i/ARB and change to another anti-HTN within 2 working days.

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12
Q

What should happen to thiazide or thiazide-like diuretics in pregnancy?

A

MAY be increased risk of congenital abnormality therefore discuss alternatives if planning pregnancy.

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13
Q

What BP should be aimed for in pregnancy for women with chronic HTN on Medication?

A

BP < 135 / 85

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14
Q

What should happen to methyl-dopa in the post natal period?

A

Must be stopped by day 2 PN and changed for another anti-HTN.

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15
Q

What US FU should be arranged for women with chronic HTN?

A

US growth, LV and doppler at 28, 32 and 36 weeks.

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16
Q

What PN monitoring should be carried out in women with chronic HTN?

A

BP OD for 2 days.
BP once between day 3 and 5.
Aim BP <140/90.

Cont anti-HTN medication and rv with GP at 2/52s.

GP medical review at 6-8 weeks.

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17
Q

What are the risk factors for developing gestational HTN?

A

P0
Pregnancy interval >10 years
Age 40+
Family history of PET
Multi-foetal pregnancy
BMI >35
Gestational age at presentation
Previous HTN or PET
Vascular disease
Kidney disease.

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18
Q

When should a women with gestational HTN be admitted?

A

If BP > 160/110.

Can be managed as outpatient if their BP falls below this.

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19
Q

What is the target BP for women with gestational HTN on treatment?

A

BP < 135 / 85

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20
Q

How frequently should a urine dip be carried out for women with gestational HTN?

A

1 - 2 times per week (i.e. when BP is taken).

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21
Q

Should PLGF be carried out in women with gestational HTN? If so, when?

A

Yes, if there is a suspicion of PET. This should be carried out between 20-36+6.

22
Q

What foetal monitoring should be carried out for women with gestational GTN?

A

USS (growth, LV and Doppler at diagnosis then 2-4 weekly).
CTG only if clinically indicated.

23
Q

What post natal management should be implemented for women with gestational HTN?

A
  1. Continue HTN medication (swap methyldopa by D2).
  2. Advise length of PN HTN treatment required is likely similar to length of AN anti-HTN medication was required.
  3. Reduce medication if BP <130/80.
  4. Stop and change methyldopa by D2.
  5. If non medicated, start medication if BP >150/100.
  6. GP medication review at 2 weeks and medical review at 6-8 weeks.
24
Q

Define PET.

A

Persistant HTN
After 20/40
With end organ damage (e.g. protinuria).

25
Q

When should women with PET be admitted for surveillence?

A
  1. Sustained BP>160.
  2. New or persistent rise in:
    Creatinine > 90micromol/L or 1mg/100mls,
    Alanine transaminase >70 or twice upper limit,
    Platelets <150.
  3. Signs of impending eclampsia or pulmonary oedema.
  4. Suspected foetal compromise.
  5. Any other clinically concerning signs.
26
Q

What risk predictor systems can be used for women with PET?

A

FullPIERS at any time in pregnancy.
PREP-S u pto 34/40.

(neither predicts foetal outcome).

27
Q

What target BP should be aimed for in women diagnosed with PET?

A

BP <135 / 85

28
Q

In women with PET, how often should their BP be monitored?

A

At least every 48 hours if BP >140/90 (more if admitted).

15-30 minutely if BP >160/110.

29
Q

When should urine dipstick be used in PET?

A

To diagnose, then does not need to be repeated.

30
Q

How often should bloods be repeated for women with PET?

A

If BP > 140/90, then 2x per week.

If BP > 160/110, then 3x per week.

31
Q

How often should USS be carried out in women with PET?

A

2 weekly.

32
Q

When should delivery be carried out in women with PET < 37/40?

A
  1. Unable to control BP despite 3 anti-hypertensive medications.
  2. Maternal sats < 90%.
  3. Progressive deterioration in bloods.
  4. Neurological features.
  5. Placental abruption.
  6. Reversed end diastolic flow in umbilical artery Doppler.
  7. Poor CTG.
  8. IUFD.
33
Q

When should magnesium sulphate be given?

A

Up to 29+6/40.

34
Q

How frequently should BP be checked in PN period for women diagnosed with PET?

A

QDS as inpatient.

If not medicated:
..OD on days 3-5.
..Alternate days until BP normalised (if abnormal on D3-5).

If medicated:
..Every 1-2 days up to 2 weeks after transfer to community.

35
Q

When should medication be started in the PN period for women diagnosed with PET?

A

If BP >150/100.

36
Q

When should anti hypertensive medication be reviewed / stopped in the PN period for women diagnosed with PET?

A

Review if BP < 140/90.
Reduce if BP <130/80.

37
Q

How often should BP be measured in labour?

A

every 15 - 30 mins if BP >160/110.

38
Q

In women with HTN in labour, is it necessary to shorten their second stage?

A

Not necessarily?

39
Q

When should a woman with PET be referred for level 3, ITU, care?

A

If they require ventilation.

40
Q

When should women with PET be referred for level 2, HDU, care?

A

Eclampsia
HELLP
Haemorrhage
Hyperkalaemia
Severe oligouria
Coagulation support
Requiring a 4th anti-HTN medication
Cardiac failure
Abnormal neurology
Initial stabilisation.

41
Q

According to the Collaborative Eclampsia Trial regime, what dose of MgSO4 should be used in management of PET?

A

Bolus of 4g over 5-15 mins.
Then 1g/hr for 24 hours (or 24 hours after last seizure).

If recurrent fits, a further bolus of 2-4g can be given.

42
Q

What are the foetal side effects of MgSO4?

A

Hypocalcaemia
Hypermagnesemia
(if prolonged used of more than 5-7 days).

43
Q

What are the signs of MgSO4 toxicity?

A
  1. Absent tendon reflexes.
  2. Pulmonary oedema.
  3. Cardiac arrhythmia.
  4. Cardiac arrest.
44
Q

What treatment should be given in MgSO4 toxicity?

A

10mls Calcium Gluconate (10% solution AKA 2.2mmol per vile) over 10 minutes by slow IVI.

Need cardiac monitoring due to arrhythmia potential.

45
Q

What anti hypertensive medications are available in pregnancy?

A
  1. Labetalol (not in asthma).
  2. Nifedipine (1st in black women).
  3. Methyl Dopa (stop by D2 PN).
  4. Enanopril PN (monitor renal function and potassium).
46
Q

If a women has HTN in this pregnancy, what is her chance of developing any hypertensive disorder in her next pregnancy?

A

20%
(1 in 5)

47
Q

If a woman has PET in this pregnancy, what is her chance of developing:
1. Any HTN
2. PET
3. GHTN
in next pregnancy?

A
  1. 14% (1 in 7).
  2. 33% if birth 28-34/40
    but 23% if birth 34-37/40.
  3. 7% (1 in 14).
48
Q

In women with chronic HTN, what is the chance of developing PET or GHTN in pregnancy?

A

2% PET

3% GHTN.

49
Q

In women with GTH, what is the risk of:
- Any HTN
- PET
- GTH
in next pregnancy?

A

Any HTN - 9% (1 in 11)

PET 10% ( 1 in 10)

GHTN 15% (1 in 7).

50
Q

What are the long term risks associated with PET?

A
  1. cardiovascular disease and mortality (2x).
  2. Stroke (1.5x in HTN but 2-3x in PET).
  3. HTN (2-4x).
51
Q

What happens to the risk if CKD in women diagnosed with any HTN in pregnancy?

A

Risk of CKD is increased.

but if no protinuria at the 6 week check, then absolute risk is low therefore do not need follow up.

My MRCOG Part 2 (37 decks)

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