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MRCOG part 2 Eoin > NICE - hypertension in pregnancy: diagnosis and management. 2019 > Flashcards

NICE - hypertension in pregnancy: diagnosis and management. 2019 Flashcards

1
Q

What are the “high” risk factors for pre-eclampsia

A

Hypertensive disease in a previous pregnancy
Chronic kidney disease
Autoimmune disease such as SLE or APS
Type 1 or 2 diabetes
Chronic hypertension

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2
Q

What are the “moderate” risk factors for pre-eclampsia

A

Nulliparity
Age >40
Pregnancy interval more than 10 years
BMI >35 at booking
FHx of pre-eclampsia
Multiple pregnancy

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3
Q

Who should aspirin be offered to?

A

Those with 1 high risk factor or 2 moderate risk factors.

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4
Q

At which level (trace, 1+, 2+,3+) on dipstick, should PCR be used to quantify proteinuria?

A

1+ or more

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5
Q

What is the diagnostic threshold for PCR ratio for significant proteinuria

A

30mg/mmol

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6
Q

What is the diagnostic ratio for significant proteinuria if using albumin creatinine ratio

A

8mg/mmol

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7
Q

What may be effect of taking ACE-inhibitors or angiotensin II receptor antagonists in pregnancy

A

Associated with renal dysfunction, oligohydramnios, neonatal anuria, skull ossification defects.
Also with cardiovascular malformation, CNS malformation

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8
Q

What may be the side effects of thiazides/thiazide like drugs if used in pregnancy

A

Lower birth weight,
preterm delivery,
malformations
fetal/neonatal electrolyte abnormalities,
jaundice
thrombocytopenia

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9
Q

When using medication for HTN in pregnancy aim for BP of

A

135/85

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10
Q

Offer PLGF based testing to rule out pre-eclampsia between ___ weeks and ___ /40 if women with chronic HTN are suspected of developing pre-eclampsia

A

between 20 weeks and 36+6

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11
Q

What is the monitoring schedule suggestion from NICE in women with chronic hypertension

A

weekly if poorly controlled
Appointments ever 2-4 weeks if HTN well controlled.

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12
Q

TOB for women with chronic hypertension

A

Do not offer planned early birth before 37 weeks to women with chronic hypertension whose BP is lower than 160/110 with or w/o medication unless other indications.

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13
Q

Postnatal monitoring for women with chronic hypertension.

A

Measure BP daily for first 2 days
Once between D3 and D5
or as clinically indicated if treatment is changed after birth.

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14
Q

BP aim for postnatal management of women with chronic hypertension.

A

below 140/90

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15
Q

In PIH what are the parameters of “hypertension” and “severe” hypertension.

A

HTN - 140/90 - 159/109
severe HTN - 160/110 or greater.

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16
Q

How often should dipstick proteinuria testing occur in PIH and severe PIH

A

Once or twice a week for PIH
Daily whilst admitted severe PIH

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17
Q

How often should bloods be taken for both PIH and severe PIH?

A

at presentation and then weekly.

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18
Q

In PIH (not severe) how often should fetal US assessment occur

A

at diagnosis and, if normal, repeat every 2-4 weeks if clinically indicated.

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19
Q

In severe PIH how often should fetal US assessment occur?

A

At diagnosis and, if normal, every 2 weeks if severe hypertension persists

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20
Q

TOB for PIH

A

Do not offer planned early birth before 37 weeks to women with PIH whose BP is lower than 160/110.

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21
Q

Postnatal monitoring BP with PIH

A

Daily D1 and D2
Once between D3 and D5
As clinically indicated if treatment changed after birth.

22
Q

postnatal management of women with PIH. Reduce treatment if BP falls below

A

130/80

23
Q

When should methydopa be stopped

A

Within 2 days after birth.

24
Q

What is the BP treatment threshold for women with PIH who did not take antihypertensive treatment and have given birth.

A

150/100

25
Q

For women with PET when reviewed, offer admission if there are concerns such as:

A

Sustained SBP 160 or >
New or persistent CR>90 or ALT >70 or fall in plt count <150
signs of impending eclampsia
Signs of pulm. oedema
Signs of severe pre-eclampsia
Suspected fetal compromise

26
Q

How often should bloods be checked in PET and PET with severe hypertension (FBC, LFT, UE)

A

PET - twice a week
Severe hypertension PET - 3 times a week

27
Q

How often should US assessment of the fetus occur in PET and PET with severe hypertension

A

At diagnosis and, if normal, every 2 weeks.

28
Q

TOB in PET. Considerations for planned early birth could include (not limited to) the following features of severe pre-eclampsia

A

Inability to control BP despite x3 or more classes of antiHTN medication in appropriate doses.
Mat SpO2 <90%
Progressive biochemical deterioration (HELLP)
Ongoing neurological features - severe intractable headache, visual scotoma
Placental abruption
Reversed EDF or abnormal CTG

29
Q

TOB in PET

A

Surveillance to 36+6
Initiate birth from 37 weeks

30
Q

How should BP be monitored in women with pre-eclampsia postnatally if they did NOT require any treatment.

A

QDS whilst inpatient
at least once between D3 and D5
On alternate days until normal if abnormal D3-D5

31
Q

How should BP be monitored in women with pre-eclampsia postnatally if they required treatment.

A

QDS whilst inpatient
every 1-2 days for up to 2 weeks after transfer to community care until she is off treatment and has no hypertension.

32
Q

At what threshold should antihypertensives be reduced postnatally

A

<130/80

33
Q

Consider transfer to community care postnatally if all of the criteria have been met.

A

No symptoms of pre-eclampsia
BP with or without treatment <150/100
Blood tests stable or improving.

34
Q

In chronic hypertension. What should the AN USS schedule be?

A

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

35
Q

In women with PIH when should they have an US?

A

US growth LV doppler at diagnosis, and, if normal every 2-4 weeks

36
Q

When should women with PET or severe PIH have US growth LV and doppler?

A

At diagnosis and if continuing with surveillance then every 2 weeks

37
Q

Consider serial US growth LV doppler between 28-30 weeks (or at least 2 weeks before previous gestational age of onset) in women with previous:

A

severe pre-eclampsia
Pre-eclampsia resulting in birth before 34 weeks
PET with baby below the 10th centile
IUFD
Abruption

38
Q

Consider the need for MgSO4 if 1 or more of the following symptoms of severe PET are present

A

Ongoing or recurring severe headaches
Scotomata
Nausea or vomiting
Epigastric pain
oliguria and severe hypertension
Progressive biochemical deterioration.

39
Q

What is the recommended regimen for MgSO4

A

Loading dose 4g over 5-15mins
Maintenance 1g/hr for 24hours

40
Q

How long should the MgSO4 infusion be continued after the last fit?

A

24hours after the last fit

41
Q

How should recurrent fits be treated whilst on MgSO4 infusion

A

A further loading dose 2-4g given IV over 5-15minutes.

42
Q

What are the potential side effects of prolonged or repeated MgSO4 administration 5-7days in pregnancy?

A

Skeletal adverse effects
hypocalcaemia and hypermagnesaemia in neonates

43
Q

In severe PET, what should the fluids be restricted to?

A

80ml/hr
Unless there are ongoing fluid losses.

44
Q

Can breastfeeding mothers take ACE-i or ARBs

A

Not recommended but not absolutely contra-indicated. not in the first few weeks.
With ACE-i: although the levels transferred are unlikely to be clinically relevent there is insufficient date to exclude a possible risk of profound neonatal hypotension.

45
Q

What should women with hypertensive disorder of pregnancy be advised about the overall risk of recurrence of any hypertensive disease

A

Overall risk is ~21% or 1in 5

46
Q

Risk of recurrence of PET if PET in previous or current pregnancy

A

Overall 16%
If birth was at 28-34 weeks - 33%
If birth 34-37 - 23%

47
Q

Risk of PET in future if PIH in current or previous pregnancy

A

7% or 1 in 14

48
Q

Risk of PIH in future pregnancy if PIH currently

A

Between 11-15%

49
Q

Risk of chronic hypertension if PET in current or previous pregnancy

A

2% or 1 in 50

50
Q

Risk of chronic hypertension if PIH in current pregnancy or previous

A

3% or up to 1in 34

MRCOG part 2 Eoin (21 decks)

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