OBAb: Hypertensive Disorder Flashcards
How do you diagnose gestational HPN?
- BP >= 140/90 after 20 weeks AOG in a previous normotensive
- No evidence of pre-eclampsia
- Hypertension resolves 12 weeks post partum
Criteria for preeclampsia
- BP >= 140/90 after 20 weeks AOG in a previous normotensive
- Proteinuria >= 300mg/24hr OR PCR >=3.0 OR +1 dipstick
- Thrombocytopenia < 100,000/uL
- Renal insufficiency Crea >1.1 or 2x baseline
- AST ALT 3x
- Cerebral symptoms
Criteria for preeclampsia superimposed on chronic hpn
- Chronic HPN +
- NEW ONSET PROTEINURIA ( no proteinuria <20 weeks AOG) plus
Sudden increase in proteinuria OR
Sudden increase in BP if with proteinuria <20 weeks AOG
plus
Thrombocytopenia
Criteria for pre-eclampsia with severe features
- BP >= 160/>=110
- (+) thrombocytopenia
- (+/-) proteinuria
- (+) Oliguria
- Elevated serum creatinine
How do you give Magnesium Sulfate for seizure protection?
- Loading dose: 4g SIVP, 5g IM at each buttocks (Total 14mg)
- Maintenance dose: 5g IM on alternating buttocks q6h x 4 doses (total of 20mg in 24hours)
Antidote: Calcium gluconate 1g SIVP
____ meqs/L where patient given MgSO4 presents with respiratory depression
10-12 meqs/L
At 12meqs/L, respiratory arrest can happen
>12meqs/L, altered consciousness
Antidote: Calcium gluconate 1g SIVP
___ meqs/L is the therapeutic dose for MgSO4 as seizure protection
4-7 meqs/L
Antidote: Calcium gluconate 1g SIVP
Cite the Tennessee Criteria for HELLP syndrome
- LDH >600 IU/L
- AST/ALT 2x elevated
- PC <100,000/uL
Cite the Mississippi Criteria for HELLP syndrome
All: LDH >=600
I PC <50 | AST/ALT >= 70
II PC 50-100 | AST/ALT >= 70
III PC 100-150 | AST/ALT >= 40
What is the BP Goal in Eclapmsia?
140/90 - 155/105
What is the most accepted risk factor of gestational hypertension?
hypertensive disorder
___ refers to immunologic habituation to paternal antigens through contact between the sperm and female GIT
immunologic habituation
___ refers to hypertension without proteinuria after 20 weeks gestation; BP returns to normal 12 weeks post partum
Gestatonal hypertenstion
If the BP known patient with GH became normal at 13 weeks postpartum, she can be labeled as?
Transient HPN
After 12 weeks, you can confirm if its transient or chronic HPN
Oliguria is a severe feature of pre-eclampsia. What is the expected UO of these patients?
<400 to 500mL/day
What are the renal changes in patients with pre-eclampsia?
- Decreased GFR
- Glomerular endotheliosis blocking filtration barrier
- increased endothelial leak causing elevated urine Na
- Increased excretion of urinary podocyte
What are the contraindications to conservative management of pre-eclampsia?
- Persistent symptoms of hypertension
- Fetal compromise
- Signs beginning HELLP
What is the dose of calcium to prevent pre-eclampsia syndrome?
High dose Calcium
1.5 to 2 grams per day before 32 weeks
When will you start aspirin for patients with pre-eclampsia to prevent pre-eclampsia syndrome?
Low dose aspiring
60 to 80 mg/day to start on the 2nd trimester
[Gestational HPN]
What are you indications for hospitalization and delivery for GH patients?
A. AOG >40 weeks
OR
B. AOG >/ 37 weeks if:
- Bishop >5
- Fetal weight <10th percentile
- Non reactive NST
C. AOG >34 weeks with
- Labor
- Ruptured membranes
- Vaginal bleeding
- Abnormal BPS
- Criteria for severe preeclampsia
What is the sonological monitoring schedule of patients with severe pre-eclampsia?
- Assess fetal size every 2 weeks
- BPS and AFI twice weekly
- Umbilical artery doppler once a week
- NST daily
What are examples of your severe features associated with preeclampsia?
- RUQ or epigastric pain
- Platelet <100,000/mL
- Transaminase 2x above nromal
- Serum crea >1.1 or 1.2mg/dL in the absence of renal disease
- Oliguria <400-500mg/day
- Pulmonary edema
- Severe headache, altered mental statu
- partial or total loss of vision in normal appearing eye
When will you deliver for patients with severe preeclapmsia?
32 to 34 weeks
Patient with severe pre-eclampsia at 33-34 weeks, what will be your next step?
- give steroids
2. deliver after 48 hours
Patient with severe pre-eclampsia at 31 weeks weeks, what will be your next step?
- Give steroids
- Daily evaluation
- Delivery if with indications
- Deliver at 32 to 34 weeks
CS if <32 weeks
Patient with severe pre-eclampsia at 35 weeks weeks, what will be your next step?
- stabilize mother
2. Deliver
What are the contraindications to conservative management for patients with severe preeclampsia?
- Persistent symptoms or severe hypertension
- Eclampsia, pulmonary edema, HELLP syndrome
- Significant renal dysfunction, coagulopathy
- Abruption
- Previable fetus
- Fetal compromise
[Urgent control of Severe HPN]
Avoid in women with asthma or CHF
Labetalol
[Urgent control of Severe HPN]
DOC
hydralazine
[Urgent control of Severe HPN]
Caution if with MgSO4
Nifedipine PO
Nicardipine
[Urgent control of Severe HPN]
How will you prepare Nicardipine drip
D5W 90mL + Nicaridipine 10mg via soluset (0.1mg/mL) at 10ugtts/min
[Urgent control of Gestational HPN]
What is the first line drug?
Methyldopa
[Urgent control of Gestational HPN]
Can inhibit labor, has synergistic action with MgSO4 in lowering BP
Nifedipine
[Urgent control of Gestational HPN]
Can cause neonatal thrombocytopenia
Hydralazine
[Urgent control of Gestational HPN]
can decrease uteroplacnetal blood flow
beta blocker
can also increase the risk of fetal growth restriction if started in 1st or 2nd trimester
[Urgent control of Gestational HPN]
Useful in combination with methyldopa and vasodilator to mitigate compesatory fluid retention
Hydrochlorothiazide
When will you deliver if patient is having eclampsia?
deliver after seizure
Induce labor if cervix is favorable
Indication for CS in eclamptic patients?
- Vaginal delivery does not appear easy and imminent
- Failure to progress after induction
- Fetal compromise
How will you give MgSO4 if with IM to prevent convulsions?
- 4g SIVP over 5-10mins
- 5g deep IM on each buttock
- 5g IM
Total = 19g
How will you give Mg SO4 if via IV
- 4g SIVP
- Infuse 2g/hr
1L D5W + 20g MgSO4
10mL amp of 50% MgSO4 x 4 to run 2g/hr via infusion pump or soluset
What are your MgSO4 precautions?
- UO at least 30mL/hour or 100mL 4 hours
- Presence of patellar reflex
- RR of not <12/min
- Calcium gluconate at bedside (10mL or 10% solution)
[Serum MgSO4 levels]
therapeutic range that prevents convulsions
4-7 mEq/L
4.8 to 8.4mg/dL
[Serum MgSO4 levels]
patellar reflex disappears
8-10 mEq/L
pATEllaer = ATE = Eight
[Serum MgSO4 levels]
prolonged AV conduction
12 mEq/L
[Serum MgSO4 levels]
respiratory depression
12-15 mEq/L
Remember, RR of not <12 as MgSO4 precaution
[Serum MgSO4 levels]
cardiac arrest
24 mEq/L
[other antiseizure drugs for eclampsia]
Diazepam preparation
LD: 10mg slow IV
Infuse: pNSS 500mL + 40mg Diazepam x 24 hours
[other antiseizure drugs for eclampsia]
Phenytoin preparation
LD: 1g slow I over 20 mins
Infuse: 100mg every 6 hours x 24 hrs
[Cardiovascular Disorders]
What is the preferred delivery in patients with CV disease?
Vaginal delivery
- Semirecumbent position with lateral tilt during labor
- Epidural anesthesia with IV sedation
[Cardiovascular Disorders]
What are the indications for CS in patients with CV disease?
- Dilated aortic root >4cm or Aortic aneurysm
- Acute severe CHF
- Recent MI
- Severe symptomatic aortic stenosis
- Warfarin administration within 2 weeks delivery
- Need for emergency valve replacement after delivery
What is the most common adverse event in patients wit congenital heart disease during pregnancy?
Arrythmia
[Asthma]
What are the components in assessing asthma severity?
- Symptoms 2 days/wk
- Awakenings 2x per mont
- Control 2days/week
- Activity None
FEV1 >80%
[Asthma]
Moderate persistent
Symptoms daily
Awakening >1/week
Control Daily
Activity some limitation
[Asthma]
What is the first line drug for asthma?
Terbutaline
[Asthma]
preferred low dose ICS
Budesonide
[Asthma]
preferred LABA
Salmeterol
[Asthma]
preferred oral corticosteroids?
Prednisode
