OGCO-C1.4 Proteinuria and hypertension Flashcards
Define proteinuria in pregnancy
- Total protein excretion of > 300 mg per 24 hours, estimated by spot urine protein to creatinine ratio or 24 hr urine collection, OR
- Dipstick reading of 2+ or more (used only if other quantitative methods not available)
Define gestational hypertension
- Two readings of blood pressure ≥140 mmHg systolic, or ≥ 90 mmHg diastolic more than 4 hours apart, after 20 weeks of gestation in a woman with previously normal blood pressure
Define severe hypertension
- Persistently raised blood pressure ≥ 160 mmHg systolic, or ≥ 110 mmHg diastolic
Define chronic hypertension
- Hypertension onset prior to pregnancy, or before 20 completed weeks of gestation
Define chronic hypertension with superimposed preeclampsia / eclampsia
- Chronic hypertension with onset of preeclampsia or eclampsia after 20 weeks’ gestation
Define preeclampsia
- New onset of hypertension after 20 weeks of pregnancy and the coexistence of 1 or more of the following new-onset conditions:
i) Proteinuria
ii) Other maternal organ dysfunction: - Renal insufficiency (creatinine 90 micromol/litre or more, 1.02 mg/100 ml or more) in absence of other renal disease
- Liver derangement (elevated transaminases – ALT or AST over 40 IU/litre)
- Neurological complications such as eclampsia, altered mental status, blindness, visual scotomata, stroke, clonus, or new-onset severe headaches not responsive to medication and not accounted for by alternative diagnosis
- Haematological complications such as thrombocytopenia (platelet count below
PROTEINURIA AND HYPERTENSIVE DISORDERS OF PREGNANCY 150,000/ microlitre), disseminated intravascular coagulation or haemolysis - Uteroplacental dysfunction such as fetal growth restriction, abnormal umbilical artery doppler waveform analysis, or stillbirth.
iii) Synonymous with “gestational proteinuric hypertension”
Define severe pre-eclampsia
Pre-eclampsia with severe hypertension (BP>160mmHg systolic, or >110 diastolic on 2 occasions) that does not respond to treatment, or with severe features such as ongoing or recurring severe headaches, visual scotomata, nausea or vomiting, epigastric pain, oliguria as well as progressive deterioration in lab blood tests such as rising creatinine or liver transaminases or falling platelet count, or failure of fetal growth or abnormal doppler findings
Define eclampsia
The convulsive manifestation of hypertensive disorders of pregnancy, defined by new- onset of seizure in the absence of other causative conditions during pregnancy, labour, or within 7 days of delivery
Define unclassified hypertension and/or proteinuria
- Hypertension and/or proteinuria found at first examination after 20 weeks of pregnancy in a woman without known chronic hypertension or chronic renal disease, or
- Diagnosed during pregnancy, labour, or the puerperium where information is insufficient to permit classification
- Can be reclassified after delivery to gestation hypertension / proteinuria / preeclampsia if hypertension and/or proteinuria disappears after delivery, or to chronic hypertension or chronic renal disease if it persists after delivery
What are Ix for proteinuria?
Whenever protein is found in the urine on routine dipstick test, the following Ix should follow
- Mid stream specimen obtained for culture and sensitivity test and urine microscopy
- A spot urine protein to creatinine ratio for estimation of total protein excretion
- BP should be monitored and blood tests including CBC, LRFT can be considered
- In cases of persistent proteinuria not obviously due to pregnancy induced hypertension/infection, send 3 morning specimens for urine for AFB. If RBC are present in significant amounts, also send urine for cytology
What are Ix for hypertension?
- Monitor blood pressure every 4 hours if admitted
- Assess for symptoms and signs of preeclampsia
- Test blood for complete blood count, liver function, renal function, urate, and clotting
profile - Assess presence of proteinuria by spot urine protein to creatinine ratio and mid-stream
urine for microscopy - Monitor fetal growth and well-being by physical examination, ultrasound and/or
cardiotocogram if indicated
What are Ix for chronic hypertension?
In addition to the above, patients presenting with newly diagnosed hypertension before 20 weeks of gestation should be worked up for secondary causes of chronic hypertension:
- Blood should be taken for anti-dsDNA, lupus anticoagulant, anti-cardiolipin antibodies, anti-ENA antibodies, thyroid function test (in pregnancy)
- Send urine for VMA to rule out endocrine causes such as pheochromocytoma
- Arrange ultrasound doppler of renal arteries to rule out renal artery stenosis
- Counsel for use of low dose aspirin to reduce risk of preeclampsia
What are Ix for eclampsia?
- Work-up for proteinuria as above
- Test blood for complete blood count, liver function, renal function, urate, clotting profile and arterial blood gas
- Type and screen
- Monitor fetal well being
What is the BP value for managing hypertension?
What is the drugs in order of priority given?
What is monitored for in eclampsia?
What is definitive management?
What is anticonvulsant therapy?
Monitoring
Keep an accurate fluid intake and output chart. Insert an indwelling catheter and monitor the urine output every hour. If oliguria of less than 30ml per hour is present for 2 consecutive hours, the senior staff should be informed.
* BP and pulse quarter hourly until the condition is stabilized
* Respiratory rate quarter hourly
* Urine output hourly and test for protein
* Level of consiousness
* Continuous fetal heart moniroting if the fetus has not been delivered
* Monitor for pulmonary edema and DIC
CVP line set up if there is any doubt about blood loss and fluid balance
Definitive: decision for induction made by senior stuff usually after convulsions have been controlled.
2nd stage should be shortened by instrumental delivery. Syntocinin infusion (high risk patients) should be used instead of syntometrine to prevent primary postpartum hemorrhage.
Anticonvulsant therapy:
(i) Loading dose of 4g of MgSO4 in 100ml normal saline given over 20 mins IV.
Hourly admin of 1-3g of 50% MgSO4 in normal saline solution
Monitoring
* Knee reflex is absent
* RR is <16 per min
* The urine output is <30ml per hour
MgSO4 infusion should be continued for 24 hours after the last convulsion, or in the case for prophylaxis, 24 hours after delivery
(ii) Diazepam 10-40mg IVI slowly
Patient will go through stages: drooping of eyelids, slurring of speech and finally sleep.
Treatment is followed by 40mg in 500ml of 5% dextrose at 30 drops/min
(iii) Thiopentone treatment: reserved for patients with recurrent or uncontrollable seizures.
