Pre-existing Hypertension, Cardiac and Renal Disease Flashcards by Miss J

Define: Chronic Hypertension

Hypertension diagnosed prior to 20 weeks gestation

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What are the 4 types of Hypertension

Gestational Hypertension
Chronic Hypertension
Pre-eclampsia
Pre-eclampsia superimposed on chronic hypertension

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What are the 3 types of Chronic Hypertension

Essential hypertension
White coat hypertension
Secondary hypertension

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Define: Essential Hypertension (type of chronic hypertension)

a BP greater than or equal to
Systolic 140mm
Diastolic 90mm

Diagnosed before pregnancy or before 20wks gestation WITHOUT a known cause

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Define: White Coat Hypertension (type of chronic hypertension)

is high BP in the presence of a clinical person but otherwise normal BP when assessed outside the clinical environment

lower risk of developing superimposed preeclampsia

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In pre-eclampsia, it is characterised by hypertension and the involvement of 1 or more of what body systems

Renal 
Haematological
Liver
Neurological
Pulmonary oedema
Fetal growth restriction

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What % of women with chronic hypertension will develop Pre-eclampsia superimposed on chronic hypertension

40-50%

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With Preeclampsia superimposed on chronic hypertension there are increased risks/rates of….

Stillbirth
Neonatal death
Prematurity
Growth restriction
NICU admission

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What are the treatments for Chronic hypertension

Antihypertensives

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Post Birth

Explain: Care and considerations for women with Chronic hypertension

Unstable BP immediately after birth- will need medication altered
BP and U/A follow-up at 6wks GP visit

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In response to the increase in blood volume what are some of the normal physical changes

Reduction in exercise tolerance
Dyspnea
Tiredness
Pronounced jugular vein – visible pulse

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What are some Cardiovascular diseases

Ischaemic heart disease
Stroke
Hypertensive heart disease
Rheumatic heart disease
Aortic aneurysms
Cardiomyopathy
Atrial fibrillation
Congenital heart disease
Endocarditis
Peripheral artery disease

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What are some syndromes that involve the heart

Marfan syndrome
Eisenmengers syndrome
Down syndrome
Brugada syndrome
Wolff-Parkinson White syndrome

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Define: Cardiomyopathy

Inflamed, enlarged and weakened heart muscle

Main causes
Hereditary
Viral infection
Bacterial infection
Fungal or parasitic infection
Ischaemia
Alcohol/drugs
Obesity
Chemotherapy/radiation

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Explain: Changes to renal system in pregnancy

Increased: renal plasma flow
Increased: kidney size
Increased: risk of UTI

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What are types of renal disease

Congenital renal disease: 
Obstruction of the urinary tract (hydronephrosis with obstruction)
Hydronephrosis without obstruction 
Cystic diseases
Metabolic diseases
Syndromes

Acute renal disease: Infection
Hemolytic uremic syndrome
Nephrotic syndrome
Poisoning

Chronic renal disease:
Diabetes
Hypertension
Glomerulonephritis
Cancer
Medication use

What are some treatment options for Renal diseases in pregnancy

Pre-conception counselling
Outcomes depends on renal functioning
Good evidence for aspirin use from early pregnancy

How do you measure Renal Function

Dipstick
24 hour collection – protein/creatinine ratio
Haematological creatinine

How do you measure BP

Sphygmo

Always use correct technique

What do beta blockers do

They work on the sympathetic nervous system acting as an antagonist blocking hormones such as adrenaline
- Which lowers BP and Cardiac output

Define: Dyuria

painful urination

Explain: Management of Gestational Hypertension

Pregnancy

Surveillance: ongoing BP checks
antihypertensive or beta blocker therapy
U/A
hydration
should be allowed to go to term before considering delivery
If high risk, delivery of fetus is priority

Labour and Birth

if high risk: before 34wks delay birth for 24-48hrs if possible to allow for cortiocosteroids
Bloods: FBC, U&E, LFT
AVOID syntometrine/ergotmetrine
BP hourly

Postnatal

Continue anti-hypertensives until BP stable
Repeat bloods 48-72hrs
Close BP obs until anit-hypertensives ceased
OB r/v at 6-8wks
GP at 6wk

Explain: Management of Chronic Hypertension

Pregnancy

Ongoing BP checks
Anti hypertensive therapy
fluids/hydration

Labour/Birth

Low dose slow incremental epidural anaesthesia to manage the stressors of labour,
TED stockings
Ongoing assessment of the mother’s haemodynamic status: B.P., pulse oximetry, CVP,
continuous ECG

Postnatal

BP is unstable for 1-2wks. Monitor BP
alter or commence anti hypertensive therapy
follow-up GP at 6wks

Define: Atrial Septal Defect (ASD)

cardiac disorder

is the incomplete closure of the wall between the upper chambers of the heart (L&R atrium)

Explain: Management of ASD

Pregnancy - If closed/treated, problems are unlikely - specialised cardiac U/S for fetus needed - Possible cardiac failure/cardiac decompensation - Possible trouble with breathing, cold extremities, chest pains or tightness Labour - Normal care if ASD treated - anaethetist r/v prior to labour - If not treated: compression stockings, anticoagulation considered if immobile - 2nd stage: restricted time frame for active pushing - 3rd stage: active management Postnatal - Baby needs cardiac screening - encourage ambulation: decreases thrombo-embolic disease - standard care - follow up with cardiac specialist and GP Possible effect on woman - atrial fibrilation - stroke - heart failure

Case Study Alison is a 32y.o G4P1 who presents to the birth unit tonight at 29 weeks with a 2 day history of UTI signs and symptoms, worsening dysuria and now haematuria. She describes a pre-pregnancy history of UTI and was treated for symptomatic bacteriuria at 14 weeks this pregnancy. On examination she describes severe right flank pain and has costovertebral angle tenderness (CVAT) What is your provisional diagnosis and why? What is your care and management for Alison and her baby?

Provisional Diagnosis: Pyelonephritis Why: - Hx UTI signs - Hx of symptomatic bacteriuria at 14wks - Haematuria - worsening dysuria - Severe right flank pain - Costovertebral angle tenderness Care/Management: - Obs (hrly) - Urgent r/v - U/A & dipstick - blood cultures ( w/ FBC & LFT) - CTG - Abx - Cannulation - fluids - Pain relief - IDC - Fluid balance

Case Study Akira is a 38y.o G2P1 now at 24 weeks and has been referred to your Day Assessment Unit for a B.P profile and other B.P investigations. The medical team are concerned that Akira is developing pre-eclampsia superimposed on existing chronic hypertension which she developed after her last pregnancy. In her previous pregnancy she was diagnosed with pre-eclampsia at 32 weeks. Discuss the issues that Akira has Management for pregnancy, birth and in the postnatal period.

Risk Factors - AMA - Hx of pre-eclampsia - Chronic hypertension Pregnancy - Increase surviellance (CTG, U/S) - Aspirin therapy - ? admit as in-patient - U/A each visit - PE bloods: FBC, U&E, LFT - Corticosteroids <34wks - Individualised care plan Labour/Birth - EDB useful inconjunction w/ anti-hypertensive therapy - AVOID ergometrine, NSAIDS - Oxytocin should be given slowly - Hourly BP - Continuous EFM Postnatal - Close BP obs - repeat bloods - continue meds until stable - obstetric r/v at 6-8weeks

Explain: Management of Pre-eclampsia

Risk Factors - AMA - Hx of pre-eclampsia - Chronic hypertension Pregnancy - Increase surviellance (CTG, U/S) - Aspirin therapy - ? admit as in-patient - U/A each visit - PE bloods: FBC, U&E, LFT - Corticosteroids <34wks - Individualised care plan Labour/Birth - EDB useful inconjunction w/ anti-hypertensive therapy - AVOID ergometrine, NSAIDS - Oxytocin should be given slowly - Hourly BP - Continuous EFM Postnatal - Close BP obs until anit-hypertensives ceased - repeat bloods 48-72hrs - continue meds until stable - obstetric r/v at 6-8weeks

Explain: Management of Pyelonephritis

Diagnose- MSU Treat: appropriate Abx if not at Pyelonephritis stage Pregnancy - monthly MSU for asymptomatic bacturia (clinically indicated if dysuria, increased urination, lower abdo pain or renal tenderness or pyrexia present) - 2L water daily - empy bladder after sex - wipe front to back ``` Pyelonephritis may require: - hospitalisation - IV hydration - monitor fluid balance - IV Abx, then oral Abx when controlled - Monitor U&E, urine and blood cultures - 4hrly temp obs ```