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Reproduction > Hypertension in Pregnancy > Flashcards

Hypertension in Pregnancy Flashcards

1
Q

Definitions of Hypertension

A

> /= 140/90 mmHg on 2 occasions

> 160/110 mmHg once

(ACOG - >30/15 mmHg compared to first trimester BP)

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2
Q

Types of hypertension in pregnancy

A

Pre-existing
PIH
Pre-eclampsia

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3
Q

Effect of maternal CVS adaptations on BP

A

Mid trimester dip in BP (slight, not so significant)

Rise in HR (also slight and not too significant)

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4
Q

When is Pre-exisiting HTN diagnosed during pregnancy

A

Diagnosed prior to pregnancy

May be retrospective diagnosis if BP has not returned to normal within 3 months of delivery

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5
Q

Secondary causes of pre-existing hypertension

A

Renal/cardiac
Cushing’s
Conn’s
Phaeochromocytoma

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6
Q

What are the risks of pre-existing HTN

A

PET (x2)
IUGR
Abruption

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7
Q

When is PIH diagnosed?

A

2nd half of pregnancy

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8
Q

Features of PIH

A

Resolves within 6/52 of delivery
No proteinuria or other features of pre-eclampsia
Better outcomes than pre-eclampsia
Rate of recurrence is high

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9
Q

What are the features of pre-ecclampsia

A

3 features (all 3 need not be present to have pre-ecclampsia):

Hypertension

Proteinuria (≥0.3g/l or ≥0.3g/24h)

Oedema

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10
Q

Aetiology of pre eclampsia and the systems it may affect

A

Diffuse vascular endothelial dysfunction widespread circulatory disturbance

Renal / Hepatic / Cardiovascular / Haematology / CNS / Placenta

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11
Q

2 classifications of pre-eclampsia

A

Early: <34 wks

  • uncommon
  • Higher risk of maternal and foetal complications
  • Associated with extensive villous and vascular lesions of the placenta

Late

  • Common
  • minimal placental lesions
  • Higher maternal mortality
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12
Q

Pathogenesis of pre-eclampsia

A

Environmental/ genetic predisposition

Stage 1: Abnormal placental perfusion ( leads to placental ischemia and infarction)

Stage 2: Maternal syndrome as a result of stage 1.
- endothelial changes/dysfunction

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13
Q

Normal placentation vs Pre-eclamptic placentation

A

Normal:

  • cytotrophoblasts invade muscle layer of spiral arteries
  • this causes spiral arteries to open up and allows adequate blood flow to foetus

Pre-eclampsia:

  • no cytotrophoblast invasion of muscle of spiral arteries
  • growth restriction
  • hypoxia/ischemia
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14
Q

Presentation of HELLP SYNDROME (subtype of severe pre-eclapmsia)

A

Epigastric/ RUQ pain
Abnormal liver enzymes
Hepatic capsule rupture

Haemolysis, Elevated Liver Enzymes, Low Platelets
- high morbidity/ mortality

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15
Q

How to identify HELLP syndrome in pre-eclampsia?

A

LFT and liver enzymes

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16
Q

Placental disease in pre-eclampsia

A

Fetal growth restriction (FGR)

Placental abruption

Intrauterine death

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17
Q

How does pre-eclampsia present?

A

Depends on the system affected (some might be asymptomatic)

CNS symptoms:
Headache
Visual disturbance

Liver: Epigastric / RUQ pain

GI: Nausea / vomiting

Rapidly progressive oedema - “do your rings get stuck on your finger?”

18
Q

What are the findings on examination (signs)?

A 
Hypertension
Proteinuria
Oedema
Abdominal tenderness
Disorientation
Small for Gestational Age (SGA) Fetus
Intra uterine fetal death
Hyper-reflexia / involuntary movements (eclamptic seizure) / clonus
19
Q

Investigations for pre-eclampsia

A

Urea & Electrolytes

Serum Urate – first change seen (specific in preg)

Liver Function Tests (HELLP)

Full Blood Count (haemolysis, thrombocytopaenia)

Coagulation Screen (liver disease, maternal clotting problems)

Urine - Protein Creatinine Ratio (PCR)

Cardiotocography (to asses baby)

Ultrasound - fetal assessment

20
Q

Management of Pre-eclampsia

A

Assess risk at booking - identify risk factors

Hypertension < 20 weeks - look for secondary cause

Antenatal screening - BP, urine, MUAD (to asses placent)

Treat hypertension

Maternal & fetal surveillance

Timing of Delivery -pre-eclampsia and HTN problems do not resolve till baby is delivered

21
Q

Risk factors for pre-eclampsia

A 
Maternal age (>40 years = 2X)
Maternal BMI (>30 = 2X) 
Family history (20-25% if mother affected, up to 40% if sister)
Parity (first pregnancy 2-3X)
Multiple pregnancy (Twins 2X)
Previous PE (7X)
Birth interval >10 years (2X)
Molar Pregnancy / Triploidy
Multiparous women develop more severe disease
22
Q

Medical risk factors for pre-eclampsia

A 
Pre-existing renal disease
Pre-existing hypertension
Diabetes (pre-existing/gestational)
Connective tissue disease
Thrombophilias (congenital / acquired- more common)
23
Q

When is low dose aspirin given to manage pre-eclampsia

A

In case risk factors are identified

24
Q

MOA of low dose aspirin in pre-eclampsia management

A

Inhibits cyclo-oxygenase thus prevents TXA2 synthesis

15% reduction in PET (NNT=90)

May be more beneficial in preventing severe early onset pre-eclampsia (MRC CLASP Trial)

Commence before 16 weeks

25
Q

Nice guidelines for low dose aspirin in pre-eclampsia

A

5mg (NICE recommendation)

100mg - better

26
Q

What is the transformation of MUA during pre-eclampsia?

A

turn from high capacity low resistance to the converse

27
Q

When can pre-eclampsia be predicted using MUAD?

A

20-24 weeks

Appears as notch waveform indicating high resistance artery and placentation hasn’t occurred as expected

28
Q

When to refer to AN Day Care Unit?

A

BP >/= 140/90
(++) proteinuria
++ oedema
symptoms - esp persistent headache

29
Q

When to admit pregnant mother for pre-eclampsia?

A

BP >170/110 OR >140/90 with (++) proteinuria

Significant symptoms - headache / visual disturbance / abdominal pain

Abnormal biochemistry

Significant proteinuria - >300mg / 24h

Need for antihypertensive therapy

Signs of fetal compromise

30
Q

What is the inpatient assessment for pre-eclampsia?

A

Blood Pressure - 4 hourly

Urinalysis - daily

Input / output fluid balance chart (to monitor kidney func)

Urine PCR - if proteinuria on urinalysis

Bloods - FBC, U&Es, Urate, LFTs. Minimum X2 per week but daily for inpatient

31
Q

When to stat treatment of HTN in pregnancy

A

Most treat if BP ≥150/100 mmHg
BP ≥ 170/110 mmHg requires immediate Rx
Aim for 140-150/90-100 mmHg - do not drop the BP to low as an increased BP is a maternal adaptation to pregnancy
Control of blood pressure does not reduce the risk of developing pre-eclampsia

32
Q

Drugs used to treat HTN in pregnancy (1st line)

A

Methyldopa -

  • Centrally acting a agonist
  • Starting dose 250mg bd
  • 1 gram tds
  • CI: Depression

Nifedipine
Ca channel antagonist
Starting dose: 10mg bd
Max dose: 40mg bd

Labetalol
a + b antagonist
start dose: 100mg bd
Max dose: 600mg qid
CI: Asthma
33
Q

2nd line drugs used to treat HTN in pregnancy

A

Hydralazine

  • Vasodilator
  • 25mg tds
  • 7mg qid (max dose)

Doxazocin

  • a antagonist
  • 1 mg OD
  • 8mg BD (max dose)
34
Q

HTN drugs to avoid during pregnancy

A

Diuretics

ACE inhibitors

35
Q

Techniques used in foetal surveillance

A

CTG - daily

Ultrasound -

  • Biometry
  • Amniotic Fluid Index
  • Umbilical Artery Doppler
36
Q

Indications for birth

A 
Eclampsia
HELLP syndrome
Pulmonary Oedema
Placental Abruption
Cerebral Haemorrhage
Cortical Blindness
DIC
Acute Renal Failure
Hepatic Rupture
37
Q

What is eclampsia?

A

Tonic-clonic (grand mal) seizure occurring with features of pre-eclampsia

More common in teenagers

Associated with ischaemia / vasospasm

38
Q

Management of severe PET/Eclampsia

A

Control BP

Stop / Prevent Seizures

Fluid Balance

Delivery

39
Q

Seizure treatment/prophylaxis in eclampsia

A

MAGNESIUM SULPHATE

Loading dose: 4g IV over 5 mins

Maintenance dose: IV 1g/h

further seizure - 2mg

Persistent seizures: Diazepam 10mg IV

40
Q

Fluid balance and eclampsia

A

Main cause of maternal death = pulmonary oedema
(Capillary leak / fluid overload / cardiac failure)

Oliguria in 30%. Does not require intervention

Any doubts about renal function  urine osmolality

Fluid challenges are potentially dangerous

Safer to run a patient “dry” - 80 ml/h

41
Q

Labour and birth

A 
Aim for vaginal birth if possible
Control BP
Epidural anaesthesia
Continuous electronic fetal monitoring
Avoid ergometrine
Caution with iv fluids
42
Q

Post-partum management

A 
Breast feeding
Contraception
BP management
Counselling  / debrief
Future risk
Depends on other medical factors
Gestation dependent (28/40 - 40%, 32/40 - 30%)
Consider long term cardiovascular risk

Reproduction (32 decks)

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