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Repro and Sexual Health > Hypertension in Pregnancy > Flashcards

Hypertension in Pregnancy Flashcards

1
Q

only cure of pre-eclampsia?

A

delivery of baby

- irrespective of gestational age of baby

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2
Q

what cardiovascular changes occur in pregnancy?

A

plasma volume increases
CO increases
stroke volume increases
HR increases
slight BP drop in mid-trimester which then rises again slightly
peripheral vascular resistance decreases (to accommodate other changes)

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3
Q

definition of hypertension in pregnancy?

A

> 140/90 on 2 occasions
or
160/110 once

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4
Q

3 classifications of hypertension in pregnancy?

A

pre-existing hypertension
pregnancy induced hypertension (PIH)
pre-eclampsia

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5
Q

how is pre-existing hypertension diagnosed?

A

usually diagnosed before pregnancy
likely to be pre-existing if present in early pregnancy
may be a retrospective diagnosis if BP hasnt resolved within 3 months after delivery

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6
Q

risks of pre-existing hypertension in pregnancy?

A

PET
IUGR
abruption

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7
Q

when does PIH generally occur?

A

2nd half of pregnancy
usually resolves within 6 weeks of delivery
high recurrence rate

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8
Q

how is PIH different to pre-eclampsia?

A

no proteinuria or other features of pre-eclampsia (oedema etc)
better outcomes than pre-eclampsia
although 15% can progress to pre-eclampsia

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9
Q

features of pre-eclampsia?

A

hypertension
protienuria (>0.3g/l or >0.3g/24hrs)
oedema
diffuse vascular endothelial dysfunction and widespread circulatory disturbance in whichever system affected (cardio, renal etc)
absence does not exclude diagnosis however
may be asymptomatic at time of first presentation

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10
Q

2 sub-types of pre-eclampsia?

A

early (<34 weeks)

  • common
  • associated with villous and vascular lesions of placenta
  • higher risk of maternal and foetal complications than late

late (>34 weeks)

  • more common
  • minimal placental lesions
  • maternal factors (such as metabolic syndrome etc) can have important roles
  • most cases of eclampsia and maternal death in late
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11
Q

phases in pathogenesis of pre-eclampsia?

A

genetic/environmental predisposition
stage 1
- failure of placental development causing abnormal placental perfusion and ischaemia
stage 2 (matenal syndrome)
- an anti-androgenic state associated with endothelial dysfunction

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12
Q

what changes occur in the placenta in pre-eclampsia?

A

abnormal placentation and trophoblast invasion leads to failure of normal vascular remodelling
spiral arteries then fail to adapt to become high capacitance, low resistance narrow vessels
placental ischaemia occurs which leads to widepsread endothelial damage and dysfunction
endothelial damage leads to
- increased capillary permeability, CAM expression, prothrombic factors and platelet aggregation and vasoconstriction

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13
Q

what systems can be affected by pre-eclampsia?

A 
CNS
renal
hepatic
haematological
pulmonary
cardiovascular
placental
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14
Q

liver disease in pre-eclampsia?

A

HELLP syndrome

  • haemolysis
  • elevated
  • liver enzymes
  • low
  • platelets
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15
Q

features of HELLP syndrome?

A

epigastric/RUQ pain
abnormal liver enzymes
hepatic capsule rupture

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16
Q

how can pre-eclampsia affect placenta?

A 
fetal growth restriction
placental abruption (can cause post partum haemorrhage)
intra-uterine death
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17
Q

common symptoms of pre-eclampsia?

A 
headache
visual disturbance
epigastric/RUQ pain
nausea/vomiting
rapidly progressive oedema
(may vary in timing, progression and order of symptoms)
18
Q

signs of pre-eclampsia?

A 
hypertension
proteinuria
oedema
abdominal tenderness
disorientation
small for gestational age
intra-uterine fetal death
hyper-reflexia/involuntary movements/clonus
19
Q

how is pre-eclampsia investigated?

A 
urea and electrolytes
serum urate (one of the 1st things to increase)
LFTs (haemolysis, thrombocytopaenia)
FBC
coagulation screen
urinalysis (protein/creatinine ratio)
cardiotocography
US (fetal assessment)
20
Q

how is pre-eclampsia managed?

A 
assess risk
if hypertension present <20 weeks - look for 2ndary cause
antenatal screening (BP, urine, MUAD)
treat hypertension
maternal and fetal surveillance
timing of delivery
21
Q

risk factors for pre-eclampsia?

A 
maternal age (>40)
maternal BMI (>30)
family history
parity (higher risk if first)
multiple pregnancy
previous pre-eclampsia
birth interval > 10 years
molar pregnancy/triploidy
disease is more severe in multiparous women
22
Q

medical risk factors for pre-eclamspia?

A 
pre-existing renal disease
pre-existing hypertension
diabetes (pre-existing/gestational)
connective tissue disease
thrombophilias (congenital/acquired)
23
Q

what can be used to prevent pre-eclamspia?

A

low dose aspirin
used in high risk women (renal, diabetes, APS, multiple risk factors, previous pre-eclampsia etc)
150mg commenced before 16 weeks

24
Q

how does aspirin work?

A

inhibits COX enzyme which prevents TXA2 synthesis

25
Q

how can US doppler scan be used in pre-eclampsia?

A

can be done at 20-24 weeks to visualise the uterine artery and iliac vessels
uterine artery can be measured
- may show notching indicating a high resistance uterine artery implying that placentation hasn’t occurred as expected which hugely increases chance of pre-eclampsia

26
Q

when are patients referred to the antenatal day care unit (AN DCU)?

A

BP >140/90
++ proteinuria
increased oedema
symptoms of pre-eclampsia (e.g headache)

investigations will be done but wont stay overnight

27
Q

when are patients admitted straight away?

A 
BP >170/110 or >140/90 with ++ proteinuria
significant symptoms
abnormal biochemistry
significant proteinuria >300mg/24 hrs
need for antihypertensive therapy
signs of foetal compromise
28
Q

what assessment is done as an inpatient?

A 
BP every 4 hrs
daily urinalysis
input/output fluid balance chart
urine PCR if proteinuria on urinalysis
bloods (FBC, U&amp;Es, urate, LFTs) basically every day
29
Q

how is hypertension managed in pregnancy?

A 
treat regardless of cause
with MAP >150 there is significant risk of cerebral haemorrhage
most people treat is BP >150/100
BP > 17-/110 needs immediate treatment
aim for 140-150/90-100
30
Q

does control of BP reduce risk of developing pre-eclasmpsia?

A

no

31
Q

what drugs are used 1st line for hypertension in pregnancy?

A

methyldopa 250mg bd - 1g tds
labetolol 100mg bd - 600mg qid
nifedipine 10mg bd - 40mg bd

32
Q

contra-indications in 1st line anti-hypertensives?

A 
methyldopa = depression
labetolol = asthma
33
Q

2nd line drugs in hypertension in pregnancy?

A

hydralazine 25mg tds - 75mg qid

doxazosin 1mg od - 8mg bd

34
Q

side effects of 2nd line anti-hypertensives?

A

doxazosin not safe in breast-feeding

35
Q

what foetal surveillance is done in pre-eclampsia?

A 
fetal movements
daily CTG
US
- biometry
- amniotic fluid index
- umbilical artery doppler
36
Q

when should the baby be delivered in pre-eclampsia?

A

mother must be stabilised before birth
try and leave it as long as possible if baby is pre-term
give steroids
- betamethasone
- dexamethasone
usually delivered within 2 weeks of diagnosis

37
Q

indications for delivery of baby?

A 
term gestation
inability to control BP
rapidl deteriorating biochemistry/haematology
eclampsia
other srisis
foetal compromise (abnormal US or CTG)
38
Q

crises in pre-eclampsia?

A 
eclampsia
HELLP syndrome
pulmonary oedema
placental abruption 
cerebral haemorrhage
cortical blindness
DIC
acute renal failure
hepatic rupture
39
Q

what happens in eclampsia?

A

tonic-clonic seizure occuring with features of pre-eclampsia
>1/3 will ahev seizure before onset of hypertension/proteinuria
ante-partum/antra-partum/post-partum
more common in teenagers
associated with ischaemia/vasospasm

40
Q

how is severe pre-eclampsia / eclampsia managed?

A

control BP
- IV labetolol
- IV hydralazine
stop/prevent seizures
- loading dose = 4g IV Magnesium sulphate over 5 mins + maintenance dose of 1g/hr IV, give another 2g is further seizures, consider 10mg IV diazepam in persistent seizures
fluid balance
- no treatment if oliguria,manage pulmonary oedema, run patient “dry” - 80ml/hr
delivery
- aim for vaginal birth, control BP, epidural, continuous foetal monitoring, avoid ergometrine, caution with IV fluids

41
Q

post-partum management of pre-eclampsia?

A 
breast feeding encouraged
contraception
BP management
counselling/debrief future risk depends on other medical factors and is gestation dependent 
consider long term cardio risk

Repro and Sexual Health (63 decks)

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