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REPRODUCTION & GYNAECOLOGY > Hypertension in Pregnancy > Flashcards

Hypertension in Pregnancy Flashcards

1
Q

What percentage of pregnancies does hypertension usually affect?

A

10-15% of all pregnancies

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2
Q

How many primigravid (1st baby) mothers experience pre-eclampsia?

A

Mild pre-eclampsia = 10% primigravid women

Severe pre-eclampsia = 1% primigravid women

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3
Q

What is eclampsia?

A

seizure as a result of severe pre-eclampsia

  • high risk of maternal death
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4
Q

When in pregnancy do changes in the cardiovascular system usually occur?

A

First 12 weeks

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5
Q

What cardiovascular changes does a mother experience in pregnancy?

A
  • Increased plasma vol and CO

- Peripheral vascular resistance decreases

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6
Q

What trends in BP and heart rate are thought to occur in 2nd/3rd trimester of pregnancy?

A
  • 2nd trimester = dip in BP (less marked than previously thought)
  • 3rd trimester = increase in HR (around 7bpm)
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7
Q

What is the quantitative definition of hypertension?

A

≥140/90 mmHg on 2 occasions
>160/110 mmHg once
(some areas of world use increase of >30/15mmHg since 1st trimester)

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8
Q

What different types of hypertension can result during pregnancy?

A
  • Pre-existing hypertension
  • Pregnancy Induced Hypertension (PIH)
  • Pre-eclampsia
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9
Q

What is the difference between Pregnancy Induced Hypertension (PIH) and Pre-eclampsia?

A

NO proteinuria or oedema in PIH

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10
Q

When is pre-existing hypertension most often diagnosed?

A
  • 1st trimester => Likely if early pregnancy

- Retrospective diagnosis after pregnancy (if BP not returned to normal within 3 months of delivery)

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11
Q

What secondary causes may be responsible for pre-existing hypertension?

A

Renal / cardiac/ Endocrine

  • Cushing’s
  • Conn’s
  • Phaeochromocytoma
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12
Q

What does pre-existing hypertension increase the risk of in pregnancy?

A
  • PET
  • IUGR
  • Placental abruption
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13
Q

When does PIH normally present and resolve?

A

Second half of pregnancy

Resolves within 6/52 of delivery

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14
Q

What risks does pregnancy induced hypertension present?

A
  • Progression to pre-eclampsia (15%)

- Rate of recurrence is high

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15
Q

What are the main features of pre-eclampsia?

A

Hypertension
Proteinuria (≥0.3g/l or ≥0.3g/24h)
Oedema

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16
Q

Pre-eclampsia can be “asymptomatic” on presentation. TRUE/FALSE?

A

TRUE

- patient may experience high BP, proteinuria and oedema but not feel unwell/ any abnormal symptoms

17
Q

Describe the difference between early and late presentations of pre-eclampsia

A

Early

  • extensive villous and vascular lesions of placenta
  • higher risk of complications than late pre-eclampsia

Late

  • minimal placental lesions
  • relatively benign disease course but can lead to eclampsia
18
Q

Describe the pathogenesis of pre-eclampsia

A
  • Genetic (eg increased risk if mother/sister affected)
  • environmental predisposition
  • Stage 1 - abnormal placental perfusion
    => placental ischaemia/ infarction
  • Stage 2 - maternal syndrome
    => trophoblast invasion
    => failure of normal vascular remodelling
    => Spiral arteries fail to adapt to become high capacitance, low resistance vessels
    => Placental ischaemia
19
Q

How does pre-eclampsia affect the liver to cause disease?

A
  • Epigastric/ RUQ pain
  • Abnormal liver enzymes
  • Hepatic capsule rupture
  • HELLP Syndrome
    => Haemolysis, Elevated Liver Enzymes, Low Platelets
20
Q

What complications can pre-eclampsia cause which are specific to the placenta?

A

Fetal growth restriction (FGR)
Placental abruption
Intrauterine death

21
Q

What symptoms normally present with pre-eclampsia?

A
  • Headache
  • Visual disturbance
  • Epigastric / RUQ pain
  • Nausea / vomiting
  • Rapidly progressive oedema
22
Q

Aside from the 3 common diagnostic signs, what other signs may be observed on examination of a mother with suspected pre-eclampsia?

A
  • Abdominal tenderness
  • Disorientation
  • Small for Gestational Age (SGA) Fetus
  • Intra uterine fetal death
  • Hyper-reflexia / involuntary movements / clonus
    (these signs develop prior to eclampsia seizure)
23
Q

What investigations should be carried out throughout pregnancy if a mother has pre-eclampsia?

A
  • Serum Urate
  • LFTs
  • FBC
  • Coagulation Screen
  • Cardiotocography
  • US
24
Q

What maternal risk factors can increase the likelihood or severity of pre-eclampsia?

A 
Maternal Age 
BMI
Family Hx
Parity (first pregnancy)
Multiple pregnancy (Twins/Triplets etc)
Previous Pre-eclampsia
Birth interval >10 years 
Molar Pregnancy / Triploidy
25
Q

Women who develop pre-eclampsia in subsequent pregnancies experience greater severity that women in their first pregnancy. TRUE/FALSE?

A

TRUE

26
Q

What conditions in a mother’s PMHx may increase the risk of pre-eclampsia in pregnancy?

A 
Pre-existing renal disease
Pre-existing hypertension
Diabetes (pre-existing/gestational)
Connective tissue disease
Thrombophilias (congenital / acquired)
27
Q

When should low dose aspirin be started in pre-eclampsia?

A
  • Commence before 16 weeks
  • Usually taken from 12 weeks until birth
    (150 mg dose Tayside, but NICE = 75mg)
28
Q

How may pre-eclampsia be predicted from a maternal uterine artery doppler?

A

High resistance and low flow found in preeclampsia appears as low flow/ minimal colour on doppler US

29
Q

When should a mother with pre-eclampsia be admitted to hospital?

A
  • BP >170/110 OR >140/90 with (++) proteinuria
  • Significant symptoms - headache / visual disturbance / abdominal pain
  • Abnormal biochemistry
  • Significant proteinuria - >300mg / 24h
  • Need antihypertensive therapy
  • Signs of foetal compromise
30
Q

How should mothers suffering from pre-eclampsia be assessed when they are inpatients?

A 
BP - 4 hourly
Urinalysis - daily
Input / output fluid balance chart
Urine PCR - (if proteinuria present)
Bloods - FBC, U+Es, Urate, LFTs usually daily (min 2/wk)
31
Q

When are most women treated for hypertension?

A

BP ≥150/100 mmHg
BP ≥ 170/110 mmHg = immediate Tx!

Control of blood pressure does not reduce risk of developing pre-eclampsia NOR DOES IT CURE PRE-ECLAMPSIA (only cure = delivery of baby)

32
Q

What agents can be used to treat hypertension in pregnancy and when are these contrainidcated?

A

Methyldopa (contraindicated in depression)
Labetalol (contraindicated in asthma)
Nifedipine SR

2nd line:
Hydralazine
Doxazosin (not suitable in breastfeeding)

33
Q

What does a decreasing or LOW Amniotic Fluid Index

indicate?

A

Baby is not producing enough urine/amniotic fluid
=> in distress/ill
=> Kidneys are not functioning well

34
Q

What can be assessed on an Umbilical Artery Doppler?

A

Blood flow to baby during diastole

- can be normal, absent or reversal of blood flow

35
Q

What indications in pre-eclampsia would suggest to deliver the baby?

A
  • Term gestation
  • Inability to control BP
  • Rapidly deteriorating biochemistry / haematology
  • Eclampsia
  • Foetal Compromise - abnormal US or CTG
36
Q

What crises can occur in pre-eclampsia that usually indicate to get the baby out?

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

When do most eclampsia seizures occur?

A

24 hours post partum

38
Q

How is severe pre-eclampsia or eclampsia itself managed?

A

Control BP - IV Labetolol or Hydralazine (beware hypotension)

Stop / Prevent Seizures - Mg sulphate IV (diazepam if this doesn’t work)

Fluid Balance - slow infusion rate to “run patient dry” => 80 ml/h
Delivery

39
Q

What should you aim for in labour when a mother has pre-eclampsia?

A
  • vaginal birth if possible
  • Control BP
  • Epidural anaesthesia
  • Continuous foetal monitoring
  • Avoid ergometrine
  • Caution with iv fluids

REPRODUCTION & GYNAECOLOGY (58 decks)

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