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Obstetrics > Hypertension in pregnancy > Flashcards

Hypertension in pregnancy Flashcards

1
Q

Definition of cHTN

A

Before 20 weeks EGA or > 12 weeks PP:
SBP > 140 mm Hg, DBP > 90
2x at least 4 hrs apart

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2
Q

Def’n of gHTN

A

HTN > 20 weeks, normal BP at 12 weeks PP

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3
Q

Def’n pre-eclampsia

A

gHTN + proteinuria

Proteinuria:

  • > 300 mg on 24 hr urine
  • UPC 0.3+
  • random urine > 30 mg/dL (dipstick reading of 2+)
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4
Q

proteinuria on dipstick and correlation

A 
\+ = 30 mg/dL
\++ = 100 mg/dL
\+++ = 300 mg/dL
\++++ = > 2000 mg/dL
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5
Q

Fatty liver of disease findings

A
  • low glucose
  • liver dysfunction
  • prolonged PTT
  • high maternal and fetal mortality
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6
Q

how do you assess in first trimster for risk of pre-eclampsia?

A

medical history:

  • personal/fam hx of pre-x
  • multifetal gestation
  • cHTN, CKD, or both
  • DM I and II

No commercial tests; low PPV

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7
Q

what can you do to prevent pre-eclampsia

A

LDASA (81 mg)- high risk for PX and women with 1+ moderate RF

  • start week 12-28 (ideally before 16 wks)
  • continue until 36 weeks/delivery?

HR:

  • hx px
  • cHTN
  • DM I or II
  • CKD
  • multifetal gestation
  • autoimmune conditions: APAS or lupus

Mod risk:

  • age > 35 yrs
  • nullip
  • obesity
  • african american
  • low socioeconomic status
  • pos fam hx (mom or sister)
  • prior adverse preg including low BW or SGA
  • > 10 yr interval between pregnancy
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8
Q

how many ecclamptic sz’s happen in absence of HTN, proteinuria?

A

15-20%

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9
Q

ddx for eclamptic sz:

A
  • stroke
  • aneurysm
  • AVM
  • sz disorder
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10
Q

ddx for pre-x like sx before 20 weeks:

A

TTP-HUS, molar pregnancy, renal disease, autoimmune disease

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11
Q

percentage of women with gHTN who go on to have pre-x?

A

50%, more common if dx before 32 weeks

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12
Q

when do you deliver gestational hypertension?

A

37 weeks

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13
Q

when do you deliver gestational hypertension with severe features/pre-x with SF?

A

34 weeks, no delay for steroids

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14
Q

with pre-x what are indications for delivery irrespective of gestational age?

A
  • first must stabilize mom
  • maternal indications: persistent neuro sx, stroke, MI, pulmonary edema, renal dysfunction (1.1 or 2x normal), suspicion of abruption, severe uncontrollable HTN, persistent epigastric pain, HELLP, eclampsia
  • fetal: no suspicion of fetal survival (ie lethal anomaly), fetal death, persistent reversed end diastolic flow, abnormal fetal testing
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15
Q

maternal and fetal monitoring for outpatient management of gHTN and pre-x w/o SF?

A
  • maternal: weekly HELLP labs, weekly proteinuria eval, at least 1 x in clinic BP, constant sx surveillance
  • fetal: weekly MVP/AFI evaluation, twice weekly testing, q3-4 growth scan
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16
Q

NNT to prevent eclampsia in asx PX with SF? sx?

A

asx: 1 in 129
sx: 1 in 36

17
Q

what are contraindications to magnesium sulfate?

A
  • myasthenia gravis
  • moderate to severe kidney disease
  • myocarditis
  • heart block
  • myocardial ischemia
  • hypocalcemia
18
Q

what medications for eclampsia ppx and tx can you use if magnesium contraindicated?

A
  • dilantin/phenytoin
  • valium (need to be able to intubate)
  • amobarbital
19
Q

dosing of mag sulfate for eclampsia?

A

IV: 4-6 g loading dose, 2 g/hr
additional 2-4 g bolus can be given for recurrent seizure
IM: 10 g IM (5 mg in each buttock), then 5 g q4hr

20
Q

what are serum concentrations associated with ttx dosing of mag sulfate, and toxicities? how to manage toxicity?

A

5-9 mg/dL -> ttx
> 9 -> loss of patellar reflex
> 12 -> respiratory paralysis
>30 -> cardiac arrest

stop infusion; check mag levels q2hr
if impending respiratory distress: 10% calcium gluconate in 10 mL inflused over 3 minutes; consider lasix

21
Q

discussion of mode of delivery

A

with gHTN and PX w/o SF -> vaginal
with PX and gHTN with SF -> individualized
at 28 wks -> likelihood of CD = 97%
at 32 wks -> likelihood of CD = 65%

IOL not harmful to low birth weight fetuses

22
Q

management of eclamptic seizure:

A

1st: basic supportive measures:
- calling for help
- prevention of maternal injury
- placement in lateral decubitus position
- prevention of aspiration
- administration of oxygen,
- monitoring vital signs with SpO2

23
Q

Ddx cHTN

A
  • Essential HTN
  • Renal disease
  • Renal artery stenosis
  • Coarctation of aorta
  • OSA
  • Cushing syndrome
  • Pheochromocytoma
  • Primary hyperaldosteronism
  • Methamphetamine or cocaine use
24
Q

% of women with cHTN go develop pre-x? cHTN wiht end organ dysfunction?

A

up to 50%. up to 75%

25
Q

maternal risks in pregnancy with cHTN?

A
  • rare (uncontrolled HTN): stroke, pulmonary edema
  • gestational diabetes 1.6 OR
  • PPH
  • CD
  • risk of abruption
  • renal injury
  • pre-x
26
Q

fetal risks of cHTN

A
  • IUGR
  • still birth
  • fetal anomalies
  • preterm birth (driven by indicated delivery)
27
Q

pre-pregnancy counseling with HTN

A
  • optimize BP control
  • weight loss, lifestyle modificaitons
  • assess for end organ damage (AST, ALT, UPC - 24 hour if 0.15 or more, CBC, +/- EKG or ECHO)
  • control with meds (avoid ACE and ARBs- can cause renal dysgenesis, calvarial hypolpasia)
28
Q

when do you decide to treat for chronic hypertension and why?

A

persistent elevation above 160 sbp and 110 dbp. based on multiple meta analyses– no proven fetal benefit, only maternal benefit was reduced progression to severe HTN

29
Q

what are protocols for urgent HTN control?

A

Labetalol 20, 40, 80 mg q 10 minutes -> hydralazine 10 mg

Hydralazine 5 mg, 10 mg, 20 mg q20 minutes -> Labetalol 20 mg

Nifedapine PO 10 mg, 20 mg q20 minutes -> Labetalol 20 mg

contraindications to labetalol: decompensated myocardial function, pre-existing myocardial disease, heart block, bradycardia. caution with asthma (can cause bronchoconstriction)

contraindications to hydralazine: headaches, abnormal fetal heart tracings

30
Q

fetal antenatal testing with chTN?

A

at least growth scan in 3rd trimester. additional testing based off this because there is no evidence to suggest more testing leads to better outcomes

31
Q

how to manage suspected/pending magnesium toxicity?

A
  • foley for close in/out
  • dc mag
  • supplemental o2
  • obtain serum magnesium level
32
Q

what are maternal risks to PO nifedipine?

A
  • maternal tachycardia

- maternal hypotension

33
Q

Recommended delivery intervals:

A 
cHTN
- well controlled: 
on meds - 37-39w6d
no meds - 38-39w6d
- not well controlled: 36-38 weeks

PX

  • severe: 34-37 weeks unless indication for delivery
  • PX with SF: 34 weeks
34
Q

When to initiate anti hypertensive in chtn in preg?

A

Persistent sbp 160+ or dbp 110+

35
Q

Goal BP for chtn

A

120-160/80-110

Obstetrics (45 decks)

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