HTN and Preeclampsia Flashcards
(94 cards)
1
Q
How does blood pressure change during pregnancy compared to baseline?
A
Systolic and diastolic Decrease by 10-15mmHg in first 2 trimesters and Increase by 10mmHg in the third with return to baseline near term
2
Q
What are the typical features of preeclampsia, as this is a multi-organ disease?
A
HTN after 20 weeks Proteinuria Thrombocytopenia Hemolytic anemia Abnormal LFT's Reduced renal function Hyperuricemia Edema is common but not a reliable sign
3
Q
What are the classes of hypertension in pregnancy and basic information about each?
A
Class I: classic preeclampsia-eclampsia, usually first pregnancy after 20 weeks
Class II: Chronic HTN, workup as usual HTN if not previously diagnosed
Class III: superimposed preeclampsia on chronic HTN, must have other features besides just elevated BP
CLass IV: transient or late HTN without evidence of preeclampsia, resolves rapidly after delivery
4
Q
What blood pressure medications should not be used in pregnancy?
A
ACE and ARB
5
Q
What types of people are more likely to have chronic HTN in pregnancy?
A
Older, Obese, and black women
6
Q
How is chronic HTN in pregnancy defined or diagnosed?
A
HTN before pregnancy or BP >140/90 before 20 weeks and without other findings suggestive of preeclampsia
7
Q
What is the best way to detect superimposed preeclampsia on chronic HTN?
A
Elevated BP and edema are not good indicators
Proteinuria is the best way: >300mg per 24 hours
8
Q
What are the pregnancy outcomes for women with mild chronic HTN in pregnancy without preeclampsia?
A
Mild, and not severe chronic HTN without preeclampsia have outcomes similar to any other pregnant woman
9
Q
Why treat severe HTN in pregnant women with diastolic >110?
A
Prevents stroke and other cardiovascular complications.
10
Q
What is preeclampsia?
A
Gestational HTN with proteinuria >300mg/24hrs
11
Q
What is eclampsia?
A
Seizures with features of pre-eclampsia
Does not have to come after pre-eclampsia and may have no preceding symptoms
12
Q
Who is at greatest risk for preeclampsia?
A
<20 years Primigravida Twin or molar pregnancies (larger placenta causes larger inflammatory burden) HLD Pregestational DM Obesity Family Hx Advanced gestational age (larger placenta)
13
Q
What is the underlying cause of preeclampsia?
A
Thought to be due to vasospasm that causes the issues seen throughout the organs that are affected
14
Q
What are the primary physical exam and lab abnormalities seen in severe preeclampsia?
A
Mental status changes Headache Visual disturbances Proteinuria Thrombocytopenia Elevated LFT's Liver tenderness Oliguria Elevated Creatinine Microangiopathic hemolysis
15
Q
What is HELLP syndrome?
A
Severe complication of preeclampsia
Hemolysis
Elevated LFT’s
Thrombocytopenia
16
Q
How do coagulation studies change in HELLP syndrome?
A
They are normal
17
Q
How can the fetus be affected by preeclampsia?
A
Abruptio placentae leading to demise or early delivery
18
Q
What are the warning signs for developing eclampsia?
A
Headache, nausea, vomiting, visual changes
19
Q
Mother 48 hours postpartum without signs of preeclampsia during pregnancy has new onset seizure. What should be on the differential in addition to eclampsia?
A
Brain bleed
20
Q
What are the worst complications of eclampsia?
A
CNS damage, intracranial bleed, renal insufficiency, death
21
Q
What is the initial workup for a patient with severe preeclampsia?
A
IV
CBC (leukocyte count predicts morbidity, HGB for hemolysis)
BMP (renal function)
LFT’s (indicators for preeclampsia and HELLP syndrome)
Coag panel
Mg level for baseline
Glucose level if having seizure
CT head if seizure to rule out bleed or central venous thrombosis
22
Q
What neurological exam should always be done on preeclampsia patients?
A
Reflexes
23
Q
What is the only means known to reduce BP and help the pregnancy last longer in preeclampsia?
A
Reduce physical activity and rest
Antihypertensives and diuresis have been unable to prolong pregnancy
24
Q
What are the features of severe preeclampsia and what is the general approach to management?
A
Headache, epigastric or RUQ tenderness, BP >160/110, visual disturbance, impaired liver function, thrombocytopenia, renal dysfunction, pulmonary edema
Manage the same as eclampsia
25
What is the treatment for eclampsia/severe preeclampsia?
Control seizures with magnesium
Control BP after seizure control if diastolic > 105
Labs: CBC, platelets, LFT's, BUN/Cr
Monitor Urine output
Limit fluids
CT head if decreased consciousness, persistent seizure, lateralizing signs
Prepare for delivery
Always consider other causes of seizure including hypoglycemia, drug overdose
26
What are the hallmarks of eclampsia?
Seizure and coma
27
What is the treatment of choice to abort and prevent seizures in eclampsia and what dosing?
Magnesium sulfate
| 4g IV loading and 2gIV/hr
28
What is monitored during Mg infusion?
Watch for loss of reflexes or respiratory depression
29
What can be given to reverse the effects of hypermagnesemia?
1g IV calcium gluconate given slowly
30
What do you do if Mg does not control the seizure?
Try other agents such as benzos, but also look for other causes of seizure
31
How should BP be managed in eclampsia?
BP often improves after controlling the seizure and additional therapy is not needed. Lowing BP too much decreases placental flow and injures the fetus.
If persistent diastolic > 105, treat with hydralazine 5mg IV Q 20 minutes
32
What are the drugs of choice for BP control in severe preeclampsia?
Labetalol and hydralazine
33
What is the dosing of labetalol for severe preeclampsia?
20mg doubled every 10 minutes up to 80mg with max total of 300mg
34
What is the dosing of hydralazine for severe preeclampsia?
5mg-10mg every 20 minutes with max total of 20-30mg in 24 hrs
35
If no IV access, what drug can be used for BP control in severe preeclampsia?
Nifedipine 30mg oral extended release
| Short acting should not be given!!!
36
What is the underlying cause of all clinical features of pre-eclampsia?
Endothelial dysfunction and systemic inflammation
37
What is the cause of pre-eclampsia and who does it affect?
Dysfunction of the spiral arteries of the uterus causing uteroplacental insufficiency with ischemia and infarction of the placenta which harms both the mother and the baby
38
What complications of PEC can affect the CNS?
```
Convulsions
brain hemorrhage
brain edema
cortical blindness
retinal edema
retinal detachment
```
39
What complications of PEC can affect the renal system?
Renal cortical and tubular necrosis
reduced clearance of uric acid is first (tubular dysfunction)
Proteinuria, Hypocalciuria, and reduced creatinine clearance come later from glomerular dysfunction
End stage is acute renal failure with cortical necrosis which is from glomerular structural changes and not from hypovolemia
40
What complications of PEC can affect the Respiratory system?
Laryngeal and pulmonary edema
41
What complications of PEC can affect the liver?
Jaundice
Hepatic infarction
HELLP syndrome
Hepatic rupture
42
What complications of PEC affect the coagulation system?
DIC
Microangiopathic hemolysis
HELLP
43
What complications of PEC can affect the placenta?
Placental infarction
| Retroplacental bleeding and abruptio placentae
44
What is the normal variation in BP throughout the day different than what is seen in PEC?
Normal BP cycle during a day will dip at night, but this goes away in PEC and in the worst cases patients will have their highest BP's during sleep
45
What is the main goal of treating blood pressure and how does this compare to the definitive treatment of PEC?
HTN is a secondary issue in PEC and treating it is not a cure for the disease but is used to prevents complications such as possibility of a brain bleed
46
How does PEC lead to edema? Where in the body does the fluid accumulate, and is edema always present in PEC?
PEC causes leaky vessels and protein loss leading to hypoalbuminemia leading to edema
Edema can be seen in the larynx, lungs (rare but really bad), peripherally, and cause ascites.
Best way to monitor is by weight gain.
Not always present in PEC
47
How does PEC affect coagulation and how is this in relation to coagulation in normal pregnancy?
Normal pregnancy is a chronic inflammatory state and is pro-thrombotic. PEC enhances this and the end stage is DIC.
48
What is HELLP syndrome?
Hemolysis, Elevated Liver enzymes, and Low platelets
It is the combination of liver injury and some degree of DIC and is a dangerous complication of PEC. Hemolysis is from microthrombi.
Liver injury is associated with infarcts of the liver and microhemorrhages. In severe cases there can be bleeding under the liver capsule leading to rupture and massive intraperitoneal hemorrhage.
49
What is eclampsia and the associated symptoms?
A form of hypertensive encephalopathy, although it is physiologically different from malignant hypertension that leads to encaphalopathy.
Causes diffuse cerebral dysfunction
Headache, nausea, vomiting, cortical blindness
Seizure are common but not always present
Blood pressure may be low or normal
There is not papilledema and retinopathy as is seen with HTN emergency
50
What is the presumed pathophysiology of eclampsia?
Vasogenic edema of the brain secondary to loss of autoregulation and endothelial dysfunction
Role of HTN itself is uncertain
There is some degree of increased cerebral arterial flow that is pathologic
51
What is the only consistent feature of pre-eclampsia?
That it is inconsistent!
There are no set patterns in the way the clinical features way present and therefore attempts to clearly define the condition are limited and exist only to alert an inexperienced clinician to potential badness
52
Pre-eclampsia is primarily a disorder?
placenta, not blood pressure
53
Why is HTN included in both research and clinical definitions of PEC?
HTN is included more from historical reasons than for logical reasons and is partly there because this is something readily measured by clinicians at bedside.
54
What is the research definition of PEC? Why is this definition problematic?
HTN after 24 weeks gestation with new onset proteinuria (>300mg over 24 hrs)
Problematic because it is so narrow in scope when PEC can have such a varied presentation and affect so much more than just the vascular or renal systems
55
What is the clinical definition of PEC?
HTN after 20 weeks with any of the following:
Proteinuria
Renal insufficiency
Hepatocellular dysfunction or epigastric pain/RUQ pain
Neuro problems: headache, seizure, scotomata
Hematologic: thrombocytopenia, DIC, hemolysis
Fetal growth restriction
56
A patient at 30 weeks gestation is found to have BP 150/90 without symptoms or other clinical abnormalities. Does she have pre-eclampsia?
No. Pregnancy induced HTN is not the same as PEC which requires not only elevated BP but also other signs of dysfunction or injury.
57
What should be the true definition of PEC?
A placenta abnormality that leads to a syndrome of problems in the mother and fetus that involve an inflammatory state and endothelial dysfunction.
58
Although the current screening tests for PEC are BP monitoring and checking for protein in urine, what are the upcoming tests that look more directly at the underlying problem?
Doppler US looking at the placental vessels which will show a high resistance flow pattern
Serum blood markers from the placenta that correlate with placental ischemia
Despite the above being more logical tests, BP monitoring and proteinuria are the tests of choice for now because of their ease, accessibility, and cost.
59
What is the typical presentation of HELLP syndrome?
Epigastric/RUQ pain and nausea/vomiting
Different from heartburn in that it is more severe, not burning, is not relieved by antacid, radiates to the back, does not radiate up into the throat, and is associated with hepatic tenderness
60
When are symptoms more likely to present in PEC and what does this mean for diagnosis?
Symptoms generally develop late in the course and therefore tests are the mainstay of diagnosis
61
How is PEC diagnosed?
New onset HTN and proteinuria basically have to be present and the presence or absence of the other features does not clearly include or rule out the diagnosis
62
What labs will show evidence of endothelial dysfunction and excessive activiation of the clotting system?
Increased von Willebrand factor and cellular fibronectin
Thrombocytopenia
Increased D-Dimer
Increased liver enzymes
63
How can chronic HTN confound the diagnosis of PEC?
If baseline BP is unknown, BP may appear "normal" in early pregnancy when it is common to have lower BP than usual. Then, in later pregnancy, when BP returns to more baseline levels for the patient it may appear that they have PIH or PEC when in fact it is just a return to their baseline levels.
64
How is creatinine used in PEC?
Not for screening for occurrence or to predict outcome, but for monitoring severity or progression of the disease and to foresee renal failure
65
What urine test can be abnormal before Creatinine and BUN but is too inconsistent to be used solely, but if abnormal is a sign that PEC is likely coming?
Serum uric acid levels
| This depends on glomerular and tubular function which is different from BUN/Cr
66
How can weight gain be related to PEC screening?
PEC can lead to edema which causes weight gain
| >1kg/week weight gain is abnormal and suggestive of developing PEC
67
How is edema used to screen for PEC?
Edema happens in 80% of pregnancies and is so easily confused with the pathologic edema of PEC that it is no longer used as a diagnostic criteria
68
Which LFT's are most useful in PEC and which are not?
AST/ALT are the best
| Alk Phos is normally high in pregnancy and therefore cannot be relied on
69
A pregnant pt presents with epigastric pain. What should you be concerned about and what blood tests would be helpful?
```
Concern for HELLP
Check platelets, AST/ALT, and consider LDH which is a marker for cell necrosis and hemolysis
Haptoglobin is helpful for hemolysis
Blood smear showing schistocytes
Bilirubin level
```
70
Which PEC patients require admission?
Any symptomatic patients or those with very clear diagnostic features
Others can possibly be managed in outpatient setting
71
What is the role and purpose of treating BP in PEC? What is the goal BP?
Treating HTN only treats the effects of the high BP and does not address the underlying cause
Treatment goal is generally <160/110, but in reality the number may be less important than how much and how fast this has risen above baseline
Overall goal is to prevent cerebral hemorrhage
72
What mechanism of BP lowering agents tends to be most effective?
Direct vasodilatory agents tend to work best to counteract the vasospasm of PEC
73
What are the common side effects of hydralazine and why do these occur?
Headache, tachycardia, anxiety, restlessness, hyper-reflexia that are likely related to the induced release of norepinephrine that is prolonged.
74
What is the time of onset for IV hydralazine?
20-30 minutes
75
Why is hydralazine not the ideal drug?
Norepinephrine release causes vasoconstriction of the uteroplacental circulation which worsens placental perfusion
76
What is the oral dosing of labetalol?
100-200mg PO BID, gradually titrated up to 800mg TID
77
What is the IV dosing of labetalol?
20mg IV bolus over 2 minutes doubled every 10 minutes to max of 80mg or total of 300mg
Infusion: start 20mg.hr, double every 30 minutes until goal or max of 120mg.hr
78
How does labetalol affect placental perfusion?
No observed effect positive or negative
79
When should nitroglycerine or sodium nitroprusside be used?
Basically never unless you really know what you are doing.
80
What is the max dose of oral nifedipine when used to supplement labetalol for BP control?
120mg per day
81
In a pt with PEC and renal dysfunction, what is the role of fluid balance and is it helpful to give additional fluids?
Renal injury is not related to hemodynamic factors but more structural factors and therefore giving additional fluid is generally more harmful than good in regard to renal function because the extra fluid is likely to just go into the lungs.
82
What symptoms may herald the onset of eclampsia?
Headache, nausea, vomiting, epigastric pain, vision changes, and neurologic irritability such as clonus or shaking
83
What percent of pts who develop eclampsia had little or no preceding signs or symptoms?
40%
84
When do most women develop eclampsia?
While in labor or shortly thereafter
85
What are the key goals in managing eclampsia?
Protect maternal airway
Manage convulsions
Control extreme hypertension
Expedite delivery
86
What medications are used to control convulsions in eclampsia?
Benzos during the event and Mg to prevent recurrence
Ativan is preferred at 4mg with close attention to respiratory depression and oversedation
Most seizures stop on their own and treatment is usually not needed
Mg is more effective at preventing recurrence than benzos or other anti-epileptics
87
What is the dosing of Mg for eclampsia?
4g IV or IM as loading dose followed by 2g/hr infusion
88
What are the consequences of overdose of Mg?
Overdose is of higher concern if there is any renal dysfunction and monitoring is mandatory
Signs of overdose: muscular weakness, respiratory paralysis, heart failure, death
89
What is the antidote to Mg toxicity?
Calcium gluconate
90
What is an easy way to monitor for Mg toxicity?
Loss of deep tendon reflexes
91
What body function must be monitored when giving Mg apart from reflexes?
urine output and creatinine
| Low urine output (oliguria), anuria or elevated creatinine are reasons to slow or stop Mg infusion
92
Does blood pressure control prevent PEC?
NO
93
Which women should receive Mg as prophylaxis for eclampsia?
Symptoms of impending eclampsia with headache, vision changes, epigastric pain
Presence of HELLP syndrome
Mg can help but will not definitively prevent eclampsia
94
What is the only thing known to help prevent pre-eclampsia?
Low-dose Aspirin and calcium supplements
