HTN Disorders Flashcards by Melissa Casielles

Chronic vs gestational HTN

Both have SBP >140 and DBP > 90
Onset with chronic is prior to pregnancy or less than 20 weeks
Onset with gestational is 20 weeks
ACEI not used for chronic (fetal renal failure, oligohydramnios, and pulm hypoplasia)
Chronic lasts past 12 weeks PP and gestational resolves by 12 weeks PP
Gestational starts at 37 weeks or after
Chronic HTN increased risk for preeclampsia

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Pathogenesis of HTN in OB patients

HTN is associated with what physiological cause

Failure of 2nd trophoblastic invasion (14-16 weeks)

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What complicated vascular proteins are involved with HTN in OB patients

PGs, TXs, endothelin, endothelium derived relaxing factor

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Associated with alterations in immune response and occurs in presence of placental issue

HTN

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Platelet dysfunction

HTN

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Severe HTN criteria and goal

Criteria >160-170/105-110
Goal 140-155/90-105
Greater reduction = decrease UPP

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Which antihypertensives are contraindicated in pregnancy

ACEI

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Management of refractory HTN

Infusions of labetalol, NTG, or nipride
A-line for severe cases
Treat HTN from DL

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Risk of pulmonary HTN and stroke are greatest when

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S/S of pre-eclampsia

HTN and proteinuria after 20th week

Sbp >140
DBP > 90
300 mg or more of proteinuria in 24 hours

Nondependent edema no longer included

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Pre-eclampsia has deficiency in

Prostacyclin and thromboxane

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Increased Prostacyclin and smaller increase of thromboxane does what

Vasodilation, decreased platelet aggregation and decreased uterine tone

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In pre-eclampsia which hormone dominates

Thromboxane (increased platelet aggregation, increased uterine tone, vasoconstriction)
Prostayclin decreases

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What causes vasoconstriction in pre-eclampsia

Increased prostaglandin, interleukin and endothelins

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What happens when uterine spiral arteries cannot dilate in pre-eclampsia

Placental ischemia

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Pre-eclampsia has an increased or decreased response to vasoactive substances

Increased

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Placenta releases _____ that causes endothelial dysfunction throughout body

Cytokines

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Pre-eclampsia has a deficiency in _____ causing increased oxidative stress from free radicals

Antioxidants

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Prostayclin does what

Increases UPBF

Decreases platelet aggregation, vasoconstriction, uterine atony

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Thromboxane does what

Decreases UPBF

Increases platelet aggregation, vasoconstriction, uterine activity

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Cardiovascular physiologic response of pre-eclampsia

Hypersensitive to vasoactive hormones
Vascular spasm, decrease in blood volume
Increased SVR
Sustained HTN

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Pulmonary physiologic response to pre-eclampsia

Pharyngolaryngeal edema
Pulmonary edema
Colloid oncotic pressure is reduced 
Antepartum 18 normal is 22
Postpartum 14 and normal is 17
Decreased colloid oncotic pressure and increased vascular permeability = loss of fluid and protein into tissues leading to edema

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Neurological s/s from pre-eclampsia

HA
Visual disturbances
CNS hyperexcitability
Hyperreflexia
Seziures

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Renal s/s from pre-eclampsia

Glomerulopathy
GFR decreased by 25%
Proteinuria
Oliguria

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Hepatic s/s from pre-eclampsia

Increased transaminases | Subcostal/RUQ pain - liver swelling, periportal hemorrhage, subcapsular hematoma, hepatic rupture

Hematologic s/s from pre-eclampsia

Hypercoagulability Fibrinolysis Platelet activation - thrombocytopenia DIC esp with placental abruption

Risk factors for pre-eclampsia

``` Previous diagnosis Multipara Pre existing HTN DM Renal vascular CT diseases BMI > 35 African american Age >40 Lupus ```

Symptoms of pre-eclampsia

``` U/o 30-50ml/hr Mild HA Blurred impaired vision NV abdominal pain Chest pain Depression of patellar reflexes ```

Lab values found in pre-eclamptic patients

``` Plts 50k-100k Ast/alt 1-2x normal IUGR Creat 0.9-1 Proteinuria ```

Pre-eclampsia severe symptoms diagnostic critieria

BP >160 DBP >110 Persistent oliguria <500/daily Progressive renal insufficiency

Pre-eclampsia severe symptoms lab values

Plt <100k AST/ALT 2X normal HEELP syndrome

Severe symptoms with pre-eclampsia

``` Unrelenting HA Partial blindness or blind spots Epigastric / RUQ pain Pulmonary edema U/O <30 ML/hr ```

Category 3 symptoms of pre-eclampsia

``` Creatinine > 1.2 Proteinuria > 500mg/daily NV abdominal pain Chest pain RR <12 ```

Eclampsia s/s

``` Pre-eclampsia with seizures HTN encephalopathy Loss of cerebral autoregulation Vasospasm Microinfarctions, punctate hemorrhages Thrombosis Cerebral edema ```

What is feared with eclampsia

CVA death

HELLP syndrome s/s

Upper abdominal tenderness/epigastric pain Hemolysis Elevated liver enzymes Low platelets <100k

Definitive treatment of HELLP and pre-eclampsia

Delivery of baby

What are HELLP patients at risk for

DIC, intra-abdominal bleeding from liver

Prophylaxis with ASA =

No change in fetal outcomes

37 weeks or signs of deterioration in pre-eclampsia

Labor induced or CS urgent

When symptoms become severe or fetal distress ensues in pre-eclampsia

Immediate delivery

Treat BP when it exceeds _______ to prevent CVA, MI, placental abruption

160/110

Mag sulfate is used for

Seizure prophylaxis

MOA of mag sulfate

Centrally via NMDA receptor antagonism | Increases prostacyclin release

Mag sulfate dose

4g bolus over 20 min then 1-2g/hr 4-6 meq/l is therapeutic range Continued in PP

Benefits of mag

Decreases SVR Increases CI Improved UPBF Tocolysis of labor

Disadvantages of mag

Narrow therapeutic window, toxic effects Increased bleeding and hypotension with hemorrhage Decreased uterine contractility (oxytocin may be required for induction of labor, increased risk of uterine atony)

Antidote for mag toxicity

1g calcium gluconate or 300mg calcium chloride

Loss of DTR =

10 meq/l

Mag level with Respiratory depression =

12-15

Mag level with respiratory arrest

Mag level with cardiac arrest

20-25

Treatment of eclamptic seizure

Small doses of barbs or benzos (midaz 1-2mg) O2 by mask If seizure persists or patient not breathing - RSI and extubate when completely awake and recovered from neuromuscular blockade and mag sulfate has been administered

Pre-anesthetic management for preeclamptic patient Volume status Airway eval Lab values you should have and want

Volume status - hypovolemic (give 250-500 prior to epidural), more prone to pulmonary edema with boluses, central line, PA catheters for resuscitation Airway eval - edema gets worse with labor and pushing Lab values you should have - HCT, platelet 70-100k, PT/PTT, TEG indicates platelet function, BUN Cr Lab values you should want- TEG, ABG, CXR if SOB (pulm edema)

What labor analgesia is preferred for pre-eclamptic patients

Epidural for decreased catecholamines, BP control, improved intervillous blood flow Avoid hypotension non glucose IV fluids Ephedrine!

Increased ICP in pre-eclampsia = which anesthetic plan

Anesthesia considerations for CS for pre-eclampsia

``` Coagulation, airway, hemodynamics Fetal status Epidural preferred 3% 2chloro for emergency Severe: avoid epi with test dose Spinal not advised bc of severe sympathectomy Avoid GA Mag increases sensitivity to NMB Don’t decrease sux ```

Indications for GA with pre-eclamptic patients

Sustained fetal bradycardia | Maternal coagulopathy, hemorrhage or refusal of regional

True or false consider awake fiberoptic with pre-eclamptic GA patients

True

Which drug should be avoided for GA pre-eclamptic patients

Ketamine

During GA for pre-eclamptic patients what drugs are used to control HTN

Hydralazine, labetalol, remi, HTG, emolol for DL | A-line for severe HTN (risk of CVA)

Best med to prevent and treat eclampsia

Mag

MOA of cocaine abuse

Ester LA | Inhibits NE reuptake in presynaptic SNS = increased SNS tone

Risks with cocaine abuse

Tachy, dysrhythmias, coronary vasoconstriction, MI | Cerebral vasoconstriction, ischemia, seizures, stroke

Fetus implications for cocaine abuse

Spontaneous abortion Premature labor Placental abruption Lower APGAR scores

Decrease or increase MAC with cocaine abuse

Chronic - decreased MAC | Acute - increased MAC

What happens with blocking beta 1 and 2 receptors with cocaine abuse patients

heart failure if patient has elevated SVR

Antihypertensive used for cocaine abuse

Labetalol for alpha action | Vasodilators can cause tachy

Why can’t you use ephedrine for hypotension in cocaine abuse

Due to catecholamine depletion | Phenylephrine !

Chronic abuse of cocaine is associated with

Thrombocytopenia | Check platelets before regional

HTN Disorders Flashcards

(70 cards)