Flashcards in HTN in Pregnancy Deck (65):
What counts as HTN in pregnancy?
Systolic over 140
Diastolic over 90
What criteria is no longer used but may indicate developing pre-eclampsia?
30mmHg systolic or 15mmHg diastolic over 2nd trimester low point
What happens to BP generally during pregnancy?
It starts high, they tapers low in the 2nd trimester, then rises in 3rd back to where it was in the 1st
-If it keeps rising over what is was in the 1st during the 3rd trimester, then it's an issue
What are 5 types of hypertensive disorders?
3. Chronic HTN
4. Chronic HTN with superimposed pre-eclampsia
5. Gestational HTN
What is the triad for pre-eclampsia?
Which triad for pre-eclampsia is least indicative?
Edema... most preggo ladies are swollen
-Really for this, it's not just cankles, it's like where the fuck are my ankles?
What are some RF for pre-eclampsia?
2. Maternal age (under 20 or over 35)
3. Family history
4. Hydatidiform mole
5. Chronic HTN
7. Renal disease
8. Multiple gestation
What 3 things do you check your preggo patients for at every visit?
1. Protein/glucose dipstick urine
What are some maternal findings of pre-eclampsia?
2. Weight gain
4. Hyper-reflexia (DTR and Clonus)
6. Epigastric pain
7. Visual changes
8. Mental status issues
Is some CNS hyperactivity normal in pregnancy?
Yes... common to see like 2-2.5 reflexes in preggo versus 1-2 in normal.... when you see 3-4 with really jumping relfexes it's a problem
What causes epigastric pain seen with pre-eclampsia?
The portal fluid is less mobile, so it backs up into the liver capsule and stretches it causing pain
Is it bad when your pre-eclamptic patient starts having CNS, HA, Visual ,Mental, and epigastric symptoms?
What is the 5 things of maternal sequelae of pre-eclampsia (yes, I speak English real good)?
1. Placental abruption
3. Renal failure
4. Hepatic failure
5. CNS hemorrhage and stroke
*By time of 3, 4, 5, really looking at more of just plain old eclampsia
What are the 3 fetal sequelae of pre-eclampsia?
1. IUGR/FGR: The placenta is fibrotic and calcified so the exchange of O2 and nutrient is compromised
3. Acute and chronic fetal distress
What are some examples of acute fetal distress?
Cord issues, placenta previa, ect.
What are some examples of chronic fetal distress?
With an old, fibrotic, crap placenta, the baby gets tired of continuously not being nourished and says fuck this, i'm going into distress
What are some laboratory changes of pre-eclampsia?
1. Elevated hematocrit
2. Elevated liver enzymes
3. Thrombocytopenia- DIC beginning
4. Decreased fibrinogen
5. Elevated fibrin split products
6. Increased uric acid
7. Elevated BUN and creatinine
What are 3 types of pre-eclampsia?
What constitutes mild pre-eclampsia?
1. BP > 140/90 (either/or, not both per say)
2. Proteinuria > 0.3gm/24 hr
3. Mild edema (could possibly be severe though)
What constitutes severe pre-eclampsia?
1. BP > 160/110
2. Proteinuria > 5gm/24 hr
3. Oliguria <500ml/24 hr
4. Visual changes
5. Pulmonary edema
6. Epigastric pain
7. Elevated liver enzymes
After Mom delivers and she was pre-eclamptic, is her peeing a lot good or bad?
GOOD... if her kidneys were shutting down with the eclampsia issues, once she delivers and starts to heal, the kidneys should open and she should be peeing a crap ton... it's a reassuring sign that she is healing
What is HELLP Syndrome?
-Pre-eclampsia assocaited with
1. Hemolysis (Abrupt anemia)
2. Elevated liver enzymes (AST/ALT)
3. Low platelets (DIC-Like)
Who acts the worse and deteriorates fastest?
Patients with HELLP syndrome
What is eclampsia?
Pre-eclampsia with convulsions
What 3 things are done for initial assessment of eclampsia?
1. Signs and symptoms
3. Fetal Well being monitoring
What labs are done for eclampsia workup?
1. CBC, platelets (if abn -> fibrinogen, FSP, LDH)
2. BUN, creatinine, 24 hr urine for protein/creatinine
3. AST, ALT, bilirubin
What fetal well-being tests are done for eclampsia workup?
What do you look for with a doppler study with a patient with pre-elcampsia?
Looking for babies end diastolic flow... if this is reduced, that means there is resistance building babies blood flow can stop or even reverse...BAD NEWS BEARS YO
What are 2 general things done for treatment of mild pre-eclampsia?
1. Rest and observation
2. Assure fetal well being (BPP/NST 2 time a week)
-Basicall just temporizing measures... can't reverse it, so just deal and watch it like a hawk
When do you deliver with pre-eclampsia?
1. 38 weeks gestation
2. Progression in signs or symptoms
3. Evidence of fetal compromise
-Really have to weigh out how bad symptoms are versus how far along the baby is and how well baby could handle being delivered
Does mild pre-eclampsia have to be managed inpatient or outpaitnet?
Either... depends on patient and doctor preferences
What things are required for outpatient management of mild pre-eclampsia?
-Must be reliable patient
-Self blood pressure monitoring
-Daily weight checks
-Fetal kick counts
-Biweekly non-stress tests
What are fetal kick counts?
In AM before momma does anything, sit for an hour and count movements felt... if get 6, all is well.
Don't hit 6 in hour 1, eat something sweet and start over... baby might have been sleeping...6 in hour 2 with sugar, all is well... still no movement, get a NST/BPP
How is severe pre-eclampsia treated?
Remain hospitalized until delivery, then differs based on before or after 32 weeks
After 32 weeks, severe pre-eclampsia?
STABILIZE AND DELIVER
Before 32 weeks, severe pre-eclampsia?
1. Bed rest
2. Control BP
3. Steroids for lung maturation
Why do we give steroids?
Helps baby mature in their
1. Lung development
2. Brains... steroids help mature the matrix in the brain surrounding their vessels to decrease risk of intracranial hemorrhage (could happen from increased pressure during birth ect....use US to screen for hemorrhage in risky babies)
What signs of deterioration require delivery?
1. Uncontrolled BP
3. Pulmonary edema
4. HELLP syndrome
7. Evidence of fetal compromise
During labor, what 2 things are done for Mom with severe pre-eclampsia?
1. Seizure prophylaxis
2. Anti-HTN treatment
What is given for seizure prophylaxis?
1. IV Mg Sulfate
2. IV Labetalol
What is magnesium an antagonist to?
Ca (which is a mediator across the NMJ)
So how does Mg Sulfate help with seizures?
It increases the threshold for a patient to have a seizure
Whats the whole shibang with dosing of Mg Sulfate for a preggo lady?
You give them a crazy high does so their lab values for everything skyrocket (to over like 7ish) and the lab will call and yell at you....
-But once you hit levels like 10, you put Mom at risk for respiratory and cardiac issues and leg weakness issues that can kill her... so you gotta watch them super close, lab values, physical exams and all that jazz
What is given for Anti-HTN treatment for ladies with severe pre-eclampsia during laboy?
1. IV hydralazine
2. IV Labetalol (1st line)
When do we start treating Mom's BP?
When it hits like 160/110
-With a preggo lady, a higher BP is "okay" because it sets up increased resistance for baby to keep blood flowing... just treat it once start hitting into that seizure risk area
What do we correct BP to for a pregnant lady?
140/90--> Lower than this, it can lead to hypoperfusion of the placenta and fetal compromise... don't want to overtreat Mommas BP
What are the 2 big goals for HTN treatment?
1. Get to 140/90
2. Decrease risk of seizure
If you have pre-eclampsia in the first pregancy, do oyu have increase likelihood of pre-eclampsia in subsequen pregnancies?
Yes (if no pre-eclampsia in 1st pregnancy, liklihood of getting it in the 2nd pregnancy goes way down)
Does history of pre-eclampsia increase the likelihood of developing essential HTN in the future?
-HTN disorders in preggo don't tend to affect BP after preg later in life.... mom develops HTN in 3/4 pregnancy, they probably had HTN issues in the 1st one
When does pre-eclampsia present?
3rd trimester (after 20 weeks)
-If HTN before this, probably underlying BP issue
What can be used for mild pre-eclampsia and is a slow treatment?
Alpha- Methyl- Dopa
What is gestational HTN?
HTN after 20 weeks gestations without proteinuria
In gestational HTN, BP returns to normal by when?
12 weeks postpartum
What must be monitored in gestational HTN?
Proteinuria: Could be a sign of development into pre-eclampsia
-This is usually self limited however
What is chronic HTN?
Known HTN prior to pregnancy
With Chronic HTN, when does it develop?
Prior to 20 weeks
So, if you have HTN found with 1st pregnancy and lasts beyond 12 weeks post-partum, what is it?
What are some acceptable drugs to control HTN in preggo?
1. Alpha Methyl dopa
Why can't preggos ladies get BB?
They can cause IUGR
Why can't preggo ladies get ACEi or ARB?
With chronic HTN, what needs to be monitored?
Proteinuria and IUGR (worry about development of superimposed pre-eclampsia on top of chronic HTN)
-Do fetal-well being tests
Can you give diuretics to a preggo lady for HTN?
No... don't want to volume reduce them
What is the requirement for chronic HTN with superimposed pre-eclampsia?
Chronic HTN with development of proteinuria >0.3gm/24 hour urine
How is chronic HTN with superimposed pre-eclampsia treated?