HTN in pregnancy

Question 1

HTN disorders in pregnancy

Answer 1

Gestational
Preeclampsia (Mild, Severe)
Chronic (with or without Preeclampsia)
HELLP

Question 2

What is preeclampsia

Answer 2

HTN (140/90) with proteinuria (300mg/24hrs) after 20 weeks

Question 3

What is severe preeclampsia

Answer 3

CV:      HTN 160/110
PULM: Pulm edema
Renal:  Proteinuria 5g
            Oliguria (<500ml/24hrs)
CNS:    AMS, HA, vision changes
GI:        Impaired liver function, capsular pain
HEELP, Fetal compromise

Question 4

What is eclampsia

Answer 4

Seizure in somebody that meets criteria for eclampsia

Question 5

Risk factors for preeclampsia

Answer 5

Prior HTN disorders
Prior Endothelial disorders: SLE, renal disease
OB Factors: Black, >40, smoking, obesity, DM

Question 6

Pathogenesis of preeclampsia

Answer 6

Endothelial dysfunction due to unknown cause

Question 7

Complications of preeclampisa

Answer 7

Maternal: DIC, CHF, Pulm Edema, ARF, Placental abruption, CVA, Shock

Fetal: IUGR, Resp Distress, Oligohydramnios, ICH

Question 8

Labs for preeclampsia

Answer 8

CBC, Coags, BMP, LFTs, UA and protein, T&S

Question 9

Monitors for preeclampsia

Answer 9

BP, Hourly DTR, Serum Mg, Foley, FHR, Uterine tone, A line if severe HTN or difficulty with NIBP

Question 10

Indications in preeclampsia for immediate delivery

Answer 10

Severe HTN (160/110) for 24 hours
Progressive TTP
Severe liver or renal dysfunction
Fetal distress
Persistent neurological signs

Question 11

Therapy goals in preeclampsia

Answer 11

Improve intravascular volume
Prevent seizure
Control BP

Question 12

How to control BP in preeclampsia

Answer 12

Labetolol (max 1 mg/kg, start with 20, double every 10 min)

Hydralazine

NTG 50-100 mcg boluses

Question 13

How to prevent seizure in preeclampsia

Answer 13

Mg bolus 4-6 mg over 20 minutes, then 1-2 g/hr.
Monitor UOP (mg leaves via kidneys), DTR, RR, serum Mg (Q4hrs)
Therapeutic at 4-6 mEq/L

Question 14

Mg Toxicity

Answer 14

Therapeutic at 4-6 mEq/L
Loss of DTR at 10, Respiratory arrest at 15, Asystole at 20

Give Calcium Gluconate 1 g or Calcium Chloride 300 mg

Question 15

What does Mg do?

Answer 15

Anticonvulsant
Potentiates DNMB and NDNMB
Decreases uterine contractility
Mild antihypertensive via vascular relaxation
Crosses the placenta: respiratory distress

Question 16

Eclampsia treatment

Answer 16

Stop Sz: propofol
Turn on left side
Support/secure airway
Start magnesium
Delivery baby

Question 17

Choice of anesthesia in preeclamptic for labor and C/S

Answer 17

Epidural: pain control, decrease circulating catecholamines, stable CO, improve blood flow to uterus, prepare for emergent c/s
Prehydrate with 10 ml/kg bolus but watch Pulm Edema
Platelet > 80K and watch trend

Can do spinal for C/S: avoids GA and risk of difficult intubation as well as HTN with DL

Question 18

Can you use epinephrine in epidural in preeclamptic?

Answer 18

Yes, but careful there isn’t vascular injection

Question 19

Uterine atony agent in preeclampsia?

Answer 19

Give Oxytocin, then 15-methylprostaglandin F2alpha (Hemabate/Carboprost)

Avoid Ergot alkaloids (Methergine/Methylergonovine)

Question 20

GA technique for preeclampic

Answer 20

• Aspiration prophylaxis (30 ml non particulate antiacid Na Citrate and H2 blocker ranitidine 10 mg)
• Preoxygenation
• RSI with cricoid, succ
• Small ETT 6.0
• 2/3 MAC of non-preg
• Continue Mg, which potentiates NMB
• Consider A-line in severe pts
• Consider labetolol, NTG or remi before DL

Question 21

What is HEELP

Answer 21

Antepartum or Postpartum
Hemolysis (bilirubin > 1.2)
Elevated Liver Enzymes
Low Platelets <100k

Increased incidence of maternal and fetal complications, DIC, abruptions, pleural effusions, ARF

Question 22

Post-op mgmt of preeclampsia

Answer 22

24 hours strict I/O, Mg therapy, BP control