Hypertension in Pregn. Flashcards by Shiv Krishnan

How common is hypertension in pregnancy?

10-15% of all pregnancies

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How common is severe pre-eclampsia?

only affects 1% of primigravid women

- whilst mild pre-eclampsia affects 10% of primigravid women

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What is the biggest cause of iatrogenic pre-term birth?

Pre-eclampsia

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How does the maternal CVS system adapt to pregnancy?

increase in plasma volume (50%)
incr. in CO, SV, HR
decr. in peripheral vascular resistance (15-20%)

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Trends in BP and HR in Normal Pregnancies?

mild dip in BP in Mid-trimester of the pregnancy

- progressive rise in HR by 7 bpm (not sudden!)

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What is hypertension define as?

> 140/90mmhg on 2 occassions

- >160/110 mmHg once

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How to dx pre-existing H/T?

if H/T does not resolve within 3 months of delivery

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Risks of pre-existing htn?

PET (pre-eclampsia) x2
IUGR
placental abruption

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What are fts of pregnancy induced htn?

no proteinuria/ other PET fts
better outcomes than PET
but 15% progresses into pre-eclampsia
recurrence is high

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How does pre-eclampsia present as?

htn
proteinuria
edema
—-absence of ONE of these 3 fts does NOT exclude PET dx

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How does PET affect blood vessels?

d/t endothelial dysfxn in whatever system is affected (renal/ hepatic/cvs/hematology/cns/placenta)

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How diff. is early pre-eclampsia vs late pre-eclampsia?

EARLY (<34wks) : HIGHER risk of maternal and FETAL complications/ uncommon/ a.w extensive villous and vascular lesions of the placenta

——LATE : majority/ minimal placental lesions/ maternal factors important (metabolic syndrome) /most caseECLAMPSIA AND MATERNAL DEATH!

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How does pre-eclampsia come about?

insufficient blood flow to the placenta secondary to INADEQUATE remodelling of spiral arteries of the uteroplacental vascular bed
trophoblasts normally cause a change in the endothelium by invading the musculoelastic walls; to allow blood for the fetus to be well recieved
in pre-eclampsia: d.t failure of normal vascular remodelling, Spiral arteries fail to adapt to become high capacitance, low resistance vessels

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What liver conditions does pre-eclampsia cause?

epigastric/ RUQ pain
- hepatic capsule rupture

Hemolysis
Elevated Liver ENzymes
Low Plates

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How does placental abruption present as?

painful ante-partum hemorrhage

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What placental disease may arise from hypertension?

FGR
Placental abruption
- Intra-uterine death

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Symptoms of pre-eclampsia?

Headache
Visual disturbance
Epigastric / RUQ pain
Nausea / vomiting
Rapidly progressive oedema (can’t fit rings in)
loss of vision!

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What are the signs of pre-eclampsia?

Hypertension
Proteinuria
Oedema
Abdominal tenderness
Disorientation
Small for Gestational Age (SGA) Fetus
Intra uterine fetal death
Hyper-reflexia / involuntary movements / clonus
----painless ante-partum hemorrhage= low-lying placenta

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Ivx for pre-eclampsia?

Urea &amp; Electrolytes
Serum Urate
Liver Function Tests (HELLP $) 
Full Blood Count (hemolysis and thrombocytopenia) 
Coagulation Screen
Urine - Protein Creatinine Ratio (PCR) (>30 )
Cardiotocography
Ultrasound - fetal assessment

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How to manage pre-eclampsia?

Assess risk at booking - identify risk factors

if Hypertension < 20 weeks - look for secondary cause (renal disease, echo-cardiac scans)
Antenatal screening - BP, urine, MUAD
Treat hypertension
Maternal & fetal surveillance
Timing of Delivery

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Risk factors of pre-eclampsia?

>40y.o
BMI >30 
Family hx (up to 40% if sis is affected/ 25% if mum) 
- parity (1st pregn: 2-3x) 
multiple preg. (twins 2x) 
previous pre-eclampsia (7x)
BIRTH interval >10 years
Molar preg./ triploidy 
- multiparous women

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Medical risk factors for pre-eclampsia?

Pre-existing renal disease
Pre-existing hypertension
Diabetes (pre-existing/gestational)
Connective tissue disease
Thrombophilias (congenital / acquired- lupus anti-coagulant)

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How does aspirin help in pre-eclampsia?

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inhibits Cyclo-oxygenase; prevents TXA2

- —-prevents thrombosis in placental blood vessels; saves perfusion of placenta

What is the dose of aspirin given, to whom and for how long ?

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used on HIGH risk women (renal disease, DM, aPS/SLE, multiple risk factors)
150mg dose
commence before 16 wks

Why does peripheral resistance reduce in pregnancy?

High resistance low capacity > low resistance high capacity blood vessels

When can pre-eclampsia be dx on the Maternal Uterine artery doppler?

20-24 weeks | -----HOW DOES it appear: as a notch

When to refer to antenatal Day care unit?

- proteinuria ++ - ^^edema - persistent headache BP >140/90

When to admit to ward?

- BP >170/110 OR >140/90 w. proteinuria - Significant symptoms - headache / visual disturbance / abdominal pain Abnormal biochemistry Significant proteinuria - >300mg / 24h Need for antihypertensive therapy Signs of fetal compromise

Inpatient assessment involves what investigations?

Blood Pressure - 4 hourly Urinalysis - daily Input / output fluid balance chart Urine PCR - if proteinuria on urinalysis Bloods - FBC, U&Es, Urate, LFTs. Minimum X2 per week

What is recommended when treating hypertension?

Aim to bring the BP down slowLY, d.t risk of hypoperfusion to fetus (aim for 140-150/90-100)

Hypertensive medication c.i in pregnant ladies?

- diuretics and ACE-Is

How is the fetus assessed?

- fetal movements - CTG - USG (biometry/ AFI/ umbilical artery doppler)

What to check for on the umbilical artery doppler?

- in 3rd trimester pregnancy | - ----with incr. reisstance; - loss of flow during disatole and reversal of blood flow

When to deliver the baby?

- mother to be stabilised - 2 DOSES OF DEXAMETHASONE (if pre-term) - ---most should be delivered in 2weeks of dx

Indications for birth?

Term gestation Inability to control BP Rapidly deteriorating biochemistry / haematology Eclampsia Other Crisis Fetal Compromise - abnormal Ultrasound or CTG

Rx of eclampsia ?

- IV LABETOLOL - IV HYDRALAZINE -----continuous perfusion; beware of hypotension

Fluid balance is a MAIN cause of maternal death and fluid challenges are potentially dangerous.... What is done to manage fluid overload?

- run the pt dry : 80ml/h

What is involved with the management of Pre-eclampsia?

- contorl BP - prevent seizures - fluid balance - delivery

Cause of 14% of maternal deaths?

hypertension

Secondary causes of pre-existing hypertension?

- renal - cardiac - Cushing's - Conn's - Phaeochromocytoma

Local vasospasm d/t pro-inflammatory release from the placenta results in various multisystemic symptoms. What are they?

- kindeys: oligouria, proteinuria - Retina: scotoma, flashing lights, blurred vision - Liver: injury and swelling, elevated liver enzymes, capsule stretching (RUQ pain)

How does hemolysis come about in pre-eclampsia?

- numerous thrombi form d.t to the dysfunctional endothelium - cause break down of RBCs - ----thrombi may also use up the platelets!

Why does generalized edema arise in pre-eclampsia? How does it present as?

- endothelial dysfxn causes vascular permeability - with reduced oncotic pressure; MORE FLUID loss in to the tissues - seen in legs, face and hands - ---PULMONARY edema: cough, sob - ----cerebral edema: headache, confusion and seizures

What pro-inflammatory factors are released by the placenta when hypoperfused?

- VEGF - sEng - Flt1 - PIGF

How effective is ASPIRIN?

- 15 % reduction of PET | - more beneficial in preventing SEVER early onset of pre-eclampsia

WHat is the 1st line rx of hypertension?

- Methyldopa (c.i in Depression) - LABETOLOL - Nifedipine (SR)

What hypertensive drug should be avoided in an asthmatic pt?

Labetolol- beta blocker

Which hypertensive drug should be avoided in a depressed pt?

- Methyldopa

Name 2nd line hypertensive rx?

1. Hydralazine (vasodilator) | 2. Doxazocin (alpha-blocker)

Which drug should be avoided when breastfeeding?

- doxazocin

What complications may arise in Pre-eclampsia?

- eclampsia - HELLP $ - Pulm. Edema - Placental abruption - cerebral hemorrhage - Cortical blindness - DIC - Acute renal failure - hepatic failure

WHat is eclampsia?

Pre-eclampsia with seizures - --tonic-clonic (grand mal) seizure - --->1/3 will have seizure BEFORE HTN onset/proteinuria

In whom is eclampsia commonly seen in? And what is eclampsia commonly a.w?

- seen in Teenagers | - a.w vasospasm

Why is fluid balance important in pre-eclamptic management?

- pulm. edema is the main cause of death

How is labour and birth any diff. in a case of eclampsia?

- aim for vaginal birth - control BP - epidural anaesthesia - continous fetal monitoring! - AVOID ergometrine - caution with IV fluids

What management is provided post-partum?

``` Breast feeding Contraception BP management Counselling / debrief Future risk ----gestation dependent Consider long term CVS risk ```

Hypertension in Pregn. Flashcards

(56 cards)