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Flashcards in Hypertension in Pregnancy Deck (47):
1

What is the most common cause of iatrogenic prematurity?

Pre-eclampsia

2

Does pregnancy cause vasodilatation or vasoconstriction?

Vasoconstriction

3

What happens to blood pressure in early pregnancy?

Falls

4

When is nadir reached?

22-24 weeks

5

What is nadir?

Lowest point of deccelaration

6

When does BP rise and fall after nadir?

Steady rise until term
Fall after delivery
Rise at day 3/4 post-natal

7

What is the diagnosis of hypertension?

>_140/90 mmHg on 2 occasions
DBP >110mmHg
ACOG - >30/15mmHg compared to booking BP

8

What are possible secondary causes of hypertension?

Renal
Cardiac
Cushing's/Conns/Phaeochromocytoma

9

When does pregnancy induced hypertension (PIH) occur?

2nd half of pregnancy
Resolves 6 weeks after delivery

10

What are the features of pre-eclampsia?

Hypertension
Proteinuria (>_0.3g/l or >_0.3g/24hours)
Oedema

11

What happens in pre-eclampsia?`

Diffuse vascular endothelial widespread circulatory disturbance

12

What happens in stage 1 and stage 2 of pre-eclampsia?

Stage 1 - Abnormal placental perfusion
Stage 2 - Maternal syndrome

13

What generally happens in pre-eclampsia?

Abnormal placentation and trophoblastic invasion --> failure of normal vascular remodelling
Spiral arteries fail to adapt to become high capacitance, low reistence vessels
Placental ischaemia --> widespread endothelial damage and dysfunction

14

What endothelial activation happens in pre-eclampsia?

Increased capillary permeability
Increased expression of CAM
Increased prothrombotic factors
Increased platelet aggregration
Vasoconstriction

15

What other bodily systems does pre-eclampsia effect?

CNS
Renal
Hepatic
Haematological
Pulmonary
Cardiovascular
Placental

16

What CNS diseases can pre-eclampsia lead to?

Eclampsia
Hypertensive encephalopathy
Intracranial haemorrhage
Cerebral haemorrhage
Cortical blindness
Cranial nerve palsy

17

What renal disease can pre-eclampsia cause?

Decreased GFR
Proteinuria
Increased serum uric acid (also placental ischaemia)
Increased creatinine/Potassium/Urea
Oliguria/Anuria
Acute renal failure - acute tubular necrosis, renal cortical necrosis

18

What liver diseases can pre-eclampsia?

Epigastric/RUQ pain
Abnormal liver enzymes
Hepatic capsule rupture
HELLP syndrome
(Haemolysis, Elevated liver enzymes, Low platelets) - high morbidity/mortality

19

What haematological diseases can be caused by pre-eclampsia?

Decreased plasma volume
Haemo-concentration
Thrombocytopenia
haemolysis
Disseminated intravascular coagulation

20

What cardiac/pulmonary diseases can be caused by pre-eclampsia?

Pulmonary oedema --> ARDS - iatrogenic, disorder related
Pulmonary embolus
High mortality

21

What placental disorders can pre-eclampsia cause?

Intrauterine growth restriction (IUGR)
Placental abruption
Intrauterine death

22

What symptoms are assoc. with pre-eclampsia?

Headache
Visual disturbance
Epigastric/RUQ pain
Nausea/Vomiting
Rapidly progressive oedema

23

What are signs assoc. with pre-eclampsia?

Hypertension
Proteinuria
Oedema
Abdominal tenderness
Disorientation
SGA
IUD
Hyper-reflexia
Involuntary movements
Clonus

24

What investigations should be done for suspected pre-eclampsia?

Urea & electrolytes
Serum urate
Liver function tests
Full blood count
Coagulation screen
UPCR
CTG
Ultrasound - biometry, AFI, Doppler

25

What's the management of pre-eclampsia?

Assess risk at booking
Hypertension <20 wks = look for secondary cause
Antinatal screening - BP, urine, MUAD
Treat hypertension
Maternal & fetal surveillance
Timing of delivery
PIH can be managed as O/P in day care unit

26

What are risk factors for pre-eclampsia?

Maternal age - >40 years
maternal BMI - >30
FHx
Parity (1st pregnancy)
Multiple pregnancy
Previous PET
Molar pregnancy/Triploidy

27

What are medical risk factors for pre-eclampsia?

Pre-existing renal disease
Pre-existing hypertension
Diabetes mellitus
Connective tissue disease
Thrombophilias (congenital/acquired)

28

What 6 reasons would make you admit someone with suspected pre-eclampsia?

1. BP >170/110 or >140/90 + proteinuria
2. Significant symptoms - headache / visual disturbances/ abdominal pain
3. Abnormal biochemistry
4. Significant proteinuria
5. Need for antihypertensive therapy
6. Signs of fetal compromise

29

How do you assess an inpatient?

Blood pressure - 4 hourly
Urinalysis - daily
Input/Output fluid balance chart
UPCR - proteinuria on urinalysis
Bloods - FBC, U&E's, Urate, LFT's, minimum X2 per week

30

How is fetal surveillance carried out?

Fetal movements
CTG - daily
Ultrasound - Biometry, amniotic fluid index, umbilical artery doppler

31

When should you deliver?

Mother must firstly be stabilised
Consider management if pre-term
Most women deliver within 2 weeks of diagnosis

32

What are indications for delivery?

Term gestation
Inability to control BP
Rapidly deteriorating biochemistry/haematology
Eclampsia
Other crisis
Fetal compromise - REDF, abnormal CTG

33

What are crises in pre-eclampsia?

Eclampsia
HELLP syndrome
Pulmonary oedema
Placental abruption
Cerebral haemorrhage
Cortical blindness
DIC
Acute renal failure
Hepatic rupture

34

What benefit do the steroids have towards the fetus?

Promote fetal lung surfactant production
Reduces neonatal respiratory distress syndrome by up to 50%

35

When should steroids be administered?

24-48hrs before delivery

36

When can be steroids be administered by?

36 weeks gestation

37

What steroid is preferred?

betamethasone (2X 12mg injections 12hrs apart)

38

What happens in eclampsia?

Tonic-clonic (grand mal) seizure occuring with pre-eclampsia features

39

What is eclampsia assoc. with?

Ischaemia
Vasospasm

40

What is the management of severe PET / eclampsia?

Control BP
Stop/prevent seizures
Fluid balance
Delivery

41

What 2 antihypertensives are used on pregnant women?

IV Labetalol
IV Hydralazine

42

What is used as seizure treatment/prophylaxis?

magnesium sulphate

43

What doses of magnesium sulphate?

Loading dose - 4g IV over 5 mins
Maintenance dose - IV infusion 1g/h

44

If further seizures happen what dose of magnesium sulphate should be given?

2g

45

What should be given if seizures are persistent?

Diazepam 10mg IV

46

What drug may be beneficial in preventing severe early onset pre-eclampsia?

Aspirin

47

When should aspirin be started?

Before 12 weeks