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Year 3 Clinical > Hypertension in Pregnancy > Flashcards

Hypertension in Pregnancy Flashcards

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1
Q

Occurrence of hypertension in pregnancy?

A

Affects 10-15% of all pregnancies

Mild pre-eclampsia affects 10% of primigravid women and severe pre-eclampsia affects 1% of primigravid women

Eclampsia is less common

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2
Q

What is the most common cause of iatrogenic prematurity?

A

Pre-eclampsia

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3
Q

CVS changes that occur in pregnancy?

A 
Increase in the following:
• Blood volume
• Plasma volume
• Cardiac output
• Stroke volume
• Heart rate

Decreased peripheral vascular resistance

Unchanged CVP

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4
Q

When do these CVS changes occur during pregnancy?

A

Occur in the 1st trimester, with the most CVS changes occurring in the first 12 weeks of pregnancy

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5
Q

Changes in BP that occur during and after pregnancy?

A

BP FALLS in early pregnancy, due to the vasodilatation that occurs during pregnancy, with nadir being reached at 22-24 weeks

This is followed by a steady BP rise until term, with pre-pregnancy BP being reached at ~34 weeks

Following delivery, BP falls but subsequently rises to peak at 3-4 days post-natal

NOTE - if a women has a normal BP at her booking appointment (in the 1st trimester), she may have had pre-existing hypertension

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6
Q

Definitions of hypertension?

A

≥140/90 mmHg on 2 occasions

OR

> 160/110 mmHg once

NOTE - in the US, hypertension is >30/15 mmHg, compared to the 1st trimester BP

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7
Q

3 categories of hypertension in pregnancy?

A
  1. Pre-existing hypertension
  2. Pregnancy-Induced Hypertension (PIH)
  3. Pre-eclampsia (PET)

NOTE:
• If the hypertension presents occurs in early pregnancy, it is likely pre-existing hypertension
• If it presents late in the pregnancy, likely to be PIH or PET
• If it occur mid-pregnancy, there is a degree of uncertainty

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8
Q

What is pre-existing hypertension?

A

Diagnosis prior to pregnancy

OR

Likely to be the case if the hypertension presents in early pregnancy

OR

May be a retrospective diagnosis if the BP has not returned to normal within 3 months of delivery

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9
Q

Potential secondary causes of pre-existing hypertension?

A

Renal / cardiac causes

Cushing’s

Conn’s

Phaeochromocytoma

etc

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10
Q

Risks assoc. with pre-existing hypertension?

A

PET

IUGR

Placental abruption

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11
Q

What is Pregnancy-Induced Hypertension (PIH)?

A

Hypertension occurring in the second half of pregnancy and resolving within 6/52 of delivery

There is no proteinuria or other features of PET

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12
Q

Risks assoc. with PIH?

A

15% of patients progress to PET (depends on the gestation)

High recurrence rate in subsequent pregnancies

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13
Q

Features of pre-eclampsia?

A

Classic triad of:
• Hypertension
• Proteinuria (≥0.3 g/l or ≥0.3 g/24h)
• Oedema

NOTE - a diagnosis of PET does not require the presence of all 3 features, e.g: patients can have 2 of the features and still have PET

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14
Q

What is pre-eclampsia?

A

Pregnancy-specific multi-system disorder with unpredictable, variable and widespread manifestations

There is diffuse vascular endothelial dysfunction and widespread circulatory disturbance

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15
Q

Stages of pre-eclampsia?

A

Stage 1 - abnormal placental perfusion leads to placental ischaemia

Stage 2 - development of the maternal syndrome, which is an anti-angiogenic state assoc. with endothelial dysfunction

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16
Q

Explain normal placentation

A

During a normal pregnancy, trophoblast infiltration leads to loss of the smooth muscle surrounding spinal arteries; this reduces resistance and increases blood flow, i.e: the spiral arteries adapt to become high capacitance, low resistance vessels

Result is normal perfusion of the placenta

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17
Q

Pathogenesis of pre-eclampsia?

A

There is a genetic / environmental predisposition

There is abnormal placentation and a failure of trophoblast infiltration, so the smooth muscle around the spiral arteries remains

The maternal response is to increase blood flow by increasing BP; this leads to widespread endothelial damage and dysfunction

Endothelial activation:
• Increased capillary permeability
• Increased CAM expression
• Increase in pro-thrombotic factors
• Increased platelet aggregation
• Vasoconstriction

Result is end-organ damage

NOTE - in pre-eclampsia, there is an imbalance between angiogenic and anti-angiogenic factors

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18
Q

End-organ damage that can occur with pre-eclampsia?

A

CNS, renal, hepatic, haematological, pulmonary, CV

Placental

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19
Q

Classifications of pre-eclampsia and the occurrence of each?

A

Early pre-eclampsia (<34 weeks) is uncommon

Late pre-eclampsia (≥34 weeks) comprises the majority of cases

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20
Q

Risks assoc. with early pre-eclampsia?

A

Assoc. with extensive villous and vascular lesions of the placenta

There is a higher risk of maternal and foetal COMPLICATIONS than with late pre-eclampsia

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21
Q

Risks assoc. wit late pre-eclampsia?

A

Minimal placental lesions

Most cases of ECLAMPSIA and MATERNAL DEATH occur in late disease

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22
Q

CNS disease that can occur in pre-eclampsia?

A

Eclampsia

Hypertensive encephalopathy

Intracranial haemorrhage

Cerebral oedema

Cortical blindness (due to cortical ischaemia)

Cranial nerve palsy

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23
Q

Signs of renal disease in pre-eclampsia?

A

Oliguria / anuria

Reduced GFR

Proteinuria

Increased serum urate / uric acid (occurs due to maternal renal disease and also due to placental ischaemia)

Increased creatinine, K+ and urea

Acute renal failure:
• Acute tubular necrosis
• Renal cortical necrosis

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24
Q

Liver disease assoc. with pre-eclampsia?

A

HELLP Syndrome:
• Haemolysis
• Elevated Liver enzymes
• Low Platelets

It can lead to hepatic capsule rupture

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25
Presentation of HELLP syndrome?
Early symptoms of epigastric / RUQ pain NOTE - all women with suspected pre-eclampsia must be asked about this
26
Haemtological disease manifestations in pre-eclampsia?
Reduced PV Haemo-concentration Thrombocytopaenia Haemolysis Disseminated Intravascular Coagulation (DIC) - PET can trigger the coagulation pathway
27
Cardiac / pulmonary disease that can occur in pre-eclampsia?
Pulmonary oedema, either iatrogenic or disorder-related, can lead to ARDS PE These are assoc. with a high mortality NOTE - generally, women are limited to 80 mls/hour fluid intake, if they have PET, to avoid fluid overloading them
28
Placental disease that can occur in pre-eclampsia?
Foetal growth restriction (FGR) Placental abruption Intrauterine death
29
Presentation of pre-eclampsia?
May be asymptomatic at the time of presentation; at every antenatal check, BP is urine is checked Headache Visual disturbance Epigastric / RUQ pain N&V Rapidly progressive oedema NOTE - these symptoms are non-specific and some of them often occur in normal pregnancies
30
Signs of pre-eclampsia?
Hypertension, proteinuria and oedema Abdominal tenderness Disorientation (confusion may be a sign of CNS damage) Small for gestational age (SGA) - if <10th centile Intra-uterine death (IUD) Hyper-reflexia / involuntary movements / clonus
31
Ix for pre-eclampsia?
U&Es, serum urate (often the 1st reading to increase, due to maternal renal disease and also placental ischaemia), LFTs, FBC and coagulation screen Urine PCR CTG USS: • Foetal biometry • Amniotic Fluid Index (AFI) • Doppler
32
General screening rules for pre-eclampsia?
Assess patient risk at booking appointment If hypertension is present <20 weeks, look for a secondary cause Antenatal screening involves: • BP • Urine • Maternal Uterine Artery Doppler (MUAD) - used to check for normal changes in the spiral arteries
33
Risk factors for pre-eclampsia?
Maternal age (>40 years) Maternal BMI (>30) FH: • 20-25% if mother affected • Up to 40% if sister affected Parity (increased risk with 1st pregnancy) Multiple pregnancy (increased risk with twins) Previous pre-eclampsia Birth interval >10 years, i.e: since last pregnancy Molar Pregnancy / triploidy (abnormal trophoblast infiltration) - tends to cause early-onset PET Multiparous women develop more severe disease, i.e: if the PET occurs in the 2nd pregnancy rather than the 1st, it tends to be more severe
34
Medical risk factors for PET?
Pre-existing renal disease Pre-existing hypertension Diabetes (pre-existing OR gestational) CTD, e.g: lupus (may be difficult to differentiate a lupus flare from pre-eclampsia) Thrombophilias (congenital OR acquired)
35
Prevention of pre-eclampsia?
``` Low-dose (75mg) aspirin for high-risk women, e.g: • Renal disease • DM • Anti-phospholipid syndrome • Multiple risk factors • Previous PET ``` It should be commenced before 12 weeks (as placentation occurs between 8 and 20 weeks)
36
Ix to predict pre-eclampsia?
MUAD at 20-24 weeks A normal MUAD shows a low resistance waveform, signalling good blood flow in both systole and diastole A notch waveform indicates that spiral artery transformation has not yet occurred, so there is an increased risk of PET; monitor this woman and repeat at 28 weeks
37
When should patients be referred with suspected pre-eclampsia?
BP ≥140/90 mmHg (++) proteinuria Oedema Symptoms, esp. persistent headache
38
When should patients be admitted?
1. BP >170/110 mmHg OR >140/90 with (++) proteinuria 2. Significant symptoms, e.g: • Headache • Visual disturbance • Abdominal pain 3. Abnormal biochemistry 4. Significant proteinuria (>300 mg/24hrs) 5. Need for anti-hypertensive therapy 6. Signs of foetal compromise
39
Inpatient assessment of a woman with pre-eclampsia?
BP (4 hourly) Daily urinalysis Input / output fluid balance chart Urine PCR (if proteinuria on urinalysis) ``` Bloods (minimum twice per week): • FBC • U&Es • Urate • LFTs ```
40
Management of pre-eclampsia?
Treatment of hypertension Maternal and foetal surveillance Plan the timing of delivery (maternal risks must be balanced against the risks of prematurity) NOTE - PIH can be managed as an outpatient
41
When is hypertension in pregnancy treated?
It is treated regardless of the aetiology Most patient are treated once their BP ≥150/100 mmHg BP ≥170/110 mmHg required immediate treatment
42
Target BP if treating hypertension in pregnancy?
Aim for 140-150 / 90-100 mmHg NOTE - control of the BP does not reduce the risk of PET
43
Drugs used to treat hypertension in pregnancy?
Labetalol (α + β antagonist) Nifedipine (Ca2+ channel antagonist) Methyldopa (centrally acting α-agonist) 2nd line: • Hydralazine (vasodilator) • Doxazocin (α-antagonist) NOTE - avoid diuretics / ACEIs
44
Contraindications of the drugs?
Methyldopa - contraindicated in depression Labetalol - contraindicated in asthma
45
Which of these drugs can be used while breastfeeding?
All except Doxazosin
46
Methods of foetal surveillance?
Checking foetal movements Daily CTG USS: • Biometry • AFI • Umbilical artery doppler
47
Interpreting an umbilical artery doppler?
Normal Absence of umbilical arterial end-diastolic flow (AEDF) Reversal of umbilical arterial end-diastolic flow (REDF)
48
Only cure for pre-eclampsia?
Delivery of the baby; mother must be stabilised beforehand NOTE - most women deliver within 2 weeks of diagnosis If preterm, consider expectant Mx NOTE - do not forget steroids, for foetal lung maturation
49
Indications for birth?
Term gestation Inability to control BP Rapidly deteriorating biochemistry / haematology Eclampsia Other crisies Foetal compromise, e.g: • REDF • Abnormal CTG
50
Crises in pre-eclampsia (require immediate delivery)?
Eclampsia HELLP syndrome Pulmonary oedema Placental abruption Cerebral haemorrhage Cortical blindness DIC Acute renal failure Hepatic rupture
51
What is eclampsia?
Tonic-clonic (grand mal) seizure occurring with features of pre-eclampsia NOTE - 1/3rd of patients will have the seizure prior to onset of hypertension or proteinuria It is assoc. with ischaemia / vasospasm
52
When do the seizures occur?
Ante-partum Intra-partum Post-partum NOTE - most occur either during labour or after labour
53
Occurrence of eclampsia?
More common in teenagers
54
Mx of severe PET / eclampsia?
Control BP Fluid balance Stop / prevent seizures Delivery (both require immediate delivery)
55
Anti-hypertensives used for severe PET / eclampsia?
IV labetalol IV hydralazine NOTE - beware hypotension, which can reduce placental perfusion and cause foetal compromise
56
Treatment / prophylaxis of seizures?
MAGNESIUM SULPHATE: • Loading dose - 4g IV over 5 minutes • Maintenance dose - IV infusion of 1g/hr If the patient has further seizures, administer 2g magnesium sulphate If the patient has persistent seizures, consider diazepam 10mg IV
57
Why is fluid balance so important, esp. in the hypertensive pregnancy woman?
Main cause of maternal death is pulmonary oedema Oliguria occurs in 30% of these patients but it does not require intervention It is safer to run a patient 'dry', i.e: limit them to 80 mls/hr
58
Ix for fluid balance?
Check renal function, if there are doubts, by checking the urine osmolality
59
Mx of labour and birth with the hypertensive pregnancy?
If possible, aim for a vaginal birth; requires continous electronic foetal monitoring Control BP and be cautious with IV fluids Epidural anaesthesia can be used NOTE - avoid ergometrine, as it has hypertensive effects
60
Post-partum Mx of a the hypertensive woman?
Encourage breastfeeding and contraception (to allow recovery time) Control BP (continue anti-hypertensives; may need to increase the dose during the first 3-4 days post-natal) Counselling and advise on future risk and long-term CVD risk

Year 3 Clinical (100 decks)

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