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Hypertensive Disorder Flashcards

(100 cards)

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1
Q

What is the most common medical disorder of pregnancy?

A

Hypertension

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2
Q

Hypertension occurs in what percentage of pregnancies?

A

6-10% of all pregnancies

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3
Q

The leading cause of maternal mortality in the developed world?

A

Hypertension

-16% of deaths in developed world

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4
Q

What complications occur in the fetus with maternal HTN?

A

Preterm birth
Fetal intrauterine growth restriction (IUGR)
Fetal/neonatal death

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5
Q

What are the 5 hypertensive disorders?

A 
Chronic hypertension
Gestational hypertension
Preeclampsia without severe features, and with severe features 
Preeclampsia superimposed on chronic HTN
Eclampsia
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6
Q

Chronic HTN constitutes what BP?

A

Systolic 140 or above
OR
Diastolic 90 or above

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7
Q

What is the most frequent cause of HTN in the pregnant population?

A

Gestational HTN

-5% of pregnancies after 20 weeks gestation

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8
Q

What are the signs of preeclampsia?

A

High BP

Proteinurea

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9
Q

Can preeclampsia occur without proteinuria?

A

Yes, but they must have some end organ involvement

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10
Q

What constitutes eclampsia?

A

New onset of seizures on top of all preeclampsia symptoms

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11
Q

How is chronic HTN diagnosed after pregnancy?

A

BP that fails to resolve postpartum after 12 weeks

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12
Q

With gestational HTN when does BP increase, and when does it decrease?

A

Increases after 20 weeks gestation

Resolves by 12 weeks postpartum

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13
Q

What along with HTN can diagnose preeclampsia when there is no proteinuria?

A

Persistent epigastric or RUQ pain (liver)
Persistent cerebral symptoms (HA, visual disturbances)
Fetal growth restriction
Thrombocytopenia
Increase liver enzymes

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14
Q

What are the vascular clinical manifestations of preeclampsia?

A

Widespread endothelial dysfunction > edema, unstable vascular tone, plt activation, local thrombosis (occurs with 2nd stage of preeclampsia)
Multi system disease

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15
Q

What percentage increase has been seen in the past several years in severe preeclampsia and/or eclampsia?

A

30%

-d/t increased maternal age, obesity, HTN, DM

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16
Q

When does preeclampsia most commonly occur?

A

In the third trimester

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17
Q

How long does it take for preeclampsia symptoms to typically resolve?

A

Within 48 hours of delivery

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18
Q

Uncommon postpartum preeclampsia usually manifests when?

A

Within 7 days postpartum

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19
Q

What emergency situation can this endothelial dysfunction cause?

A

Placental abruption

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20
Q

What is the only way to FIX preeclampsia?

A

Get baby out

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21
Q

What are the CNS clinical manifestations of preeclampsia?

A 
Loss of cerebral autoregulation
Vascular barotrauma
Hyperexcitability
Severe HA
Visual disturbances
Hyperreflexia 
Coma
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22
Q

What are the airway clinical manifestation of preeclampsia?

A

Edema
Mucosal capillary enlargement
Decreased internal diameter of trachea
Difficult with laryngoscopic visualization of landmarks
Airway obstruction from subglottic edema (hoarseness, stridor, snoring, hypoxemia)

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23
Q

What are the pulmonary clinical manifestation of preeclampsia?

A 
Pulmonary edema (3% of women with preeclampsia)
-decreased colloid pressure from decreased plasma albumin increases vascular permeability and increase intravascular hydrostatic pressure
Acute respiratory distress syndrome
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24
Q

What are the cardiovascular clinical manifestations of preeclampsia?

A

Increased vascular tone > greater sensitivity of vasoconstrictors
Vasospasm from exaggerated response to circulating catecholamines
HTN and end organ ischemia
Most patients have hyperdynamic LV function

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25
What is the risk of preeclampsia in smokers?
It actually decreases their risk | -the more they smoke the more it is decreased
26
What else decreases the risk for preeclampsia?
Recreational activity
27
What are the hematologic clinical manifestations of preeclampsia?
Thrombocytopenia Mild hypercoagulability in patients with mild preeclampsia DIC occurs in some
28
What are the hepatic clinical manifestations of preeclampsia?
Periportal hemorrhage Fibrin deposition in hepatic sinusoids HELLP syndrome Subcapsular bleeding
29
When is DIC more likely to occur with preeclampsia?
When there is liver involvement, or | A bleeding issue (placental abruption, postpartum hemorrhage etc)
30
What are the renal clinical manifestations of preeclampsia?
``` Persistent proteinuria Decreased GFR Hyperuricemia Oliguria possibly a late manifestation, reflects severity of disease Progression to renal failure is rare ```
31
What typically proceeds progression to renal failure with preeclampsia?
Hypovolemia Placental abruption DIC
32
What are the uteroplacental clinical manifestations of preeclampia?
Increased downstream resistance of uteroplacental bed Diastolic flow velocity decreases IUGR
33
What occurs in normal pregnancy that does not in preeclampsia that causes this decrease in blood flow to the fetus?
Normally the spiral arteries dilate, in the first stage of pregnancy, with preeclampsia they do not
34
Oliguria is what?
< 500mL of urine in 24 hours
35
Compare the morbidity of preeclampsia with chronic HTN with superimposed preeclampsia?
Chronic HTN with superimposed preeclampsia has greater morbidity
36
How can preeclampsia on top of chronic HTN be detected?
New onset proteinuria OR Sudden increase in proteinuria and/or hypertension OR Other manifestations of severe preeclampsia
37
When do most seizures occur with eclampsia?
Intrapartum or within the first 48 hours after delivery
38
Eclampsia has a high risk of what?
Perinatal death rate | -infant death within 7 days
39
What is the clinical presentation of eclampsia?
``` Persistent HA Blurred vision Epigastric or RUQ pain Photophobia Hyperreflexia Altered mental status Abrupt onset of seizures -tonic clonic preceded by facial twitching -apnea -postictal phase ```
40
Eclampsia management
``` Stop convulsions Establish airway Prevent major complication Anti-HTN therapy (labetalol) Induction or augmentation of labor Expedite delivery (preferably vaginal) ```
41
What is the first drug of choice to stop seizures in eclampsia?
Magnesium sulfate
42
What side effects can occur with Mg treatment?
``` Respiratory depression Higher incidence of c-section Warm/flush, red face N/V Muscle weakness Low BP Drowsy Confusion HA ```
43
What is HELLP syndrome?
Hemolysis Elevated liver enzymes Low platelets Preeclampsia
44
Is HELLP syndrome a variant of severe preeclampsia or does it represent a distinct pathophysiologic entity?
XXXX | Many preeclamptic patients don’t have HELLP
45
HELLP syndrome has a higher risk of what?
Maternal death
46
What risks does HELLP syndrome carry?
``` Increased risk of DIC Placental abruption Pulmonary edema ARF CVA Respiratory distress syndrome Sepsis Acute liver hemorrhage or failure ```
47
What carries an increased risk of perinatal mortality and morbidity from prematurity?
HELLP syndrome
48
What is the onset of HELLP syndrome in antepartum, and postpartum (%)?
Antepartum: 70% Postpartum: 30%
49
What percentage of babies from mother’s with HELLP are born premature?
70%
50
What is the hallmark sign of HELLP syndrome?
Hemolysis
51
What blood work value drops very fast with HELLP syndrome?
Platelet count
52
When are platelet transfusions for significant bleeding or all parturients with a plt count of?
<20,000
53
Platelet transfusions are given for surgery when plt count is?
<40,000
54
Neuraxial anesthesia is not performed with a plt count?
< 80,000
55
What kind of anesthesia is preferred in HELLP patients?
Continuous lumbar or spinal | -unless mother or baby in jeopardy
56
What should be avoided with a test dose in neuraxial anesthesia? Why?
Epi in the test dose due to exaggerated vasopressin response (Assuming this means just for HELLP patients) XXX
57
When you give corticosteroids to help fetal lung development, what else do they do?
Increase platelet count
58
What is the first line drug for HTN (out of the hospital) in pregnancy?
Aldomet (methyldopa)
59
What drug category is methyldopa?
Category B
60
What do studies show with use of methyldopa in pregnancy?
Increase risk of preterm birth | -no teratogenic risk
61
What happens when BP continues to rise even with home treatment?
Hospitalization
62
What are the goals in avoiding/treating this HTN in pregnancy?
Avoid HTN encephalopathy Avoid CVA Avoid CHF Avoid pulmonary edema
63
What are the most commonly used medications for this unresponsive BP?
Hydralazine and labetalol
64
Onset and duration and peak of hydralazine
Onset 10-20 minutes Duration 2-6 hours Peak 15-30 minutes
65
What is the dosage of hydralazine?
5mg IV every 20 minutes up to a max of 20mg
66
What is seen more with hydralazine compared to labetalol?
More maternal tachycardia and palpitations, but less neonatal bradycardia and hypotension than with labetalol
67
What can be given to avoid hypotension with hydralazine?
Volume expansion
68
What category is hydralazine?
Category C
69
What is the onset and duration of labetalol?
Onset 5-10 minutes | Duration 4-6 hours
70
What is the dose for labetalol?
``` 20mg IV (is what the book says, this is ALOT start with ~5 or 10mg) then in 10 minutes give 40-80 mg every 10 minutes up to a max of 220mg ```
71
What category is labetalol?
Category C
72
If a regional is given and HTN persists, how much labetalol can be given?
Start with 5mg and reevaluate in 5 minutes, repeat if necessary
73
What other medications are used for HTN but less commonly than hydralazine and labetalol?
Esmolol Nitroprusside Nifedipine
74
What is esmolol associated with?
Fetal bradycardia - it is transient, doesn’t last forever - most don’t use
75
What are the things to watch out for with nitroprusside use?
Smooth muscle vasodilator, titration to effect using arterial BP Fetal cyanide toxicity -unlikely with short term use
76
What do you watch out for with using Nifedipine?
CCB relaxes arterial/arteriolar smooth muscle | SL administration has been associated with cerebral ischemia, infarction, MI, complete HB, and death
77
When should you NOT use Nifedipine?
With CAD, DM, aortic stenosis | -can cause sudden cardiac death
78
What is given for seizure prophylaxis in worsening preeclampsia?
Magnesium sulfate
79
What else can Mg sulfate be used for?
To slow preterm labor | Help attenuate increased BP (has neroprotective effects on fetal brain)
80
What is the seizure prophylaxis dose of Mg sulfate?
Started at 4g over 20-30 minutes
81
What is the dose of Mg sulfate for fetal neuroprotective effects?
6gm
82
What is the maintenance dose of Mg sulfate?
1-2g/hr
83
What is the onset of Mg sulfate?
Immediate
84
How fast is Mg sulfate cleared once stopped?
In 24 hours | -about 90% of it
85
What is the category of Mg sulfate?
Was A changed to D in 2013 | -d/t studies showing harm to fetus with prolonged use (5-7 days); osteopenia
86
What is believed to the MOA of Mg sulfate in seizure prophylaxis?
Cerebral vasodilation > reduces ischemia and risk for seizure It acts competitively with Ca by blocking entry into synaptic ending so you don’t have neuromuscular transmission
87
What are the side effects of Mg sulfate tx?
``` Chest pain/tightness Palpitations Nausea Blurred vision Sedation Hypotension Pulmonary edema ```
88
How can you prevent more serious side effects from Mg sulfate?
Titration to preserve deep tendon reflexes
89
What is the therapeutic blood level for Mg sulfate?
5-9 mg/dL
90
What is the anticonvulsant blood level for Mg sulfate?
2.5-7.5 mg/dL
91
At what Mg sulfate blood level are patellar reflexes lost?
12 mg/dL
92
At what Mg sulfate blood level does respiratory arrest occur?
15-20 mg/dL
93
At what Mg sulfate blood level does asystole occur?
25 mg/dL
94
How is Mg sulfate excreted?
Renally | -normal doses can be toxic with renal dysfunction
95
How long is Mg given?
24 hours postpartum or longer if needed
96
What is the treatment Mg sulfate toxic/too high levels?
Stop infusion Ca gluconate 1g over 10 minutes Intubate for respiratory depression
97
What affects occur to the baby exposed to Mg?
Floppy or listless at birth | -goes away as drug is cleared
98
Who should NOT have Mg? Why?
Myasthenia gravis: nerve muscle conduction is already impaired severe skeletal muscle weakness may occur Muscular dystrophy
99
With use of Mg, what is typically not used in c-sections? Why?
ND-NMB because abdominal wall is already stretched and relaxed Mg increases the potency and duration with increased need for mechanical ventilation after routine doses
100
Mg also potentiates what drug?
Volatile anesthetics

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