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OB Test 2 > Hypertensive Disorder > Flashcards

Hypertensive Disorder Flashcards

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
Q

What is the risk of preeclampsia in smokers?

A

It actually decreases their risk

-the more they smoke the more it is decreased

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26
Q

What else decreases the risk for preeclampsia?

A

Recreational activity

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27
Q

What are the hematologic clinical manifestations of preeclampsia?

A

Thrombocytopenia
Mild hypercoagulability in patients with mild preeclampsia
DIC occurs in some

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28
Q

What are the hepatic clinical manifestations of preeclampsia?

A

Periportal hemorrhage
Fibrin deposition in hepatic sinusoids
HELLP syndrome
Subcapsular bleeding

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29
Q

When is DIC more likely to occur with preeclampsia?

A

When there is liver involvement, or

A bleeding issue (placental abruption, postpartum hemorrhage etc)

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30
Q

What are the renal clinical manifestations of preeclampsia?

A 
Persistent proteinuria
Decreased GFR
Hyperuricemia 
Oliguria possibly a late manifestation, reflects severity of disease
Progression to renal failure is rare
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31
Q

What typically proceeds progression to renal failure with preeclampsia?

A

Hypovolemia
Placental abruption
DIC

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32
Q

What are the uteroplacental clinical manifestations of preeclampia?

A

Increased downstream resistance of uteroplacental bed
Diastolic flow velocity decreases
IUGR

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33
Q

What occurs in normal pregnancy that does not in preeclampsia that causes this decrease in blood flow to the fetus?

A

Normally the spiral arteries dilate, in the first stage of pregnancy, with preeclampsia they do not

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34
Q

Oliguria is what?

A

< 500mL of urine in 24 hours

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35
Q

Compare the morbidity of preeclampsia with chronic HTN with superimposed preeclampsia?

A

Chronic HTN with superimposed preeclampsia has greater morbidity

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36
Q

How can preeclampsia on top of chronic HTN be detected?

A

New onset proteinuria OR
Sudden increase in proteinuria and/or hypertension OR
Other manifestations of severe preeclampsia

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37
Q

When do most seizures occur with eclampsia?

A

Intrapartum or within the first 48 hours after delivery

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38
Q

Eclampsia has a high risk of what?

A

Perinatal death rate

-infant death within 7 days

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39
Q

What is the clinical presentation of eclampsia?

A 
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
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40
Q

Eclampsia management

A 
Stop convulsions
Establish airway
Prevent major complication
Anti-HTN therapy (labetalol) 
Induction or augmentation of labor
Expedite delivery (preferably vaginal)
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41
Q

What is the first drug of choice to stop seizures in eclampsia?

A

Magnesium sulfate

42
Q

What side effects can occur with Mg treatment?

A 
Respiratory depression
Higher incidence of c-section
Warm/flush, red face
N/V
Muscle weakness
Low BP
Drowsy
Confusion
HA
43
Q

What is HELLP syndrome?

A

Hemolysis
Elevated liver enzymes
Low platelets
Preeclampsia

44
Q

Is HELLP syndrome a variant of severe preeclampsia or does it represent a distinct pathophysiologic entity?

A

XXXX

Many preeclamptic patients don’t have HELLP

45
Q

HELLP syndrome has a higher risk of what?

A

Maternal death

46
Q

What risks does HELLP syndrome carry?

A 
Increased risk of DIC
Placental abruption
Pulmonary edema
ARF
CVA
Respiratory distress syndrome
Sepsis
Acute liver hemorrhage or failure
47
Q

What carries an increased risk of perinatal mortality and morbidity from prematurity?

A

HELLP syndrome

48
Q

What is the onset of HELLP syndrome in antepartum, and postpartum (%)?

A

Antepartum: 70%
Postpartum: 30%

49
Q

What percentage of babies from mother’s with HELLP are born premature?

A

70%

50
Q

What is the hallmark sign of HELLP syndrome?

A

Hemolysis

51
Q

What blood work value drops very fast with HELLP syndrome?

A

Platelet count

52
Q

When are platelet transfusions for significant bleeding or all parturients with a plt count of?

A

<20,000

53
Q

Platelet transfusions are given for surgery when plt count is?

A

<40,000

54
Q

Neuraxial anesthesia is not performed with a plt count?

A

< 80,000

55
Q

What kind of anesthesia is preferred in HELLP patients?

A

Continuous lumbar or spinal

-unless mother or baby in jeopardy

56
Q

What should be avoided with a test dose in neuraxial anesthesia? Why?

A

Epi in the test dose due to exaggerated vasopressin response
(Assuming this means just for HELLP patients)
XXX

57
Q

When you give corticosteroids to help fetal lung development, what else do they do?

A

Increase platelet count

58
Q

What is the first line drug for HTN (out of the hospital) in pregnancy?

A

Aldomet (methyldopa)

59
Q

What drug category is methyldopa?

A

Category B

60
Q

What do studies show with use of methyldopa in pregnancy?

A

Increase risk of preterm birth

-no teratogenic risk

61
Q

What happens when BP continues to rise even with home treatment?

A

Hospitalization

62
Q

What are the goals in avoiding/treating this HTN in pregnancy?

A

Avoid HTN encephalopathy
Avoid CVA
Avoid CHF
Avoid pulmonary edema

63
Q

What are the most commonly used medications for this unresponsive BP?

A

Hydralazine and labetalol

64
Q

Onset and duration and peak of hydralazine

A

Onset 10-20 minutes
Duration 2-6 hours
Peak 15-30 minutes

65
Q

What is the dosage of hydralazine?

A

5mg IV every 20 minutes up to a max of 20mg

66
Q

What is seen more with hydralazine compared to labetalol?

A

More maternal tachycardia and palpitations, but less neonatal bradycardia and hypotension than with labetalol

67
Q

What can be given to avoid hypotension with hydralazine?

A

Volume expansion

68
Q

What category is hydralazine?

A

Category C

69
Q

What is the onset and duration of labetalol?

A

Onset 5-10 minutes

Duration 4-6 hours

70
Q

What is the dose for labetalol?

A 
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
Q

What category is labetalol?

A

Category C

72
Q

If a regional is given and HTN persists, how much labetalol can be given?

A

Start with 5mg and reevaluate in 5 minutes, repeat if necessary

73
Q

What other medications are used for HTN but less commonly than hydralazine and labetalol?

A

Esmolol
Nitroprusside
Nifedipine

74
Q

What is esmolol associated with?

A

Fetal bradycardia

  • it is transient, doesn’t last forever
  • most don’t use
75
Q

What are the things to watch out for with nitroprusside use?

A

Smooth muscle vasodilator, titration to effect using arterial BP
Fetal cyanide toxicity
-unlikely with short term use

76
Q

What do you watch out for with using Nifedipine?

A

CCB relaxes arterial/arteriolar smooth muscle

SL administration has been associated with cerebral ischemia, infarction, MI, complete HB, and death

77
Q

When should you NOT use Nifedipine?

A

With CAD, DM, aortic stenosis

-can cause sudden cardiac death

78
Q

What is given for seizure prophylaxis in worsening preeclampsia?

A

Magnesium sulfate

79
Q

What else can Mg sulfate be used for?

A

To slow preterm labor

Help attenuate increased BP (has neroprotective effects on fetal brain)

80
Q

What is the seizure prophylaxis dose of Mg sulfate?

A

Started at 4g over 20-30 minutes

81
Q

What is the dose of Mg sulfate for fetal neuroprotective effects?

A

6gm

82
Q

What is the maintenance dose of Mg sulfate?

A

1-2g/hr

83
Q

What is the onset of Mg sulfate?

A

Immediate

84
Q

How fast is Mg sulfate cleared once stopped?

A

In 24 hours

-about 90% of it

85
Q

What is the category of Mg sulfate?

A

Was A changed to D in 2013

-d/t studies showing harm to fetus with prolonged use (5-7 days); osteopenia

86
Q

What is believed to the MOA of Mg sulfate in seizure prophylaxis?

A

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
Q

What are the side effects of Mg sulfate tx?

A 
Chest pain/tightness
Palpitations
Nausea
Blurred vision
Sedation
Hypotension
Pulmonary edema
88
Q

How can you prevent more serious side effects from Mg sulfate?

A

Titration to preserve deep tendon reflexes

89
Q

What is the therapeutic blood level for Mg sulfate?

A

5-9 mg/dL

90
Q

What is the anticonvulsant blood level for Mg sulfate?

A

2.5-7.5 mg/dL

91
Q

At what Mg sulfate blood level are patellar reflexes lost?

A

12 mg/dL

92
Q

At what Mg sulfate blood level does respiratory arrest occur?

A

15-20 mg/dL

93
Q

At what Mg sulfate blood level does asystole occur?

A

25 mg/dL

94
Q

How is Mg sulfate excreted?

A

Renally

-normal doses can be toxic with renal dysfunction

95
Q

How long is Mg given?

A

24 hours postpartum or longer if needed

96
Q

What is the treatment Mg sulfate toxic/too high levels?

A

Stop infusion
Ca gluconate 1g over 10 minutes
Intubate for respiratory depression

97
Q

What affects occur to the baby exposed to Mg?

A

Floppy or listless at birth

-goes away as drug is cleared

98
Q

Who should NOT have Mg? Why?

A

Myasthenia gravis: nerve muscle conduction is already impaired severe skeletal muscle weakness may occur
Muscular dystrophy

99
Q

With use of Mg, what is typically not used in c-sections? Why?

A

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
Q

Mg also potentiates what drug?

A

Volatile anesthetics

OB Test 2 (4 decks)

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