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Flashcards in Hypertensive disorder pregnancy Deck (17)
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1
Q

Discuss hypertensive categories in preganancy

A

Gestational hypertension – occurs during pregnancy, resovles with delivery recognized by a new blood pressure of 140/90 mmhg or higher

Pre-eclampsia – gestational hypertension with one or more of the followin

  • renal impairment – proteinuria >300mg in 24hours , high Cr
  • liver disease – epigastric pain, liver tenderness, -elevated transaminases
  • neurological problems – seizures, visual disturbance, -papilloedema, clonus
  • haematological disturbance – thrombocytopaenia, -haemolysis, DIC
  • fetal growth restriction – non reassuring CTG, reverse flow on Doppler, IUGR

Eclampsia is the occurence of siezures in the patients with signs of pre-eclampsia – progression is unpredictable and may develop rapidly

Preganancy aggrevated hypertension – chronic HTN with syperimposed pre-eclampsia or eclampsia

2
Q

Discuss risk factors for the development of pregnancy related hypertensive disorders

A

Epi-
-Women under 20 or over 35

Pregnnacy

  • Primigravidas
  • Twin pregnancy
  • Molar pregnancies

Co-morbidities

  • those with hyperlipidaemia
  • pregestational diabetes
  • obesity - BMI >30
  • family history
-Prothrombotic 
connective tissue disorders -SLE 
protein C and S deficiencies
antiphospholipid syndrome
factor V leiden mutation
hyperhomocysteinemia
3
Q

Discuss pathophysiology of pre-eclampsia

A

vaso-spastic disease unique to pregnancy – unknown cause
Vasospasm, ischaemia and thrombosis associated with pre-eclamptic change cause injury to maternal organs, placental infarction and abruption and foetal death from hypoxia or prematurity

Vascular responsiveness is usually depressed in pregnancy with a high output low resistance state – in pre-ecmplasia there is an even higher output state with an unusually high vascular resistance

Cause is unclear but may be due to imbalance between prostocyclin and thromboxane from ednothelial dysfucntion – this is supported by the fact that antiplatelet agents reduce risk of development of PET

4
Q

Discuss clinical features of PET

A

HTN
Proteinia although not always present
Odema – difficult to asses in pregnant women as usually some degree of dependent odema

Neuro

  • Headache - persistent or severe
  • Visual (scotomata, photophobia, blurred vision, temporary blindness)
  • Eclampsia
  • Hyperreflexia

CVS

  • Increased SVR
  • Raised CO

GIT

  • Severe epigastric pain
  • RUQ pain
  • HELLP

Renal

  • Proteinuria - >30mg/mol
  • Oliguria <500ml/day

Haem

  • Haemolysis
  • THrombocytopenia

Foetus

  • Foetal demise
  • foetal growth restriction
5
Q

Discuss complications of PET

A

HELLP syndrome develops in 5-10% of women with pre-eclampsia. Characterized by haemolysis, elevated liver enzymses, low platelt count.

Eclampsia – occurence of seizures or coma\
warning sings include headache, nausea and vomiting, visual disturbances. elevated total leukocyte count and creatinine
Particularly in early eclampsia <32 weeks gestation seizure may develop early and HTN may not be assoicated with oedema or proteinuria

Pulmonary oedema
Placental abruption

Foetal risk

  • > 24 weeks delaying pregnancy is outweighed by the high maternal risk
  • 24-33 weeks foeus risks are RDS, longer ICU admission and high risk of c section
6
Q

What percentage of post partum women who develop eclampsia were undiagnosed with pre-eclampsia at delivery

A

55%

7
Q

How long can patient present with pre-eclamptic or eclamptic symptoms after delivery

A

For up to 4 weeks

8
Q

Discuss diagnositic testing in eclampsia

A

Foetal and maternal monitoring
FBC, U&E, LFTS, coags platelet count
Baseline magnesium level is important
Glucose level especially in those with true seizures

If nil history of pre-eclampsia was obtained prior to seizure or refractory to magnesium sulfate a CT head should be performed to exclude central venous thromobosis or intracranial haemorrhage both of which can occur without HTN

CT changes can be seen in 50% of patients with eclampsia

9
Q

Discuss management of pre-eclampsia -non pharm

A

Need to determine the gestation of the child to inform further treatment
Bed rest and minimal exertion is the only demonstrated means of reducing blood pressure and allowing the pregnancy to be sustained longer

Definitive treatment is for delivery of the child – although expectant management is standard for women less than 34 weeks of gestation

left lateral postion to avoid aorto-caval compression

10
Q

Discuss management of eclampsia - seizure

A

Eclamptic seizures are controlled in almost all cases with adequate doses of magnesium – start with a 4 gram loading dose and then 2gram/hour (LIFTL 5 gram loading 1gram.hr – MAGPIE trial) – monitor for overdose,

  • respiratory depression
  • drowsiness
  • loss of reflexes

If seizures persist can trial other anti seizure medications – diazapam, phenytoin

As in all seizure alternative causes should be considered – hypoglycaemia, epilepsy, intracranial catastrophy

11
Q

Discuss management of eclampsia and pre-eclampsia - htn

A

Rapid lowering of blood pressure can result in uterine hypoperfusion so specific antihypertensives should not be used unless diastolic >105

Aim BP <140/110

  1. methyldopa PO 0.5-3g/day
  2. labetalol IV 5-10mg injected slowly
  3. nifedipine PO 10-20mg or IV 100-200mg over 2 min
  4. beta-blockers (metoprolol, pindolol, propanolol, esmolol)
  5. hydrallazine IV 10-20mg slowly
  6. GTN IV 0.1-0.8mcg/kg/min
  7. SNP IV 1-4mcg/kg/min
12
Q

Discuss intra-operative management of eclampsia

A

single shot spinal, CSE and epidural have all been employed
hypotension less common
GA; abate hypertensive response to intubation (1mg alfentanil), monitor for APO @ emergence
use arterial line
avoid syntometrine and ergometrine -> acute hypertension

13
Q

Postoperative/delivery Management

A
continue antihypertensives
continue MgSO4
NSAIDS if not contraindicated
thromboprophylaxis
manage APO in standard manner (LMNOP)
14
Q

Discuss fluid balance in eclampsia

A

Although TBW is excessive in eclamptic patient the intravascular volume is contracted and the eclamptic patient is sensitive to fluid shift.

Diuretics and hyperosmotic agents should be avoided

Catious fluid replacement as excessive fluid increases extravascular fluid stores that are difficult to mobilise post partum and lead to increase risk of APO.

15
Q

List risk factors for the development of pre-eclampsia

A
Past histroy 
Pregestational daibetes
Chornic hypertension 
Preprgancny overweight or obesity
SLE, antiphospholipid syndrome 
CKD
Multifeotal pregnancy 
Nulliparity
Family histroy 
Extremes of age particuarlly advanced >35
Use of assisted reproductive technology
16
Q

Discuss diagnositc criteria for pre-eclampsia

A

Pre-eclampsia refers to the new onset of HTN and proteinuria or the new onset of HTN and significant end-organ dysfunction with or without proteinuria after 20 weeks gestation.

Systolic blood pressure >140/90 on at least 2 occasions at least 4 horus apart after 20 weeks gestation in a previously normotensive patient and the onset of 1 or more of the following

1) protenuira >0.3g in a 24hour urine spec or protein creat ratio >0.3protien/mg creatinine (30mg/mol) in a random urine spec or a dip protiein of 2+
2) platelat count <100
3) serum creat 97 or doubling of the creat concentration
4) liver transminases at least twice the upper limit of normal
5) pulmonary oedema
6) new onset persistent headache not accounted for by alternative diagnosis
7) visual symptoms (blurring vision, flashing lights or sparks, scotomata)

17
Q

Discuss criteria for severe pre-eclampsia

A

In a patient with diagnosed pre-ecalmapsia one of more of the following indicates a diagnosis of PET with severe featreus

1) Severe elevation in BP >160 systolic or a diastolic of >110 on 2 occasions at least 4 hours apart

2) Symptoms of CNS dysfunction
- new onset cerebral or visual distruabnace such as
- -photopsia, scotomata, cortical blindness, retinal vasospsam
- - severe headache (incapacititating)

3) Hepatic abnormality
- Serum transaminase concentration >2 times upper limit or severe persistent RUQ or epigastric pain unresponsive to medication and not accounted for by an alternative diagnosis

4) Thrombocytopenia
- <100

5) renal insuffieiciny