Hypertensive disorders Flashcards Preview

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Flashcards in Hypertensive disorders Deck (22):
1

Definition

BP 140/90 on 2 separate readings 4 h
hours apart or +systolic >30mmHg, diastolic
>15mmHg from booking visit

2

Deadly triad

1. Hypertension
2. Hemorrhage
3. Infection
?VTE

3

Classification of hypertension in pregnancy

1. Gestational hypertension
2. Chronic hypertension
3. Chronic hypertension superimposed w/ pre-eclampsia

4

Define pre-eclampsia

1. Pregnancy specific
2. Reduced organ perfusion
3. Secondary to vasospasm and endothelial activation
4. >140/90 on 2 occasions w/ proteinuria or systemic involvement: renal insufficiency (Cr >80) or liver dysfunction: AST/ALT +, RUQ/epigastric pain due to liver necrosis, ischemia and edema

5

Etiology

1. Failed invasion of trophoblast cells->maladaption of maternal spiral arterioles
2, Immune intolerance
3. Maternal maladaption to CV/inflammatory changes of pregnancy
4. Dietary deficiencies
5. Genetic influences

6

Pathogenesis

1. Abnormal invasion--> abnormal prostacyclin:thromboxane
ratio--> +thromboxane= vasoconstriction,
PLT aggregation
2. maladapt arterioles % vasospasm (immune and genetic)-->abnormal villous development=placental insufficiency
3. fetal growth restriction,
4. ++vascular resistance + HTN
5. endothelial cell activation after damage
++coagulation
6. Inflammatory activation--> +vascular permeability= HTN
and proteinuria
7. PLTS, fibrinogen deposit subendotheliallum, edema-->
manifest eclampsia (cerebral edema) and HELLP (liver vascular dysreg + edema causing abdominal
pain) pulmonary edema (cap leak)

7

Hematological changes in pre-eclampsia

Thrombocytopenia
Hemolysis
DIC

8

Neurological changes in pre-eclampsia

Severe headache
Visual disturbances
Hyperreflexia w/ sustained clonus
Convulsions
Stroke

9

Risk factors for preeclampsia

•Previous history of preeclampsia
• Family history of preeclampsia
• Inter-pregnancy interval > 10 years
• Nulliparity
•Pre-existing medical conditions
o APLS
o Pre-existing diabetes
o Renal disease
o Chronic hypertension
o Chronic autoimmune disease
•Age > 40 years
•BMI > 35 kg/m2
• Multiple pregnancy
•Elevated BP at booking
• Gestational trophoblastic disease
• Fetal triploidy

10

Evaluation for hypertension at >20 weeks

1. History
Abdominal pain
Blurred vision
Edema, rapid weight gain
Fetal movements
Urine output
2. Examination
BP
Visual field
Hyper-reflexia, clonus
Abdominal examination->fetal presentation etc
Fetal assessment->CTG, USS
3. Investigations
Urine dipstick
Spot urine PCR
FBC
UEC
LFTs, LDH
Urate
4. Consider initiation of hypertensives
Commence= >160 or d>110
Consider= >140/90
5. Consider admission

11

Options for antihypertensives

1. Methyldopa
2. Labetolol
3. Nifedipine
4. Hydralazine
5. Clonidine

12

Outpatient vs inpatient care

1. Outpatient if:
Mild HTN w/o pre-eclampsia
2. Consider admission
Concern for fetal wellbeing
SBP >140 or dBP >90
Symptoms of preeclampsia, proteinuria or abnormal bloods

13

Inpatient monitoring

1. BP 4 hourly if stable
2. CTG daily
3. Daily ward urinalysis
4. Maintain fluid balance
5. Daily review
6. Normal diet
7. Bed rest not usually required
8. VTE prophylaxis

14

Indications for birth

• Non-reassuring fetal status
• Severe fetal growth restriction
• ≥ 37 weeks
• Eclampsia
• Placental abruption
• Acute pulmonary oedema
• Uncontrollable hypertension
• Deteriorating platelet count
• Deteriorating liver and/or renal
function
• Persistent neurological symptoms
• Persistent epigastric pain, nausea
or vomiting

15

Stabilising prior to birth and postpartum management

1. Prior to birth
Control HTN
Correct coagulopathy
Consider eclampsia prophylaxis->Mg Sulphate
Attention to fluid status
2. Postpartum
Close clinical surveillance
VTE prophylaxis
Timing of discharge
Arrange F/U in 6 weeks to determine if underlying hypertension
Maternal screening

16

Maternal risks of pre-eclampsia

1. CVA
2. Renal failure
3. Liver failure
4. Coagulation failure
5. Adrenal failure
6. Eclampsia

17

Fetal risks

1. Asymmetrical IUGR
2. Placental abruption
3. Iatrogenic preterm delivery

18

Management of eclampsia

1. DRSABCD
2. Control seizures
Loading magnesium sulphate
If ongoing diazepam
Maintenance Mg sulphate
3. Monitoring
BP and pulse/5 minutes
RR, patellar reflexes
T 2nd hourly
Continuous CTG
Urine output via IDC
Fluid balance monitoring
Check serum Mg levels
3. Control hypertension
Aim for 130-150 and 80-100
Avoid hypotension
Nifedipine
Hydralazine
Labetolol
Diazoxide
4. If antepartum, plan birth
Continue fetal monitoring
Stabilise mother
Ergometrine not used
VTE prophylaxis
Consider use of steroids for lung maturation if preterm
5. Investigations
FBC, PLTs
UEC
LFTs/LDH
Coagulation
Group and hold

19

What is HELLP syndrome

1. Variant of severe preeclampsia
2. Hemolysis, +LFTs, -ve PLT

20

Management of HELLP

1. Liase with obstetrician/hematologist/anesthetist
2. >34 weeks, plan for birth
3. Consider Mg sulphate infusion
4. Consider PLT infusion

21

Prevention of pre-eclampsia in subsequent pregnancies

1. Aspirin

22

Outpatient care for mild pre-eclampsia

1. Attendance to day unit->rest and recheck blood, CTG, do investigations
2. Three times weekly visits for BP, blood results, proteinuria, fetal moevements and CTG
3. USS for growth, AFI, umbilical cord flow->monitoring for IUGR
4. Expectant management if doesn't worsen util 37-38 weeks and induction of labour advised.