Wk 3: Hypertension/Pre-eclampsia/Clinical Deterioration

Question 1

What blood pressure is defined as pregnancy hypertension and thus the threshold for pre-eclampsia screening?

Answer 1

Systolic blood pressure (BP)= ≥ 140mmHg
and/or
Diastolic blood pressure= ≥90 mmHg
*some require proteinuria

These measurements should be confirmed by repeated readings over several hours.
- clinicians should commence therapy to target a blood pressure less than or equal to 140/90

Question 2

What are the thresholds hypertension?

Answer 2

Mild Hypertension
Systolic BP 140 - 149
Diastolic BP 90 - 99

Moderate Hypertension
Systolic BP 150 -159 mmHg
Diastolic BP - 100-109 mmHg

Severe Hypertension
Systolic BP ≥160 mmHg (some say 170)
and/or
Diastolic BP ≥110 mmHg

Severe Hypertension requiring immediate treatment
Systolic BP ≥170 mmHg
and/or
Diastolic BP ≥ 110 mmHg

Question 3

Define gestation/pregnancy-induced hypertension

Answer 3

• New onset of hypertension after 20 weeks gestation
• without any maternal or fetal features of pre-eclampsia
• BP returns to normal within 3 months postnatally

Question 4

What is a key practice point for managing sever pre-eclampsia?

Answer 4

Lower blood pressure carefully, as inadequate placental perfusion may occur where placental circulation has adapted to a higher blood pressure.

If lowered to quickly, can cause;
- cerebral haemorrhage
- hypertensive encephalopathy

Question 5

What is the management of severe hypertension?

Answer 5

• Admit to Hospital for Acute Treatment
• Do not allow BP to fall below 140/80
  Antihypertensive therapy with (for all those with systolic >170 or diastolic >110);
• Nifedipine, maximum 40 mg, oral
• Labetalol, 20–80 mg, IV bolus over 2 minutes
• Hydralazine, 5–10 mg, IV bolus over 5 minutes administered by a medical officer, or IM injection

Fluid restriction
- Nil by mouth
- 80 ml/hr IV crystalloid

Observations during acute Treatment of severe hypertension
- 15 minutely BP
- 30 minutely - complete set of vital signs, and assessment of response to treatment
- continuous oxygen saturation monitoring
- continuous fetal monitoring.

Question 6

What assessment should be considered for hypertension?

Answer 6

Maternal assessment
- history: headache, visual disturbances, epigastric or right upper quadrant pain
- Vital signs: BP, pulse, respiratory rate, temperature
- General examination: abdominal palpation, reflexes, clonus.
- Spot urine PCR
- FBE
- platelets are < 100 x 109/L include:
- Liver function test - AST, ALT and LDH
- Clotting profile - coagulation profile (APTT, PT, fibrinogen)
- group and hold
- Urea, creatinine, electrolytes
- Abdominal palpation
- Reflexes and clonus
- Oedema
- MSU
- uric acid (in some organisations)

Fetal assessment
- Fetal movements
- CTG if >28wks
- US assessment of fetal growth,
AFI, UA dopplers
- Antenatal corticosteroids (Betamethasone) administration to a woman who is expected to birth pre-term should be considered
- Antenatal Magnesium Sulphate administration to the woman who is expected to birth pre-term (<30 weeks gestation) is recommended for the purpose of fetal neuroprotection

Question 7

What further investigations should be considered for suspected pre-eclampsia?

Answer 7

Features of pre-eclampsia:
- urinalysis for protein
- urine microscopy

Thrombocytopenia or a falling
haemoglobin:

• investigate for disseminated
  intravascular coagulation
  and/or haemolysis

Question 8

What is the management for moderate hypertension?

Answer 8

Ongoing treatment with antihypertensive medication
= Aim for BP <150/100

First line agents:
- Labetalol 100–400 mg TDS
- Methyldopa 250–750 mg TDS

Second line;
- nifedipine

Antenatal care – aim for BP <150/100
- Individualise schedule of antenatal visits
- BP monitoring as clinically indicated
- Routine CTG not indicated
- 28–30 weeks US for growth
- 30–32 weeks US for growth

Question 9

What is the management of mild hypertension?

Answer 9

• optional antihypertensive therapy

Question 10

What are some fetal and maternal indications for immediate delivery in the context of hypertension?

Answer 10

Maternal
- Inability to control hypertension
- uncontrollable pre-eclampsia
- uncontrolled hypertension
- Deteriorating biochemistry
aka deteriorating platelet count, deteriorating liver function and deteriorating renal function.
- Placental abruption
- Persistent neurological symptoms
- Persistent epigastric pain, nausea or vomiting with abnormal LFTs
- Acute pulmonary oedema
- Gestational age > 37 weeks
- HELLP Syndrome

Fetal
- Severe fetal growth restriction
- Abnormal CTG requiring immediate delivery
- gestational age >37wks

Question 11

Explain the drug methyldopa. Including the;
- dose
- actions
- contraindications
- practice points

Answer 11

Dose: 250 mg-750 mg
every 8 hours/TDS

Actions: centrally acting adreergic agonist

Contraindications: depression

Practice points:
- Slow onset of action over
24 hours
- dry mouth
- sedation
- depression
- blurred vision

Withdrawal effect:
rebound hypertension

Prescribed;
- hypertension of any kind in pregnancy e.g. chronic hypertension

Question 12

Explain the drug labetalol for ongoing treatment and acute treatment of hypertension. Including the;
- dose
- actions
- contraindications
- practice points

Answer 12

Dose:
Ongoing: 100mg-400mg every 8hrs/TDS
Acute: 20–80 mg; max 80mg/dose

Actions: Beta blocker with
mild alpha vasodilator effect

Contraindications: Asthma, chronic airways limitation

Side effects:
- Bradycardia
- bronchospasm
- headache
- nausea
- scalp tingling which usually
resolves within 24 hours

Question 13

Explain the drug nifedipine in both the acute and ongoing context. Including the;
- dose
- actions
- contraindications
- practice points

Answer 13

Dose:
Acute: 10 mg tablet; max 40 mg
Onoging: 30mg or 60mg slow
release every 12 hours

Actions: calcium channel blocker/antagonist

Contraindications: aortic stenosis

Practice points:
- Severe headache in first
24 hours
- flushing
- tachycardia
- peripheral oedema
- constipation

Prescription:
- used in acute hypertensive situations
- may be used as a second line agent with labetalol or methyldopa

Question 14

Define chronic hypertension

Answer 14

= Pre-existing hypertension that is a strong risk factor for the development of preeclampsia
and requires close clinical surveillance

Includes essential hypertension, secondary hypertension and white coat hypertension.

Question 15

Define essential hypertension

Answer 15

= A systolic BP ≥ 140 mmHg and/or a diastolic BP ≥ 90 mmHg before pregnancy or before 20 weeks gestation without a known cause. It may include women presenting early in pregnancy on anti-hypertensive medications where no secondary cause for hypertension has been determined.
Considered chronic hypertension

Question 16

Define secondary hypertension

Answer 16

= hypertension due to a condition such as;
- chronic kidney disease (e.g. glomerulonephritis, reflux nephropathy and adult
polycystic kidney disease)
- renal artery stenosis
- systemic disease with renal involvement (e.g. diabetes mellitus, systemic lupus erythematosus)
- endocrine disorders (e.g. phaeochromocytoma, Cushing’s syndrome and primary hyperaldosteronism)
- coarctation of the aorta
- medications.

Question 17

Define white coat hypertension

Answer 17

= raised BP in the presence of a clinical attendant but normal BP in any other setting

Question 18

What is the management of hypertension at A/N app?

Answer 18

• ?signs and symptoms of pre-eclampsia
• ?risk factors for pre-eclampsia and commence prophylaxis if present (150mg of aspirin daily, nocte + 1.5g calcium daily)

If sever hypertension
- follow hospital guidelines/previously discussed treatment of meds, FBC, NBM, crystalloid

If mild-mod
- ?first diagnosis or pre-existing
- ?medicated if pre-existing
Provide ongoing care of;
- Ophthalmic examination
- ECG (if not done recently)
- 24-hour urine catecholamines (if medicated)
- Urinalysis for proteinuria and spot urine PCR
- Serum electrolytes

Antenatal care – aim for BP <150/100
- Individualise schedule of antenatal visits
- 20 week US for morphology
- 28–30 weeks US for growth
- 30–32 weeks US for growth
- CTG if clinically indicated: e.g. abnormal fetal growth,
decreased fetal movement, unstable BP

Question 19

What are some key practice point for antihypertensive therapy?

Answer 19

• a BP ≥ 160/100 mmHg treatment is essential
• mild-mod= Antihypertensive drug therapy is optional
• Antihypertensive drug therapy confers no clear benefit to women with mild pre-eclampsia.
• Lower blood pressure carefully, as inadequate placental perfusion may occur where placental circulation has adapted to a higher blood pressure.

Question 20

Define pre-eclampsia

Answer 20

= A multi system disorder unique to pregnancy, characterised by hypertension and involvement of one or more organ systems and/or the fetus after 20 weeks’ gestation.
- resolves after delivery of the placenta, however, deranged blood values can take up to 3/12 to fully recover.

• Proteinuria is a common, recognised additional feature after hypertension but is not a sign necessary for clinical diagnosis.

Question 21

Define superimposed pre-eclampsia

Answer 21

= chronic hypertension that develops one or more of the systemic features of pre-eclampsia after 20 weeks of gestation.

Question 22

Define eclampsia

Answer 22

= New onset Grand Mal Seizure in a pregnant woman with pre-eclampsia
- Cause unknown, lots of theories as to the cause.
- some suggest that seziures are a result of cerebral vasospasm and endothelial damage leading to cerebral ischaemia, microinfarctions and oedema.
- can occur antenatally, intrapartum and postnatally
- most commonly occurs 24hrs postnatally
- is not the most commonest cause of seizures in pregnancy and the differential diagnosis includes
epilepsy and other medical problems that must be considered carefully, particularly when typical features of severe preeclampsia are lacking.

Question 23

Define HELLP syndrome?

Answer 23

= HELLP =Haemolysis, elevated liver enzymes, low platelets
- Life-threatening pregnancy complication considered to be a variant of pre-eclampsia
H: hemolysis= break down of RBCs
EL: elevated liver enzyme
LP: low platelet count
- Mortality rate 1 - 2%

Question 24

What are the symptoms of HELLP syndrome?

Answer 24

*may at first seem like pre-eclampsia
- Headache
- Nausea and vomiting/indigestion with pain after eating
- Abdominal or chest tenderness ad upper right quadrant pain from liver distension
- Shoulder pain or pain when breathing deeply
- Bleeding
- Changes in vision
- Swelling
Signs to consi
- Epigastric (abdominal) or substernal (chest) pain, including abdominal or chest tenderness and upper right side pain (from liver distention)
- upper r) quadrant pain indicative of hepatic involvement.
- pain relief responds poorly
- Nausea, vomiting, or indigestion with pain after eating
- Headache that won’t go away, even after taking medication such as acetaminophen
- Shoulder pain or pain when breathing deeply
- Bleeding
- Changes in vision including blurred vision, seeing double, or flashing lights or auras
- Swelling, especially of the face or hands
- Shortness of breath, difficult breathing, or gasping for air

Question 25

What are some diagnostic markers of HELLP syndrome?

Answer 25

- High blood pressure - Protein in the urine - Abnormalities in laboratory blood work (increased liver enzymes, decreased platelets, and the presence of hemolysis)

Question 26

What are some risk factors for developing HELLP syndrome?

Answer 26

- preeclampsia and eclampsia - family history - family history of certain autoimmune conditions - family history of certain clotting disorders

Question 27

What are the severity classes of HELLP syndrome?

Answer 27

= classified based on the blood test values which reflect the condition of the mothers blood vessels, liver and other organs. Classes *the lower class, the more dangerous the situation. - Class I (severe thrombocytopenia): AST ≥ 70 IU/L, LDH ≥ 600 IU/L, platelets ≤ 50,000/uL - Class II (moderate thrombocytopenia): AST ≥ 70 IU/L, LDH ≥ 600 IU/L, platelets > 50,000 ≤ 100,000/uL - Class III (mild thrombocytopenia): AST ≥ 40 IU/L, LDH > 600 IU/L, platelets > 100,000 ≤ 150,000/uL

Question 28

What is the significance of the platelets component of HELLP syndrome classing/diagnosis?

Answer 28

= (also known as thrombocytes) are colorless blood cells that help blood clot and stop bleeding by clumping and forming plugs in blood vessel injuries. - Thrombocytopenia is a condition in which you have a low blood platelet count and is one of the defining characteristics of HELLP syndrome.

Question 29

What is the treatment of HELLP syndrome?

Answer 29

- delivery of baby and placenta - blood transfusions (sometimes with specifically RBC, platelets or plasma) - corticosteroids for fetal lung development in very preterm pregnancy

Question 30

How can HELLP syndrome be prevented?

Answer 30

- good physical health pre pregnancy - regular antenatal care - understanding of the warning and early signs - aspirin if at risk. Prevents pre-eclampsia and thus chnaces of developing HELLP syndrome.

Question 31

What is the impact of HELLP syndrome on the baby?

Answer 31

- if >1000g at birth appears to be no adverse long-term outcomes and same survival rates as non-HELLP babies. - <1000g at birth long hospital stays., increased chance of needing ventilator support - Placental abruption - Placental failure with intrauterine hypoxia/asphyxia - Extreme prematurity

Question 32

Who are the three at-risk (based on a diagnosis) groups for hypertension?

Answer 32

- pre existing primary hypertension - secondary chronic hypertension - those who develop new onset hypertension in the second half of pregnancy

Question 33

When is transfer to a tertiary hospital indicated in the context of hypertension and pregnancy?

Answer 33

- All pre-term pregnancies with severe pre-eclampsia, eclampsia or HELLP syndrome - All term pregnancies complicated by eclampsia or HELLP syndrome - Any pregnancy in which the health care provider believes his/her health care facility would be unable to manage the complications of hypertension in pregnancy.

Question 34

What is the management of hypertension found in an antenatal setting?

Answer 34

- recheck in 15mins - consult and refer to supporting hospital. - if >160 systolic or >100 diastolic reccomende ambulance transfer.

Question 35

Explain the normal progression of blood pressure in pregnancy

Answer 35

- falls in first trimester - reaching a nadir by the second trimester - rises again to pre-conception levels towards end of third trimester.

Question 36

Define proteinuria

Answer 36

= urinary excretion of ≥0.3 g protein in a 24-hour specimen. = ≥1+ reading on dipstick (must be with no evidence of UTI)

Question 37

What are the 7 classifications of hypertension related conditions we must be aware of?

Answer 37

- Preeclampsia – eclampsia - Gestational hypertension - Chronic hypertension - essential - secondary - white coat - Preeclampsia superimposed on chronic hypertension

Question 38

How can pre-eclampsia be diagnosed?

Answer 38

1. hypertension after 20wks 2. accompanied with one or more of the following signs of organ involvement. Renal involvement - Significant proteinuria – a spot urine protein / creatinine ration > 30mg / mmol - Serum or plasma creatinine greater than or equal to 90 micromol/L or - Oliguria < 80mL / 4 hours Haematological involvement - Thrombocytopenia < 100,000 /µL - Haemolysis: schistocytes or red cell fragments on blood film, raised bilirubin, raised lactate dehydrogenase > 600mIU/L, decreased haptoblobin - DIC Liver involvement - Raised transaminases - Severe epigastric or right upper quadrant pain Neurological involvement - Convulsions (Eclampsia) - Persistent visual disturbances (photopsia, scotomata, cortical blindness, posterior reversible encephalopathy syndrome, retinal vasospasm) - Persistent, new headache - Stroke - Pulmonary oedema - Fetal growth restriction (FGR)

Question 39

Define superimposed preeclampsia

Answer 39

= when a woman with pre-existing hypertension develops systemic features of preeclampsia, after 20 weeks gestation. - Worsening or accelerated hypertension should increase surveillance for preeclampsia but is not diagnostic.

Question 40

What are some risk factors for pre-eclampsia?

Answer 40

Moderate risk - Age 40 years or more - First pregnancy/nulliparity - Multiple pregnancy - Interval since last pregnancy of more than 10 years - Body mass index of >35 at presentation - Family history of pre-eclampsia High risk - Autoimmune disease e.g. Systemic Lupus Erythematosus (SLE), antiphospholipid syndrome - Chronic hypertension - Chronic kidney disease - Hypertensive disease during a previous pregnancy - Diabetes - African American ethnic background - PAPP-A <0.45 MoM - Antiphospholipid syndrome

Question 41

What is the management of new onset hypertension after 20wks gestation?

Answer 41

- assess for signs and symptoms of pre-eclampsia - ?need to admit to unit - admit if preeclampsia symptoms are identified

Question 42

What is the management of eclampsia?

Answer 42

- Resus - IV mag sulph (4g IV over 20mins loading dose) - if seziure occurring/ongoing while preparing mag sulf= diaz 5-10mg at rate of 2–5 mg/ minute (maximum dose of 10 mg) or Clonazepam 1–2 mg IV over 2–5 minutes OR Midazolam 5–10 mg IV over 2–5 minutes or IM - maintenance dose of mag sulf of 1g IV via controlled induction live for 24/hr post birth. - if seziures continue with mag stuff then consider bolous or diasepam, midazolam or clonazepam. *note: if impaired renal function; reduce maintenance dose of magnesium sulfate to 0.5 g/hour and start O\ongoing serum monitoring - prevention of further sezirues - control of hypertension - do avoid hypo - nifedipine, hydralazine, labetalol, diazoxide - delivery Monitor - BP and pulse every 5 minutes until stable then every 30 minutes - Respiratory rate and patellar reflexes hourly - Temperature 2nd hourly - Continuous ^CTG monitoring - Measure urine output hourly via IDC - Strict fluid balance monitoring - Check serum magnesium if toxicity is clinically suspected - Therapeutic serum magnesium level 1.7–3.5 mmol/L Stop function/review management when; - Urine output < 80 mL in 4 hours - Deep tendon reflexes are absent or - Respiratory rate < 12 breaths/minute

Question 43

When is magnesium sulphate indicated?

Answer 43

= recommended for use antepartum, intrapartum and within the first 24 hours postpartum for severe pre-eclampsia or in eclamptic episode for its anticonvulsant properties when the following factors are present: - persistently elevated blood pressure despite adequate hypotensive therapy and appropriate fluid management, - evidence of CNS dysfunction, thrombocytopenia or liver disease

Question 44

Define pre-eclamptic angina and what does it often indicate?

Answer 44

= Epigastric or right upper quadrant pain. - often represents hepatic involvement

Question 45

What is the antenatal management of HELLP?

Answer 45

- platelet transfusion pre-operative delivery

Question 46

What is the postpartum management of HELLP?

Answer 46

- ?platelet transfusion if any bleeding related to pre-eclampsia thrombocytopenia - ?platelet transfusion in first 72hrs only if platelets fall below 40,000 despite no bleeding but there is a concern for bleeding e.g. after c/s - If the count remains below 40,000 after 72 hours from delivery without significant bleeding and without sign of impending recovery, consultation with the Consultant Haematologist or Obstetric Physician is indicated.

Question 47

What baseline assessments should be carried out on a women who presents with chronic hypertension?

Answer 47

Maternal - Ophthalmic examination. - Spot urine protein: creatinine ratio where there is doubt about proteinuria on dipstick, i.e., +1 or +2 proteinuria. - Serum electrolytes. - ECG (if not done recently). - 24 hour urine catecholamines if there is severe hypertension. Fetal - Baseline ultrasound for the assessment of fetal anatomy. - Follow-up ultrasound at 26-28 weeks. - From 28 weeks, ultrasound every 2-3 weeks to evaluate fetal growth. - Weekly non-stress tests from 30 weeks.

Question 48

Explain the post partum management of chronic hypertension

Answer 48

- note it may be partcularly high on the 3rd-6th day after delivery so may need to increase or commence antihypertensive meds at that time. * blood pressure is unstable for 1-2 weeks after delivery and may be difficult to control

Question 49

What are some risk factors for preeclampsia?

Answer 49

- previous Hx - antiphospholipid antibodies - pre-existing diabetes - multiple pregnancy - nulliparity - family history - elevated BMI >25 - maternal age >40 Diastolic BP >80mmHg at booking - chronic hypertension - pre existing renal disease - congenital heart defects - autoimmune disease - >10 years since previous pregnancy - short sexual relationship prior to conception - other thromophilias - maternal ages <20 or >35 years maternal depression or anxiety - assisted reproduction tech - fetal triploidy

Question 50

What should be involved in pre-pregnancy counselling for those at sever risk of developing pre-eclampsia?

Answer 50

- discussion of risk factors, symptoms and management - offer calcium and low dose aspirin supps - ?labetalol or methyldopa to optimise blood pressure - pre conception counselling

Question 51

What calcium should be offered in pregnancy and why?

Answer 51

= calcium supplements of 1200mg – 2000mg daily. - seen to almost half risk of pre-eclampsia and reduces complications

Question 52

Explain the use of low-dose aspirin in those at risk of pre-eclampsia.

Answer 52

= those at risk should commence before or at 16wks and cease at 37wks.

Question 53

If the decision to expodite birth is made in the context of hypertension, what efforts to stabilise the situation pre-birth must be made?

Answer 53

- control hypertension - correct coagulopathy - consider eclampsia prophylaxis - attention to fluid status

Question 54

What is used as an anecdote/reversal agent for mag sulf?

Answer 54

= 10% calcium gluconate 10 mL IV over 5-10 minutes - requires ECG during administration due to risk of cardiac arrhythmias

Question 55

What are some key practice points to follow at the birth of a women with hypertension?

Answer 55

- Actively manage third stage - Ergometrine should NOT be used in severe preeclampsia or eclampsia * Consider *carbetocin if increased risk of PPH * Consider VTE prophylaxis

Question 56

What are the first trimester screening options for those t risk of sever pre-eclampsia?

Answer 56

Placental growth factor (PlGF) - Lowered levels in women at risk of pre-eclampsia15 and in fetal aneuploidies and/or impaired placentation2 disorders (which can also be associated with pre-eclampsia) - Positive predictive detection value of 56%15 for pre-eclampsia Pre-eclampsia ratio test (PERT) - measures proteins released from the placenta to assist in identifying women who will progress on to develop pre-eclampsia or not.. Uterine artery pulsatility index (UTPI) - Measured between 11+0 and 13+6 weeks gestation15 - Positive predictive detection value of 48% for early onset preeclampsia Pregnancy associated plasma protein A (PAPP-A) - Levels less than 0.4 MoM, associated with an increased risk of HDP, preterm birth and fetal growth restriction34 - Present in 8–23% of women with pre-eclampsia15 - Low positive predictive detection value of 16%15 Combined first trimester screening - VCGS offer testing called Early-Onset Pre-eclampsia (EO-PE) screening with a detection rate of 75% - Blood is taken between 11-13.6 weeks measuring serum pregnancy-associated plasma protein -A (PAPP-A) and placental growth factor (PIGF) in maternal blood. - u/s as well to assess placental blood flow. *not covered by medicare *these coupled with fam history and maternal BP=diagnosis

Question 57

What are the possible short and long term complication of hypertensive disorders?

Answer 57

Short term - prem - SGA - admission to SCN - stillbirth/death Long term - insulin resistance - Diabetes melitis - CAD - hypertension - increased risk of CVD - overweight or oesity

Question 58

What are some indicators of fetal compromise in the context of hypertension?

Answer 58

- reduced fetal movements - abnormal ctg - small amniotic deepest vertical pocket - low AFI - oligohydramnios - >10th centile - fall in growth velocity - symmetrical vs asymmetrical growth - umbilical artery pulsatility >95centile - severe if absent or reversed end diastolic flow on umbilical artery - Ductus venosus doppler showing; Absent or reversed “a” wave or Identification of an abnormal ductus venosus waveform is not diagnostic in isolation when there is no other Doppler abnormality - middle cerebral artery showing cerebral redistribution

Question 59

What mode of birth is indicated for hypertension in pregnancy if it is indicated?

Answer 59

- Recommend vaginal birth unless a caesarean section is required for other obstetric indications - If vaginal birth is planned and the cervix is unfavourable, recommend cervical ripening to increase the chance of successful vaginal birth

Question 60

Explain the drug hydralazine for ongoing treatment and acute treatment of hypertension. Including the; - dose - actions - contraindications - practice points

Answer 60

Dose: Acute: 5–10 mg (first dose 5 mg if fetal compromise) Ongoing: 25–50 mg tds Action: Vasodilator Contraindications Practice points/side effects; - Flushing, headache, nausea, lupus-like syndrome

Question 61

What is the necessary BP monitoring during the intrapartum phase for those with hypertension?

Answer 61

BP <160/110 mmHg – hourly BP measurement BP ≥160/110 mmHg – continuous BP measurement. Intrapartum analgesia

Question 62

At what gestation should the corticosteroid of betamethasone be considered at if sever hypertension/pre-eclampsia?

Answer 62

anything less than or qual to 36+3

Question 63

What are those with chronic hypertension and pre-eclampsia at risk for?

Answer 63

- accelerated hypertension in the third trimester - superimposed pre-eclampsia - fetal growth restriction - placental abruption, premature delivery - stillbirth Pre-eclampsia specific - chronic hypertension - ischaemic heart disease - cerebrovascular disease - peripheral vascular disease - deep vein thrombosis - end-stage renal disease - type 2 diabetes - elevated TSH - all cancers

Question 64

What are signs of magnesium toxicity?

Answer 64

- decreased deep tendon reflexes - respiratory rate <12 breaths per minute - reduced urine output: <40 mL per hour - serum magnesium concentration >3.5 mmol/L

Question 65

What is the necessary maternal observations during the use of mag sulf?

Answer 65

During loading dose: - 5-minutely BP, pulse (PR) and respiratory rate (RR) - at completion of loading dose, record BP, PR, RR and deep tendon reflexes - observe for adverse effects. During maintenance dose: - hourly BP, PR and RR - hourly urine output - hourly deep tendon reflexes. Maintain an accurate record of fluid balance. Before discontinuing MgSO4 therapy: - BP should be stable (consistently below 150/100) - woman should have adequate diuresis - woman should be clinically improved, with no headache or epigastric pain

Question 66

What are some key practice points in the post partum management of HELLP?

Answer 66

- Daily obstetric review - 4-hourly observations for 48 hours: - vital signs - reflexes - clonus - Send the placenta for pathological examination and follow up results - Enalapril is the preferred antihypertensive agent: - 5 mg daily - can be used safely by breastfeeding mothers of term infants - exercise caution with breastfeeding mothers of preterm infants. - Hypertension may persist for up to three months and will require monitoring and slow withdrawal of antihypertensive therapy. - education

Question 67

Compare the drugs available for acute treatment of hypertension vs those used for maintenance/long term.

Answer 67

Acute: labetalol, nifedipine, hydralazine Ongoing 1st line: labetalol and methyldopa 2nd line: hydralazine, nifedipine (if available) and prazosin *multiple may be required **all compatible with breast feeding

Question 68

What medication classes may make sense to use for hypertension, but are contraindicated in pregnancy?

Answer 68

- Angiotensin converting enzyme (ACE) inhibitors - angiotensin receptor blockers (ARBs) *3rd trimester use has been associated with FDIU and neonatal renal failure. *can be used post partum and care computable with Breastfeeding

Question 69

What organ systems may be effected in pre-eclampsia and what may occur?

Answer 69

Renal involvement - significant proteinuria - spot urine protein/creatinine ratio greater than or equal to 30mg/mmol - Serum or plasma creatinine > 90 micromol/L - Oliguria - < 80ml of urine over 4 hours Haematological involvement - Thrombocytopenia < 100 x 109/L - Haemolysis - DIC Liver involvement - Raised serum transaminases (AST and ALT >70IU/L - Severe epigastric or right upper quadrant pain Neurological involvement - Convulsion/eclampsia - Hyper-reflexia with sustained clonus (>3 beats) - Persistent, new headache - Persistent visual disturbances (photophobia, cortical blindness, posterior reversible encephalopathy syndrome, retinal vasospasm - Stroke, usually haemorrhagic Pulmonary oedema Fetal growth restriction

Question 70

What is the intent behind prolonging a pre-eclamptic pregnancy?

Answer 70

= is of no benefit to the woman but may be a considered practice at early gestations to improve fetal outcome. - thus is preeclampsia develops before 34wks delay birth 24-48hrs for administration of corticosteroids.

Question 71

What is the pharmacological management for those at a moderate to high risk of hypertension in pregnancy?

Answer 71

- Low dose Aspirin 100-150mg from 16 weeks gestation, taken at night - 1.5 G calcium daily

Question 72

What are some complications of pre-eclampsia? - maternal - fetal - neonatal

Answer 72

Maternal - intercerebral haemorrhage - placenta abruption - eclampsia - HELLp syndrome - disseminated IV coagulation - acute renal failure - pulmonary odema - acute respiratory distress - ascites - liver rupture - eclampsia -1:200-300 women Fetal - FGR - Oligohydramnios - hypoxia from placental insufficiency - placental abruption - iatrogenic preterm birth - FDIU Neonatal - all those associated with pre term birth - hypoxia and neurological injury - preinatal death

Question 73

Who should be involved in the multidisciplinary team treating a pt with acute preeclampsia?

Answer 73

Obstetrician Midwife Anaesthetist Physician Haematologist Paediatrician

Question 74

What is the managements of a hypertensive pregnant person at; - > or at 37wks - <37wks - <34wks

Answer 74

Management ≥37+0 weeks - Birth is indicated - Control BP as per Severe hypertension Management <37 weeks - Control BP – see Severe hypertension - Prior to delivery: - aim for BP <150/100 - optimise fluid status - correct coagulopathy - consider MgSO4 - See - At ≥34 weeks, do not delay delivery as continuation of pregnancy is associated with risk to the fetus. Management < 34 weeks - Control blood pressure – see Severe hypertension - At <34 weeks delivery should be delayed for 24–48hrs - if fetal and maternal status permit - to allow for administration of corticosteroids.

Question 75

When is Magnesium Sulfate (MgSO4) (Magnesium Sulfate Heptahydrate) indicated in the context of pregnancy hypertension?

Answer 75

- for women with pre-eclampsia for whom there is concern about the risk of eclampsia - first-line management of an eclamptic seizure - first-line treatment of any seizure during pregnancy - neuroprotection of preterm infants - if diagnosis of sever pre-eclampsia is made e.g. of clinical situation - increased reflexes associated with clonus and/or severe headache, visual changes

Question 76

WHat are some key practice points of administering mag sulf?

Answer 76

- 20ml/hr of urine output is inadequate - caution should be taken with any additional intravenous fluid administration to manage hypotension because of the potential risk of pulmonary oedema.

Question 77

What is the load and maintenance doses of mag sulf?

Answer 77

Loading dose: - Using a 10mL vial of magnesium sulfate (10ml= 500mg/ml) prepare 4 gram (i.e. 8mL) of magnesium sulfate 50% in a 10mL syringe - Configure the pump to accept the 10mL syringe and set the pump to 32mL/hr for 15 minutes Maintenance dose: - Once the loading dose has been completed, use the prepared 25g in 50mL magnesium sulfate syringe and re-set the pump to accept the 50mL syringe. - Set the pump to administer the maintenance rate of 1g/hr (2mL/hr) or as ordered, until at least 24 hours post birth/delivery.

Question 78

What are some side effects of mag sulf?

Answer 78

- hypotension secondary to reductions in systemic vascular resistance - facial flushing - visual disturbances - flushing at injection site - chest pain - nasal stuffiness - ECG changes - circulatory collapse - gastro-intestinal upset - urinary retention - magnesium toxicity - tissue necrosis at the injection site

Question 79

What are some contraindications of mag sulf?

Answer 79

- caution in women being treated with cardiac glycosides/digitalis. - Concurrent use of magnesium sulfate and CNS depressants may result in an enhanced CNS depressant effect.

Question 80

What is the likely effect of the varying concentrations of mag sulf per mmol/L

Answer 80

0.8 - 1.0= normal plasma level 1.7 - 3.5= therapeutic range 2.5 - 5.0= ECG changes (P-Q interval prolongation, widen QRS complex) 4.0 - 5.0= reduction in deep tendon reflexes > 5.0= loss of deep tendon reflexes > 7.5= sinoatrial and atrioventricular blockade. Respiratory paralysis and CNS depression > 12= cardiac arrest Note: If serum magnesium level is >3.5mmol/L, cease infusion and consult with obstetrician

Question 81

What should the obs regimen be when administering mag sulf?

Answer 81

During administration of the loading or bolus dose: - 5 minutely blood pressure and pulse (x 4 readings) - observe for the development of side effects - check patellar reflexes after administration During administration of the maintenance infusion: - ½ hourly blood pressure, pulse, and respiratory rate (pre-treatment respiratory rate should be ≥ 16per minute). These may be undertaken hourly post-birth. - 1 hourly patellar reflexes - 1 hourly urine measures, 4 hourly testing of urinary protein - 2 hourly temperature - continuous electronic fetal monitoring from 26 weeks gestation until clinical review/discussion by medical staff. Between 24- 26 weeks gestation, individualised management with regard to fetal monitoring will be considered - maintain a strict fluid balance chart.

Question 82

What are some signs of mag sulf toxicity?

Answer 82

- urine output <100mL in 4 hours - absent patellar reflexes - respiratory depression

Question 83

What are the main aspect of care for a women with sever pre-eclampsia?

Answer 83

Stabilise - Control BP - IV Labetalol is the primary drug of choice for urgent control of severe hypertension in pregnancy. Hydralazine is the drug of choice for women with asthma or congestive heart failure. - Prevent seizures using Magnesium Sulphate IV Monitor - vital signs - urinary output - neurological status - clotting factors - fetal condition Plan for labour/birth - The choice of either Caesarean section or Induction of labour is dependent upon: - severity of the maternal disease - gestational age - fetal condition - if the woman is in labour, consider epidural - if the woman is in 2nd stage, consider expediting the birth. - Consider thromboprophylaxis as pre-eclampsia is a risk factor for venous thromboembolism (VTE) - Fluid management- this is closely monitored due to decreased urine output but risk of pulmonary oedema - Strict fluid balance chart - Oliguria is common with severe pre-eclampsia and in isolation does not require fluid replacement unless plasma creatinine is rising - Hourly urine output measurements - Limit fluids to 60-80ml/hr - Timing of birth - dependent on severity of maternal disease, gestational age and fetal condition - prior to 34 weeks, aim to delay birth until administration of corticosteroids, if maternal and fetal condition permit - consider Magnesium Sulphate for neonatal neuroprotection for women < 30 weeks gestation - active 3rd stage management however DO NOT use Ergometrine or Syntometrine as routine oxytocics

Question 84

What monitoring should occur postnatally for a women with pre-eclampsia?

Answer 84

- Daily obstetric review - 4-hourly observations for 48 hours: - vital signs and when BP is stable - reflexes - clonus - Send the placenta for pathological examination and follow up results - Magnesium sulphate should stop at a minimum of 24 hours post birth but as clinically indicated may continue beyond this time - Enalapril is the preferred antihypertensive agent: - 5 mg daily - can be used safely by breastfeeding mothers of term infants - exercise caution with breastfeeding mothers of preterm infants. - Slow withdrawal of anti-hypertensive medication and regular BP monitoring (may take up to 3 months for BP to stablise) - A diuresis has occurred and urine output has normalised (initially hourly IDC measurements) - FBE, LFT's and U&E are stable/improving - After birth, all clinical and laboratory derangements of preeclampsia recover, but there is often a delay. - The woman and her family are often overwhelmed and distressed from their experience and appropriate counselling post-partum should include psychological and family support. - All women who develop pre-eclampsia and gestational hypertension are at risk of these disorders in future pregnancies and should receive appropriate counselling before embarking upon another pregnancy.

Question 85

WHat are some maternal and fetal complications of eclampsia?

Answer 85

- coma - intracerebral haemorrhage - resp distress - perinatal death

Question 86

What is the first linea treatment for eclampsia?

Answer 86

- Magnesium sulfate (MgSO4) - Diazepam is not an appropriate first line treatment.

Question 87

What are some signs of impending eclampsia?

Answer 87

- sever frontal headache due to cerebral oedema - Hyperreflexia- impending eclampsia - Reduced urine output- renal failure - Blurred vision/visual disturbance- retinal oedema - Epigastric pain- due to haemorrhage in subcapsular layer of liver - Vomiting and nausea - due to cerebral oedema and liver damage

Question 88

What are the signs of an eclamptic episode?

Answer 88

- generalised seizures with jerking limb and head movements - may be cyanosed - tongue biting - urinary incontinence - are generally single and self-limiting lasing less than 90 seconds

Question 89

What is the management of a prolonged seizure from ecalmpsia?

Answer 89

- may be due to other intracerebral pathology, in which case benzodiazepines are appropriate: - intravenous diazepam (2 mg/min to maximum of 10mg) or - Midazolam (0.1 – 0.2 mg/kg IV or IM). - Urgent CT scan/MRI is recommended

Question 90

What is the management of eclampsia if birth is being planned?

Answer 90

- Nil by mouth - 80ml/hr IV crystalloids - Continuous fetal monitoring is required whilst awaiting birth as there is no reason for delaying birth once an eclamptic seizure has occurred. - Prepare for Caesarean section if required. - Prepare for a potentially pre-term birth- Paediatrician informed and present at birth - If the woman is to birth, active 3rd stage of labour with Oxytocinon - DO NOT use Ergometrine or Syntometrine

Question 91

What documentation needs to occur in an eclamptic event?

Answer 91

- Note the time the seizure occurred and its duration - Note the time of the emergency call and time of arrival of staff - Accurate documentation of all fluids administered and output - All observations and treatments to be documented

Question 91

What considerations need to be made regarding the women environment in the context of hypertension in pregnancy?

Answer 91

- it is high enough acuity - is there adequate peads - Once the woman is stabilised, ongoing care should occur in a high dependency unit or intensive care unit with one on one care - High dependency level care should continue for 24-48 hours post seizure and if stable, then transfer to a Postnatal ward. - Enable the woman to spend time with her baby and encourage this - Support the woman with her feeding choices, commence expressing with the woman's consent - Psychological support is paramount following a situation such as this.

Question 92

What is the main risk with HELLP?

Answer 92

- expectant management is harmful with a 6.3% incidence of maternal death and an increased risk or placental abruption. - In such cases delivery should be planned as soon as feasible. (KEMH 2018)

Question 93

What are some maternal complications of HELLP syndrome?

Answer 93

- Liver rupture - Cerebral oedema - Cerebral haemorrhage - Maternal death

Question 94

Define disseminated Intravascular Coagulation (DIC)

Answer 94

= an acquired syndrome characterized by the intravascular activation of coagulation (aka initiation of clotting) with a loss of localisation arising from different causes. - It can originate from and cause damage to the microvasculature, which if sufficiently severe, can produce organ dysfunction - always secondary to another underlying cause - Overproduction of thrombin leads to fibrin deposition and clots= - these microthrombi cause organ dysfunction - because of this massive clotting action the body becomes depleted of platelets

Question 95

What are the signs of DIC

Answer 95

- thrombosis and/or bleeding as it is a thrombo-haemorrhagic disorder. - sever bleeding (PV, intrauterine, intraabdominal) - oozing from the skin/mucosa - shock - dyspnea, hemoptysis, acute renal failure

Question 96

What are some common primary complications that DIC can stem from?

Answer 96

- Placental abruption (most common cause) - Amniotic fluid embolism - Pre eclampsia/HELLP syndrome - Retained stillbirth - Acute fatty liver of pregnancy - Severe infection - Massive bleeding (PPH, acreta) - septic abortion

Question 97

What results when DIC occurs?

Answer 97

= there is an excessive consumption of platelets and clotting factors resulting in: - prolonged clotting time (prolonged prothombin time and partial thromboplastin time) - low platelets (thrombocytopenia) - low fibrinogen - Raised D-Dimers - haemorrhage

Question 98

Which professionals should be involved in the management of a pt with DIC early?

Answer 98

Haematology- to advise on appropriate blood products required to correct the clotting Senior Obstetrician Anaesthetic staff Intensive care staff

Question 99

What is the management of DIC?

Answer 99

- the cause should be investigated promptly and treated appropriately - Full blood examination - Cross- matching - Clotting profiles - Fibrinogen - Tranexamic acid (TXA) should be considered.