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Hypertension in Pregnancy Flashcards

1
Q

what % of pregnancies does HT usually affect?

A

10-15%

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2
Q

how many primigravid (1st baby) mothers experience pre-eclampsia?

A

mild PET = 10%

severe PET = 1%

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3
Q

what is eclampsia?

A

seizure as a result of severe pre-eclampsia

high risk of maternal death

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4
Q

when in pregnancy do changes in CV system usually occur?

A

first 12 weeks

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5
Q

what CV changes does a mother experience in pregnancy?

A

increased plasma volume and CO

peripheral vascular resistance decreases

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6
Q

what trends in BP and heart rate are thought to occur in 2nd and 3rd trimester of pregnancy?

A

2nd trimester = dip in BP (less marked than previously thought)

3rd trimester (increase in HR by around 7bpm)

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7
Q

what is the quantitative definition of hypertension?

A

> 140/90mmHg on 2 occasions
160/110mmHg once

*some areas of world use increase of >30/15mmHg since 1st trimester

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8
Q

what different types of HTN can result during pregnancy?

A

pre-existing hypertension
pregnancy induced hypertension (PIH)
pre-eclampsia

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9
Q

what is the difference between PIH and PET?

A

no proteinuria or oedema in PIH

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10
Q

when is pre-existing hypertension most often diagnosed?

A

1st trimester - likely if early pregnancy

retrospective diagnosis after pregnancy (if BP not returned to normal within 3 months of delivery)

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11
Q

what secondary causes may be responsible for pre-existing hypertension?

A

renal causes
cardiac causes
endocrine causes - cushings, conns, phaeochromocytoma

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12
Q

what does pre-existing HTN increase the risk of in pregnancy?

A

PET
IUGR
placental abruption

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13
Q

when does PIH normally present and resolve?

A

normally presents second half of pregnancy

resolves within 6/52 of delivery

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14
Q

what risks does pregnancy induced hypertension present?

A

progression to pre-eclampsia (15%)

rate of recurrence is high

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15
Q

what are the main features of pre-eclampsia?

A

hypertension
proteinuria (>0.3g/l or >0.3g/24h)
oedema

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16
Q

pre-eclampsia can be asymptomatic on presentation - true or false?

A

true

patient may experience high BP, proteinuria and oedema but not feel unwell

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17
Q

describe the difference between early and late presentations of pre-eclampsia?

A

early

  • extensive villous and vascular lesions of placenta
  • higher risk of complications than late pre-eclampsia

late

  • minimal placental lesions
  • relatively benign disease course but can lead to eclampsia
18
Q

describe the pathogenesis of pre-eclampsia?

A

genetic and environmental predisposition

stage 1 = abnormal placental perfusion
- placental ischaemia / infarction

stage 2 = maternal syndrome

  • trophoblast invasion
  • failure of normal vascular remodelling
  • spiral arteries fail to adapt to become high capacitance, low resistance vessels
  • placental ischaemia
19
Q

how does PET affect the liver to cause disease?

A

epigastric / RUQ pain

abnormal liver enzymes

hepatic capsule rupture

HELLP syndrome (haemolysis, elevated liver enzyme, low platelets)

20
Q

what complications can PET cause which are specific to the placenta?

A

foetal growth restriction (FGR)

placental abruption

intrauterine death

21
Q

what symptoms normally present with pre-eclampsia?

A 
headache 
visual disturbance 
epigastric / RUQ pain 
nausea / vomiting 
rapidly progressive oedema
22
Q

aside from the 3 common diagnostic signs, what other signs may be observed on examination of a mother with suspected PET?

A 
abdominal tenderness
disorientation
SGA foetus 
intrauterine foetal death
hyper reflexia / involuntary movement / clonus (these signs develop prior to eclampsia seizure)
23
Q

what investigations should be carried out throughout pregnancy if a mother has PET?

A 
serum urate 
LFTs
FBC
coagulation screen 
cardiotocography 
US
24
Q

women who develop PET in subsequent pregnancies experience greater severity than women in their first pregnancy - true or false?

A

true

25
Q

what conditions in a mothers PMH may increase the risk of PET in pregnancy?

A 
pre-existing renal disease
pre-existing HTN
diabetes 
connective tissue disease
thrombophilias
26
Q

when should low dose aspirin be started in pre-eclampsia?

A

commence before 16 weeks if at least 2 moderate risk factors or one high risk factors for PET

usually taken from 12 weeks until birth (150mg dose Tayside, but NICE = 75mg)

27
Q

how may pre-eclampsia be predicted from a maternal uterine artery doppler?

A

high resistance and low flow found in pre eclampsia appears as low flow / minimal colour on doppler US

28
Q

when should a mother with PET be admitted to hospital?

A

BP >170/110 OR >140/90 with ++ proteinuria

significant symptoms - headache / visual disturbance / abdominal pain

abnormal biochemistry

significant proteinuria - >300mg/24 hours

need antihypertensive therapy

signs of foetal compromise

29
Q

how should mothers suffering from PET be assessed when they are inpatients?

A 
BP - 4 hourly 
urinalysis - daily 
input / output fluid balance chart
urine PCR (if proteinuria present)
bloods - FBC, U&Es
urate, LFTs usually daily (min 2/week)
30
Q

what are moderate risk factors of PET?

A 
first pregnancy 
age >40 
pregnancy interval >10 years
BMI >35 at first visit 
FH of pre-eclampsia 
multiple pregnancy
31
Q

what are high risk factors of PET?

A 
hypertensive disease during previous pregnancy 
CKD
autoimmune disease - SLE, APS
type 1 or 2 DM 
chronic hypertension
32
Q

when are most women treated for hypertension?

A

BP >150/100mmHg
BP >170/110mmHg = immediate!

control of BP does not reduce risk of developing PET nor does it cure PET (only cure is delivery of baby)

33
Q

what agents can be used to treat HTN in pregnancy and when are these contraindicated?

A

methyldopa (contraindicated in depression)
labetalol (contraindicated in asthma)
nifedipine SR

2nd line

  • hydralazine
  • doxazosin (not suitable in breastfeeding)
34
Q

what does a decreasing or LOW amniotic fluid index indicate?

A

baby is not producing enough urine / amniotic fluid

  • in distress / ill
  • kidneys are not functioning well
35
Q

what can be assessed on an umbilical artery doppler?

A

blood flow to baby during diastole

*can be normal, absent or reversal of blood flow

36
Q

what indications in PET would suggest to deliver the baby?

A 
term gestation 
inability to control BP 
rapidly deteriorating biochemistry / haematology 
eclampsia 
foetal compromise 
abnormal US or CTG
37
Q

what crises can occur in PET that usually indicate to get the baby out?

A 
eclampsia 
HELLP syndrome or hepatic rupture 
pulmonary oedema 
placental abruption 
cerebral haemorrhage 
cortical blindness 
acute renal failure
38
Q

when do most eclampsia seizures occur?

A

24 hour post partum

39
Q

how is severe pre-eclampsia or eclampsia itself managed?

A

control BP - IV labetolol or hydralazine (beware hypotension)

stop/prevent seizures - Mg sulphate IV (diazepam if this doesn’t work)

fluid balance - slow infusion rate to “run patient dry” - 80ml/h

delivery

40
Q

what should you aim for in labour when a mother has pre-eclampsia?

A 
vaginal birth if possible 
control BP 
epidural anaesthesia 
continuous foetal monitoring 
avoid ergometrine 
caution with IV fluids

Reproduction (45 decks)

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