Obgyn Hypertension In Pregnancy

Front 1

Chronic HTN (in pregnancy)
1. def?
2. mild vs severe?
3. signs of superimposed preeclamspia?

Back 1

1. HTN present before the 20th week of pregnancy or existing before pregnancy
2. mild: SBP > or = to 140-180 mmHg or DBP > or = to 90-100 mmHg
severe: SBP > or = to 180mmHg or DBP > or = to 100 mmHg
3. acute onset of proteinuria or worsening HTN

Front 2

Gestational HTN
1. def?
2. risk of developing superimposed preeclampsia

Back 2

HTN that develops AFTER 20 weeks of gestation in the ABSENCE of proteinuria. Returns to normal postpartum. occurs in 5-10% of pregnancies and 30% of multiples
2. about 25% of women with gest HTN go on to develop preeclampsia or eclampsia. If late in pregnancy and unsure if gest HTN or preeclampsia-- tx as preeclampsia
2.

Front 3

Preelampsia
1. def

Back 3

1. development of HTN with proteinuria and edema AFTER 20 weeks gestation. SBP >/= 140 mmHg or DBP >/= 90 mmHg AFTER 20 weeks gestation in a women with a previously normal BP.
Proteinuria- 24 hr urine spec with >/= 0.3 g protein (300mg)

Front 4

Severe preeclampsia
1. def?
2. tx?

Back 4

1)One or more of the following:
1. BP >/= 160 mmHg systolic or >/= 110 mmHg diastolic on two occasions at least 6 hours apart while the patient is on bed rest
2. Marked proteinuria (>/= 5 g protein on 24 hr protein or 3+ protein on 2 dipsticks that are at least 4 hours apart)
3. Oliguria (<500 mg/24 hours)
4. cerebral or visual disturbances (headache or scotomas--spots)
5. pulmonary edema or cyanosis
6. Epigastric or RUQ pain prob caused by subcapsular hepatic hemorrharge-- stretching
7. hepatic dysfunction
8. Thrombocytopenia
9. IUGR

2) Tx: delivery REGARDLESS of gestational age or maturity

Front 5

Eclampsia
1. def?
2. incidence in women with preeclampsia
3. when occur?

Back 5

1. presence of grand mal seizures (convulsions) in women with preeclampsia that is not explained by neuro disorder
2. 0.5-4% of preeclamptics
3. Most occur within 24 hrs of delivery by 3% occur betwen 2-10 days pp

Front 6

HELLP syndrome
1. def
2. diagnostic criteria
3. Management?

Back 6

1. Hemolysis, Elevated Liver enzymes, Low Platelets-- occurs in 4-12% of women with severe preeclampsia
2. dx criteria: 1) microangiopathic hemolysis, Thrombocytopenia, 3) hepatic dysfunction
3) delivery at any gestational age

Front 7

Pathophys of preeclampsia and gestational HTN

Back 7

maternal vasospasm
(possibly endothelial damage, lack of trophoblast medicated relaxation), increased platelet activation, low antithrombin III levels, Thromboxin A2 (TXA2)> Prostacyclin (PGI2), dec NO, inc lipid peroxide and free radicals

Front 8

Effects of Preeclampsia
1. CV
2. Heme
3. Renal
4. Neuro
5. Pulm
6. Fetal

Back 8

1. inc BP (vasoconstriction + inc CO)
2. plasma volume contraction (inc HCT), thrombocytopenia, DIC, third spacing from dec oncotic pressure and inc BP
3. dec GFR and proteinuria (atherosclerotic-like changes in renal vessels), inc uric acid
4. hyperreflexia, grand mal/eclamptic seizures
5. pulm edema (2ndary to dec oncotic pressure, cap leak, LV failure)
6. decreased intermittent placental perfusion--> IUGR, oligohydramnioa, increased perinatal mortality, inc risk of placental abruption, non reassuring FHT--> C/S)
- decreased placental size and function due to vasospasm

Front 9

signs of vasospasm in HTN during pregnancy?

Back 9

visual disturbances (especially scotomata- spots) and persistent or severe headaches

Front 10

normal changes in BP during pregnancy?

Back 10

BP generally decreases slightly in the 2nd trimester and returns to the prepartum level near term

Front 11

edema in preeclampsia

Back 11

persistent peripheral edema unresponsive to resting supine or edema in upper extremities, face or sacral region

Front 12

tx of chronic HTN in preg

Back 12

monitor maternal BP and watch for signs of superimposed preeclampsia (new onset proteinuria or worsening HTN). watch for appropriate fetal growth
- medical tx if SBP > 150-160 mm Hgor DBP >100-110 mmHg. Tx is given to prevent maternal stroke
(methyldopa, labetalol, nifedipine). Continue diuretics if on before pregnancy

Front 13

tx of mild preeclampsia

Back 13

rest and frequent monitoring of fetus and mother.
-Test for fetal growth restriction, oligohydramnioa by twice-weekly non stress tests, biophysical profiles or both
- US for fetal growth restriction or oligo every 3 weeks
- daily fetal movement assessment
- hospitalization for new onset preeclampsia

Front 14

tx of severe preeclampsia

Back 14

magnesium sulfate to prevent and treat eclamptic seizures- given IM or IV- IV more common
- therapeutic level = 4-6 mg/dL

Front 15

magnesium sulfate
1. therapeutic levels
2. monitoring for mag toxicity
3. excretion
4. reversal

Back 15

1. 4-6 mg/dL
2. DTRs (patella, achilles), respirations
3. solely kidney- maintain UOP of 25 mL/hr or more
4. Slow IV admin of calcium gluconate + supplemental O2 and supportive care

Front 16

When is anti-HTN tx recommended in preg?

Back 16

SBP > 160mmHg and DBP > 105-110 mmHg

Front 17

initial anti-HTN of choice in severe preeclampsia?

Back 17

hydralazine 5-10 mg IV until adequate control achieved.
- takes 10-15 minutes to see response to dose
(may also use labetalol)
- goal is to decrease DBP to 90-100 mmHg

Front 18

3 therapies for severe preeclampsia

Back 18

1. magnesium sulfate
2. hydralazine or labetalol
3. delivery after 1 and 2 (IOL tried first then C/S if necessary)

Front 19

when do eclamptic seizures typically occur?

Back 19

25% before labor, 50% during labor, 25% after labor
(3% in pp days 2-10)
- vasospastic process usually begins to decrease within 24-48 hours of delivery-- along with brisk diuresis

Front 20

tx of eclamptic seizures in mother

Back 20

oxygen, padden tongue blade, IV access, maintain airway, 4-6 g of Mg if not already on Mag
-- if already on Mag-- give 2 g
slowly
- do NOT usually need diazepam as these seizures are self-limited for the most part

Front 21

tx of fetus during maternal eclamptic seizure

Back 21

transient uterine hyperactivity occurs for up to 15 min-- may see bradycardia or comp tachy, decreased variability or late decels-- they are usually self-limited and ONLY need to be treated if lasting LONGER than 20 minutes
- Do NOT DELIVER baby during this time
- get maternal ABG, insert foley
- may get CVP catheter and continuous ECG

Front 22

1. Who does HELLP often occur in?
2. Signs/sx?
3. Tx of HELLP?

Back 22

1. multiparous women with lower BP than preeclamptics
2. liver dysfunction, RUQ pain, first sx= n/v, non-specific viral-like syndrome
3. transfer to high-risk OB center, CV stabilization, coagulation abn correction, and delivery-- PLT transfusion is PLT < 20,000, or <50,000 if going for C/S