Hypertensive Disorders of Pregnancy

what is placental insufficiency?

blood flow is not as sufficient → IUGR, fetal hypoxia, and fetal death

what are risk factors of hypertensice disease?

• Nulliparity

• Extremes of maternal age 18yrs/ or 40 older

• Pregnancy interval of more than 10 years

• New partner

• Family history of pre-eclampsia, mother, sister

• Multiple pregnancy

• BMI of 35 or more

• Previous history of pre-eclampsia or gestational hypertension

• Pre-existing vascular disease

• Pre-existing kidney disease

what is the requirement for hypertensive disease?

Systolic blood pressure greater or equal to 140 mmhg

Diastolic blood pressure greater or equal to 90 mmhg

what test is done for renal involvement?

urinalysis — automated reagent strip reading device

what are other signs of kidne involvement besides proteinuria?

raised serum, increased creatinine or oliguria

what is the gold standard for proteinuria quantification?

a 24 hour urine collection

what level is significant for the 24 hour urine collection?

>300mg

What test gives an immediate protein result?

Spot protein/creatinine ratio

What level is significant on a spot protein/creatinine?

≥30 mg/mmol

what labs show liver involvement?

inc liver enzymes (serum transaminases)

what are symptoms of liver involvement?

epigastric pain, RUQ pain, liver tenderness

What severe neuro complication can occur?

eclampsia (seizures)

what are common neuro signs of eclampsia?

Hyperreflexia + clonus, severe headache, visual changes

What type of edema is concerning in preeclampsia?

Edema in non-dependent areas (face, eyes, hands)

How does edema progress?

Starts in legs/hands → spreads upward. Rapid onset possible.

What is dangerous edema in pregnancy?

Pulmonary edema.

what is chronic hypertension?

hypertension that predates the pregnancy or appears before 20 weeks gestation

• had hypertension prior to being pregnant but did not know

what is essential (primary) chronic hypertension?

Hypertension confirmed before confirmed pregnancy or before 20 weeks gestation without a known cause

what is secondary chronic hypertension?

Hypertension secondary to an underlying cause (kidney disease, Cushing's syndrome)

what is transient hypertensive effect?

Elevated BP d/t environmental stimuli (painful contractions)

when is chronic hypertension morbidity/mortality?

when associated with

• Placental insufficiency

• Placental abruption

• Super-imposed gestational hypertension

• Super-imposed pre-eclampsia

what medication is contraindicated in pregnancy?

Angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs) d/t increased risks of congenital abnormalities

what is the main medication used for hypertension?

labetalol is the 1st line antihypertensive

when should the baby be delivered for someone with chronic hypertension?

Delivery should be considered at 38+0 – 39+6 weeks

what is gestational hypertension?

the new onset of hypertension after 20 weeks gestation without any maternal or fetal features of pre-eclampsia, followed by a return of blood pressure to normal within 3 months post-partum

what is gestational hypertension associated with?

• Enlarged placenta

• Hydatidiform mole

• Multiple pregnancy

• Cases where circulation to the placenta is compromised (e.g. diabetes)

how is gestational hypertension diagnosed?

after 20 weeks !

• before 20 weeks is chronic

when should the BP in gestational hypertension return to normal?

return of BP to normal after 3 months PP

• if hasn’t resolved then likely chronic

how is mild hypertension treatment?

• weekly BP measurement and urinalysis

• blood tests at time of diagnosis and repeat if clinically indicated

• no pharmacological tx

how is moderate hypertension treated?

• needs pharmacological tx

• BP and urinalysis twice a week

how is severe hypertension treated?

• needs pharmacological tx

  • corticosteroids if <36 weeks

• immediate admission to hospital until BP is stable

• BP measurement regularly (Q4)

• daily urinalysis

• daily CTG while inpatient, USS every 2 weeks

how would the delivery of a baby happen for a woman with gestational hypertension?

Induction of labor after 37 weeks is associated with significant reduction in adverse maternal and neonatal outcomes

what is pre-eclampsia?

multi-system disorder unique to human pregnancy, typically after 20 weeks

what is the main characteristic of pre-eclamspia?

hypertension and involvement of one or more organ systems and or/the fetus

• proteinuria is common but no longer mandatory for dx

when is pre-eclampsia diagnosed?

when hypertension arises after 20 weeks gestation — accompanied by one or more signs of organ involvement

what are examples of involvement of one or more organ systems?

• Significant proteinuria

• Renal insufficiency (serum or plasma creatinine > 90mmol/l)

• Hematological involvement (thrombocytopenia, hemolysis, or disseminated intravascular coagulation)

• Liver involvement (elevated liver enzymes, epigastric pain)

• Neurological involvement (headache, visual disturbances)

• Pulmonary edema

• Fetal growth restriction

why is blood sent for pre-eclampsia?

• Urea, creatinine, urate and serum electrolytes

• Liver function tests

• Full blood count

• Clotting screen

• Group and save serum

how is superimposed pre-eclampsia diagnosed?

Woman with chronic hypertension or pre-existing proteinuria develops one or more of the systemic features of pre-eclampsia

• after 20 weeks gestation

what are indicators of severe pre-eclampsia?

• eclampsia

• severe hypertension with proteinuria

• moderate hypertension with

  • Severe headache with visual disturbance

  • Epigastric pain

  • Signs of clonus

  • Liver tenderness

  • Platelet count falling below 100

  • Alanine amino transferase rising to above 50

  • Creatinine > 100

how is pre-eclampsia managed?

• Woman in a quiet, well-lit room in a high dependency care type situation

• One-to-one OB nursing/midwifery care

• Consultant obstetrician on duty should be informed

• Large bore IV cannula

• Control fluid administration

what monitoring should be done for someone with pre-eclampsia?

• Vital signs measured every 15 minutes until stable and then half hourly

• Continuous oxygen saturation

• Strict input and output (IDC)

• Arterial line

• Neurological assessment hourly

what medication is given for prevention/treatment of pre-eclampsia?

magnesium sulphate — prevents seizures

when is magensium sulphate given?

administer in cases of severe pre-eclampsia and eclampsia, laoding dose IV boulus

what are side effects of magnesium sulphate?

• Motor paralysis

• absent tendon reflexes

• respiratory depression cardiac arrythmia

what observations should be done to a patient when giving MgSO4?

• Formal clinical review every 4 hours

• Hourly vital signs

• Continuous pulse oximetry

• 3 lead ECG

• Hourly urine output

• Deep tendon reflexes every 4 hours

how do you watch for MgSO4 toxicity?

monitor urine output closely — low urine output means magensium is being held in the body

when should you stop/reduce the infusion of MgSO4?

if biceps reflex not present or RR < 12

what is the antidote of MgSO4?

10ml 10% calcium gluconate given slowly IV

what fetal assessments should be done when mom has pre-eclampsia?

• abdominal palpation for growth

• fetal movement assessment

• fetal HR auscultation

• CTG

what happens in term of delivery is moms pre-eclampsia condition deterioates?

• pre-term delivery

• induction of labor

• emergency or elective LSCS

what considerations are imp when deciding timing and mode of delivery for a mom with pre-eclampsia?

• severity of the condition

• fetal factors = gestation, lie, presentation

  • may be appropriate to delay delivery for corticosteroids

what could happen if the woman with pre-eclampsia is unstable during delivery?

delivery is inappropriate and increases risk — stabilize with antihypertensives and MgSO4

when is induction of labor not indicated for mom with pre-eclampsia?

induction of labor before 34 weeks is NOT likely to be successful

what care should be done during the third stage of labor for mom with pre-eclampsia?

Syntocinon 5 IU intravenously or 10 IU intramuscular and examination of placenta

what medications are not given during third stage of labor for mom with pre-eclampsia?

Do NOT medications that contain ergometrine — contraindicated bc it raises BP