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Hypertensive Disorders in Pregnamcy - Coggle Diagram
Hypertensive Disorders in Pregnamcy
Hypertensive Disorders
Pre-existing hypertension
BP ≥ 140 / 90 pre pregnancy or < 20 weeks
Gestational Hypertension
BP ≥ 140/90 after 20 weeks with no proteinuria / multisystem disorder
Pre-eclampsia
BP ≥ 140/90 after 20 weeks with proteinuria with multisystemic disorder
Pre-Eclampsia
Symptoms
↑ BP
Renal
Reduced urine output
Hepatic
Blood
Placenta
CNS
Headache
Visual distubance
Nausea / vomiting / epigastric pain
Sudden oedema / weight gain
Reduced fetal movement
Asymptomatic
Pathophysiology
Ischaemic placents
Factor X released into blood
Endothelial cell damage
Ischaemic Placent Triad
Pre-eclampsia
Fetal growth restriction
Placental abruption
Maternal Risks
Brain
Eclamptic seizure
Stroke
PRES - reversible posterior encephalopathy syndrome
Lungs
Pulmonary odema - often iatrogenic
Cardiac
Cardiomyopathy
Liver
Hepatic rupture
Kidney
Renal failure
HELLP
Haemolysis, Elevated liver enzymes, Low platelets
Abruption
DIC
Maternal death
Foetal Risks
Fetal growth restriction
Preterm delivery
Placental abruption
Perinatal morbidity / mortality
Epidemiology / Risk Factors
Nulliparous
New partener
Previous hx
Fhx - mother or sister ++
High BMI > 35
Maternal age >40 or <18
Pre-existing BP
Medical disorder
Multiple pregnancy
Trophoblastic disease - can present before 20 weeks
Antenatal Detection
Pt education
Health professional education
Routine visits with BP and Urinalysis
Unscheduled visit
Signs
Epigastic pain / RUQ tenderness - liver disturbance
SFH small
Oedema
Hyper-reflexia / clonus
Papilloedema - late / severe
Pulmonary oedema - late severe
Tense tender uterus - late/ severe
Complications
HELLP syndrome
Hepatorenal syndrome
Eclampsia
DIC
Assessment of PET
Blood Pressure Measuring
Booking visit
Baseline BP recorded
Routine BP at each antenatal visits
Screening
Pre existing HTN
Two-Four Weekly BP
Gestational HTN
Twice weekly BP check
In patient PET
4 hourly
Severe hypertension >160/110
Every 15 min
24hr BP monitoring
Home self monitoring
Urine Testing
Urine dipstick
+1/+2/+3 protein → Proteinuria
24 hour collection
Protein >300mg / 0.3g → PET
Severe PET: >5g in 24 hrs
Protein creatinine ratio
30 mg/mmol (0.3g) → PET
Input / Output chart
Positive balance
Volume > 30 ml/hr
Blood Tests
FBC
Hb↑↓
↓ Platelets
U&E
↑ K+
↑ Urea
↑ Creatinine
↑ Uric acid
↓ Na+
LFTs
↑ ALT
↑ AST
↑ LDH
↓ Alb
Coag
↑ PT
↑ APTT
↓ Fibrinogen
PlGF
Abnormally low level suggests PET
Normal level - furles out PET
Prediction of 7-14 days (20+0-36+6)
Management
Antihypertensives in Pregnancy
Labetalol
Oral / IV
Avoid in Asthma - beta blocker
B Blocker
1️⃣ line
Nifedipine
CCB
S/E headache
Methyldopa
Oral
Avoid Postnatal - low mood
Hydralazine
IV
Acute management
Use with caution - hypotension
Targert BP
135 / 85
Pre-existing Hypertension
Optimise BP prepregnancy
Review anthypertensives - stop ACE / ARB
Change to labetaol, nifedipine, methyldopa
Offer aspirin prophylaxis 12 weeks - birth
Book under consultant care
Monitor BP 2-4 weekly if well controlled
Monitor getal growth +/- scan
If stable deliver at / near term
Potsnatal care plan
May develop BP - look at urine - low threshold for blood tests
Gestational hypertension
Admit for stabilisation / assessment / PIGF
If BP perist > 140/ 90 treat
If stable manage as out-pt
Twice weekly reviews
Growth scan 2 weekly
Deliver at / near term if stable
Postnatal care paln
Aspirin prophylaxis in future
May develop PET
Pre-Eclampsia
Term > 37+0
Stabilise / Deliver
Preterm
Control Hypertension
Monitor mother / fetus (usuall in pt)
Corticosteroirds (24hr before delivery) / MgSo4 (immediately before up to 24hrs after)
Deliver if benefits outweight risks
<24 Ethical legal dilemma
24-31
32-36
Definitive tx is deliver - issue at placenta
Maternal Monitoring
Admit
Monitor 4 hr BP
Fluid input / output (in 80ml/hr; out 30ml/hr)
Twice weekly blood tests
Urine PCR (>003g/mg)
24hr urine (>0.3g/>2g)
Daily medical review / as required
Fetal Monitoring
Movement - self reporting
DAily CTG - repeat if concerns
USS - 2 weekly
Labour / Delivery
Induction / CS - vaginal birth if possible
Control BP - IV labetalol / hydralazine
Epidural / spinal (Unless Platelets <80)
Continous EFM - CTG
Restrict fluids - 80-100ml/hr or 1ml/kg
Avoid ergometrine - vasocontrictor
Eclampsia
Call for help / ABC / MDT
Tilt to avoid aortocaval compression
IV access, urgent bloods, catheter
MgSo4 loading dose 4g IV
Infusion 1g/hr x24 hr
Antihypertensive - IV labetalol / hydralazine
Stabilise / deliver
HDU care
Obs Emergency
Post Partum
Breast feeding - BP meds
BP management in GP / day unit
Contraception avoding COCP
Counselling / future risk 10-30%
Boom early in future - BP / aspirin
Underlying disorder - BP / Kidney / SLE
Evidence Based Practice
Corticosteroids
Indication
Neonatal RDS / PNM
Dose
Bethamethasone 12mg IM 2 doses 12-24hr apart
MgSO4
Indications
Eclampsia
Severe PET
Neuroprotection
Dose
4g loading IV
1-2g/hr maintenance x 24hrs
Aspirin
Indication
PET prophylaxis
Dose
75-150mg from 12 week to birth