Hypertensive Disorders in Pregnancy Exam Study Guide

Gestational hypertension High blood pressure after 20 weeks of pregnancy Multi-organ, vasospastic process of reduced organ perfusion(hypoperfusion), activation of the coagulation cascade Patho of Gest. HTN: Etiology Origin unknown Is related to Hypoperfusion Vasospasm Endothelial cell damage Platelet aggregation Theories:::: - limited to humans Preeclampsia HTN and proteinuria after week 20 or in the early postpartum period in someone previously normotensive. If no proteinuria new onset HTN with new onset of any of these: - Thrombocytopenia - Renal insufficiency - Impaired liver function - Pulmonary edema - Cerebral or visual symptoms Eclampsia Onset of seizures in a preeclamptic woman Convulsions or coma not from other causes in a preeclamptic woman No history of preexisting seizure related pathology 1 in 2,000 -1 in 3,448 births 50% develop during the pregnancy Can occur immediately postpartum Chronic hypertension High blood pressure present before pregnancy or lasting longer than 12 weeks postpartum Superimposed preeclampsia Preeclampsia or eclampsia occurring in a woman with chronic hypertension Hypertension Blood pressure reading of 140/90 or higher 140/90 HTN if either is elevated 6 hours apart Positioning Appropriate sized cuff Risk factors for preeclampsia Primigravida, first pregnancy at age extremes (under 19, and over 35), chronic hypertension, pre-gestational diabetes, nephropathy, vascular disorders connective tissue disorders, family history, maternal infection/inflammation (UTI/dental disease), obesity, race, multiple gestation, fetal hydrops (10x greater risk) hydatidiform mole (10x greater risk) multiple gestation (5x greater risk) previous preeclampsia Paternity Change in paternity increases the risk of preeclampsia Multiparous woman with change in paternity Same risk as nulliparous woman Fathers of preeclampsia complicated pregnancy are at higher risk of doing so in different women (2x as likely) Pre-e: Placental ischemia Reduced blood flow to the placenta causing endothelial cell dysfunction and poor tissue perfusion in organs Endothelial cell dysfunction Generalized vasospasm Poor tissue perfusion in organs Increased peripheral resistance and BP Increased endothelial cell permeability Reduced kidney perfusion Plasma colloid osmotic pressure decreases Decreased liver perfusion Pre-e: Neurologic complications Cerebral edema, cerebral hemorrhage (could have either a hemorrhagic OR ischemic stroke), central nervous system irritability Is there a screening tool to detect Pre-e? No reliable test or screening tool There is no definitive test to diagnose preeclampsia Tx: LOW DOSE ASA (81mg) may help! Things to Assess if Pre-e is suspected: Accurate BP measurement Assessment of edema (no longer included in definition of preeclampsia) Assess for hyperactive reflexes DTR's Clonus Proteinuria Presence of excess protein in the urine Proteinuria: 24 hour urine Little relationship between degree and outcome Assess for: Headache Epigastric pain RUQ pain Visual disturbances Goals for gestational hypertension and preeclampsia WITHOUT severe features Ensure maternal safety, deliver healthy newborn as close to term as possible, manage outpatient if possible, monitor labs and fetus, no bedrest Goals for gestational hypertension and preeclampsia WITH severe features Ensure maternal safety, formulate a plan for delivery, expectant management for women less than 37 weeks, hospitalization, interprofessional team, antihypertensive meds, corticosteroids Gest. HTN WITH severe featuresL Intrapartum care Continuous monitoring of fetal heart rate and uterine contractions, bed rest with side rails up, darkened environment, assess for signs of abruption Interventions to prevent Pre-e complications: Magnesium Sulfate Medication used to prevent and treat eclamptic seizures Magnesium Sulfate Prevents and treats seizure IV piggyback on a pump Initial loading dose then maintenance Little effect on maternal BP Unclear mechanism of action High alert medications Control BP Use antihypertensive medications to manage blood pressure Postpartum care: Monitoring vital signs, deep tendon reflexes, level of consciousness, administration of magnesium sulfate for 24 hours Significant risk of developing preeclampsia in future pregnancy: Increased likelihood of experiencing preeclampsia again in subsequent pregnancies Also Increased risk of developing chronic HTN and CVD later in life HELLP Syndrome: Hemolysis, elevated liver enzymes, lowered platelet count occurs 0.2-0.6% of pregnancies Hemolysis that occurs is microangioplastic hemolytic anemia HELLP coined in 1982 Morbidity and mortality rates as high as 25% Studies link high mortality and morbidity with nadir of the platelets Cerebral hemorrhage: Bleeding in the brain, a common cause of maternal death Circulatory collapse Sudden loss of blood flow causing a drop in blood pressure HTN Disorders of Pregnancy: 5-10% of pregnancies - Major cause of morbidity and mortality - Infant: uteroplacental insufficiency, preterm birth - Mother: renal failure, coagulopathy, cardiac or liver failure, placental abruption, increased seizure risk, increased stroke risk 50,000 maternal deaths annual in the world One woman every 7 minutes Classifications of Gest. HTN: - Gestational Hypertension - Preeclampsia - Eclampsia - Chronic essential HTN - Superimposed Preeclampsia Gestational HTN: HTN after 20 weeks if previously normotensive No proteinuria No other systemic findings Systolic over 140 OR a Diastolic over 90 Resolution Usually in first postpartum week Must resolve by 12 weeks to meet this classification Risk Factors for Preeclampsia: Primigravida 6-8x greater risk First pregnancy at age extremes 19 and 35 (20% incidence among teens) 2-3x greater if primigravida is over 40 Info About Preeclampsia recurring: Preeclampsia in a previous pregnancy (especially if the onset was early and severe) Recurrence of preeclampsia 65% if it occurred prior to 30 weeks gestation or is superimposed on chronic 25% if occurred in last trimester Pre-e WITH severe features: Progressive renal insufficiency: Serum creatinine concentration 1.1mg/dL or a doubling of serum creatinine concentration in the absence of other renal disease Pulmonary Edema Visual disturbances: flashing lights, auras, light sensitivity, blurry vision, spots in vision Markedly elevated blood pressure: or equal to 160 over or equal to 110 x 2 Taken 4 hours apart on bedrest Platelet count 100,000: Elevated liver enzymes to twice normal Severe persistent epigastric or RUQ pain unresponsive to meds Eclampsia: Cause of seizure is unknown Cerebral vasospasm Hemorrhage Ischemia Edema Platelet and fibrin clots that occlude cerebral vasculature Premonitory signs of eclampsia: Persistent headache and blurred vision Epigastric or RUQ pain Altered mental status Seizures can appear without warning What to do if someone with eclampsia seizes? Ensure patent airway and safety Note time of onset and duration of seizure Call for help (remain calm) Remain at bedside Complications of Eclampsia: (d/t the periods of hypoxia in mother and fetus) Risk of aspiration CVA Cerebral edema Anoxia Coma Maternal death Preeclampsia superimposed on chronic hypertension If chronic, 25% chance to have superimposed Morbidity is 25-35% higher Increased risk of intracranial bleed and abruption Labs associated w/ HELLP Syndrome: CBC CMP Uric Acid - increases BUN - increases 24 hour urine for protein and creatinine clearance Serum creatinine - increase