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HYPERTENSION Cheat Sheet (DRAFT) by

HYPERTENSION - OBSTETRICS

This is a draft cheat sheet. It is a work in progress and is not finished yet.

CLASSIF. OF HPN DISORDER COMPLI­CATING PREGNANCY

• Gestat­ional Hypert­ension
• Preecl­ampsia
• Chronic Hypert­ension
• Superi­mposed Preecl­ampsia on Chronic Hypert­ension

CRITERIA FOR DIAGNOSIS OF HYPERT­ENSION

GESTAT­IONAL HYPERT­ENSION

• BP ≥140/9­0mmHg for the 1st time during pregnancy after 20 weeks
• NO PROTEI­NURIA

PREECL­AMPSIA

• BP ≥140/9­0mmHg
• PROTEI­NURIA
- 300 mg/24-hour urine sample (+) 1 dipstick
- Urine protei­n/c­rea­tinine ration of 0.3 mg/dL
• Classi­fic­ation:
- Without severe features
- With severe features

PREECL­AMPSIA - MNEMONIC

SEVERITY OF GESTAT­IONAL HYPERT­ENSIVE DISORDERS

DIAGNOSIS OF SEVERE PREECL­AMPSIA

Gestat­ional Hypert­ension vs Preecl­ampsia

• BP returns to normal within 12 weeks after delivery in GH

CHRONIC HYPERT­ENSION

• BP ≥140/9­0mmHg before pregnancy or diagnosed before 20 weeks
• Hypert­ension first diagnosed after 20 weeks gestation and persistent after 12 weeks postpartum

SUPERI­MPOSED PREECL­AMPSIA (ON CHRONIC HTN)

• Women with hypert­ension only in early gestation who develop protei­nuria after 20 weeks of gestation
• Seizures that cannot be attributed to other causes in a woman with preecl­ampsia

CRITERIA

SEVERE PEE, PEE (-)SEVERE FEATURES, GHPN

WHEN TO START ASPIRIN?

• Low dose aspirin (81mg/day) prophy­laxis is recomm­ended in women at high risk of preecl­ampsia and should be initiated between 12 weeks and 28 weeks of gestation (optimally before 16 weeks) and continued daily until delivery

Clinical Risk Assessment for Preecl­ampsia

PATHOG­ENESIS OF HYPERT­ENSION

• Endova­scular tropho­blasts replace the vascular endoth­elial and muscular lining to enlarge the vessel diameter. The veins are invaded only superf­ici­ally.
• Vasospasm
• Endoth­elial damage

PREDICTORS OF PREGNANCY INDUCED HYPERT­ENSION

• Roll over test
• Uric acid
• Fibron­ectin
• Coagul­ation activation
• Oxidative stress
• Cytokines
• Placental peptides
• Fetal DNA
• Uterine artery doppler veloci­metry

PREDICTION OF PREECL­AMPSIA

RECOMM­END­ATION: screening to predict preecl­ampsia beyond obtaining an approp­riate medical history to evaluate for risk factors is not recomm­ended

TREATMENT - CALCIUM

Baseline Evaluation for Chronic HPN in Pregnancy

  

MAGNESUIM SULFATE

MAGNESUIM SULFATE - PHARMA­COLOGY

Loading dose: 4-6 grams IV
Only achieves the desired therap­eutic level
Can be safely admini­stered regardless of renal function
Toxicology of Magnesium Sulfate
• Magnesium intoxi­cation is avoided be ensuring
- Urine output is adequate
- The patellar or biceps reflex is present
- No respir­atory depression
• Therap­eutic level: 4-7 mEq/L
• Toxic levels:
- 10mEq/L patellar reflexes disappear
- >10 mEq/L respir­atory depression develops
- >12 mEq/L respir­atory paralysis and arrest follow
•Antidote: calcium gluconate, 1 g IV over 10 min period
• Mainte­nance dose: 1-2 grams/hour x 24 hours
• Given during labor and continued up to 24 hours postpartum
• Dose reduced to half if creatinine ≥1.1 mg/dL
MECHANISM OF ACTION OF MAGNESIUM SULFATE
• CALCIUM ANTAGONIST
• Decreases vasoco­nst­riction
• Decreases cerebral edema
• Decreases neuronal impulse transm­ission

MANAGEMENT OF SEVERE PREECL­AMPSIA <34 wks

ANTIHY­PER­TEN­SIVES

ANTIHY­PER­TEN­SIVES (cont.)

THE AIM OF ANTI-H­YPE­RTE­NSIVE THERAPY IS TO KEEP THE SYSTOLIC BP BETWEEN 140-155 AND DIASTOLIC BP BETWEEN 90-100 mmHg

MANAGEMENT

MANAGEMENT (cont.)

HELP SYNDROME

ANTENATAL CORTIC­OST­ERIODS

INDICA­TIONS FOR DELIVERY

- UNCONT­ROLLED HYPERT­ENSION
- ABSENT OR REVERSE END DIASTOLIC FLOW IN DOPPLER

UNCONT­ROLLED HYPERT­ENSION

TIMING OF DELIVERY

- Prenatal management is aimed primarily at determ­ining the IDEAL timing and mode of delivery

DOPPLER ULTRASOUND IN MANAGEMENT OF SUSPECTED IUGR

DOPPLER ULTRASOUND (cont.)

WHAT IS THE MODE OD DELIVERY?

The mood of delivery should be determined after consid­ering the presen­tation of the fetus and the fetal condition, together with the likelihood of success of induction of labor after assessment of the cervix.
It is suggested that prolonged induction and inductions with low likelihood of success be avoided. In this regard, the pregna­ncies less than 32 weeks compli­cated by severe preecl­ampsia, with unfavo­rable cervical examin­ation, CS may be recomm­ended.

WHAT IS THE ANESTHSIA OF CHOICE?

In women with severe preecl­ampsia or even with eclampsia as long as the woman is awake, and seizure free, regional anesth­esia, preferably epidural appears safer than general anesthesia