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What is the definition of Pre-E?
HTN with proteinuria after 20 weeks
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Most adverse effects of PIH are attributable to the elevated blood pressure?
False
**mostly due to underlying cause (vasospasm)
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Who is at high risk for Pre-E? (6)
- 1. Nulliparous
- 2. mult gestation
- 3. AMA
- 4. Hx of Pre-E
- 5. Chronic HTN
- 6. Pre-gestation DM
- 7. AA
- 8. obesity
- 9. Antiphospholipid syndrome
- 10. nephropathy/ vasculature d/o
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Mild Pre-E will progress to severe Pre-E before an eclamptic seizure occurs?
False--> eclampsia effects both mild and severe
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What percentage of patients with GHTN will develop Pre-E later in their pregnancy?
~25%
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The mainstay of treatment for Pre-E is?
-Rest and frequent monitoring
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How does MgSO4 work in Pre-E?
- -Prevents or treats seizures
- -Decreased smoothe muscle vasospasm, &lowering seizure threshold in brain
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Is MgSO4 used to treat hypertension?
NO! Just to treat/prevent seizures. Sometimes a side effect is lower BP because of smooth muscle relaxation
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What happens to the Diastolic BP in pregnancy?
-decreases from week 7- 24 or 32, then rises to pre-pregnancy norms by term
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How much does the total blood volume increase to by term?
increases 35%
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Define chronic HTN in pregnancy?
HTN presenting before pregnancy or before 20 weeks.
- Mild: >140-180 or DBP >90-100
- Severe: >180/100
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How do you differenciate worsening chronic HTN from super-imposed Pre- E?
-Look for worsening HTN WITH proteinuria and other symptoms of Pre-E (floaters, H/As, epigastric pain)
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What is the recommended pharm treatment for Chronic HTN in pregnancy?
- -Don't usually start BP meds unless > 150-160/100-110
- -If already on meds, may consider discotinueing or decreasing dose until BP become severe
- **Methyldopa, labetolol, nifedapin
- **NO ACE in 2nd/3rd Tri
- If already on diuretics or has severe BP, diuretics may be an option
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Is proteinuria seen with GHTN?
NO
- **30% of mult gestation will develop GHTN
- **BP returns to normal after pregnancy
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What is the definition of Pre-E?
BP >140/90 after 20 weeks gestation with previously normal BP AND >300mg protein in 24hr urine
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What is the definition of severe Pre-E?
-BP >160/110 on 2 separate occassions 6 5hrs apart while patient is on bedrest
And/or
->5g protein in 24hr or 3+ on 2 separate dipsticks
AND combination of below
- -visual changes, H/A, Pulm edema
- -epigastric pain
- -evidence of hepatic dysfunction
- -thrombocytopenia
- -IUGR
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T or F. Severe pre-E is always and indication to deliver.
True
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What are some possible causes of Pre-E?
- 1. Immunologic problems (sperm theory)
- 2. Age extremes
- 3. Genetic predisposition
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What is the main issue causing problems in Pre-eclamptic women?
Maternal vasospam
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Besides vasospasm, what are other patho findings during Pre-E?
- 1. Vascular remodeling in uterus/placenta
- 2. Activation of coagulation cascades
- 3. Decreased plasma volume
- 4. Enlarged gomerulus
- 5. oxidative stress
- 6. Endothelial injury
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What are some S/S of disease to watch out for?
- -Edema (outside of LE)
- -Visual changes or floaters
- -Severe H/A unrelieved w/ pain meds
- -Epigastric pain
- -Hyperreflexia
- -COnstriciton of retinal vessels (fundoscopic exam)
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What lab studies are needed for mom and testing for fetus for Pre-E?
Labs--> CBC, platelet, LFTs, serum creatinine, 2hr urine (protein)
Fetal--> frequent monitoring for wt, growth, AFI, NST (BPP later in pregnancy)
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What are some fetal complications from Pre-E?
- 1. IUGR
- 2. Increase mortality
- 3. Placental abruption
- 4. Inadaquate perfusion, non-reassuring FHTs during labor
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What often should fetal growth and AFI be tested for Pre-E?
every 3 weeks
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How often should an NST and BPP be performed?
Twice weekly
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How often should IUGR or oligohydramnios be tested
twice weekly
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What is the treatment for Pre-E?
-Maybe hospitalize initially to see if worsens, if mild, can be sent home with rest and frequent monitoring
-If severe-- MgSo4, BP meds as needed, close monitoring of mom/fetus, delivery as needed
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What is the antidote for magnesium?
slow calcium gluconate push
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What should you monitor when a patient is on continuous MgSO4?
- -patellar reflex
- -respirations
- -urine output
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What is the therapeutic level for MgSO4 for Pre-eclampsia?
Serum--> 4-6
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When are EKG changes seen and when are patellar reflexes lost? (what serum Mg level)?
-EKG changes can occur w/ level at 5-10
-Patellar reflexes are lost between 8-10
**if these symptoms occur, Mg must immediately be stopped, consider Ca gluconate is symptoms severe or respiratory depression occurs
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When are anti-hypertensive used in Pre-E? What is the goal?
BP >160/105
Goal--> slow decrease to DBP 90-100. Don't want to drop quickly or may decrease perfusion to placenta
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When should labetalol NOT be given?
-asthma, heart failure, placental insufficiency--> may cause fetal brady
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What BP meds are best for Pre-E?
- -Methyldopa or nifedapine (ca+ channel blocker)
- -Labetolol and hydraline (esp in labor)
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How long should mg be continued after delivery?
24hrs
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Define HELLP syndrome.
- Hemolysis
- Elevated liver enzymes
- Low Platelets
**indication for delivery
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When is the greatest risk for an eclamptic seizure to occur?
-within 24hrs of delivery
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What are risk of eclampsia?
- 1. injury
- 2. hypoxia
- 3. aspiration
- 4. status epilepticus
- 5. danger to fetus if uterine hyperactivity >20min
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What is the treatment for eclampsia?
- -watch for maternal physical safety
- -maintain airway/O2
- -Make IV access
- -Initiate MgSO4 (IM/IV)
- -ABGs
- -Foley
- -Consider central line/EKG
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