2.1 - Hypertension In Pregnancy

Question 1

Explain the characteristics and diagnostic criteria for the various hypertensive disorders of pregnancy

Answer 1

• systolic blood pressure greater than or equal to 140 mmHg
• Diastolic blood pressure grater than or equal to 90 mmHg (Korotkof 5)
• chronic hypertension
  
  • includes essential hypertension
  • hypertension secondary to other medical conditions
  • HTN pre conception or early diagnosed in pregnancy<20
• Gestational hypertension
  
  • nw onset of hypertension >20 weeks gestation
  • no maternal or fetal features of preeclampsia
  • followed by a return to normal BP within 3 months postpartum
• preeclampisa
  
  • HTN >20 weeks
  • involvement of one or more organ system and/or fetus
  • renal/haematological/liver/neuro/pul oedema/FGR
  • proteinuria common (not mandatory)

Question 2

Describe the pathophysiology of hypertensive disorders of pregnancy, risk factors and potential complications - preeclampsia

Answer 2

• preeclampsia
  
  • one or multi-system involvement
  • raised BP is common but not always first manifestation
  • proteinuria common
  • Fetus involvment
• Renal
  
  • significant proteinuria - spot urine protein/creatinine ratio >30mg/mmol
  • serum or plasma creatinine >90umol/l
  • Oligure <80ml/4hours
  • (urate is not included as a diagnostic feature)
• Haematological involvement
  
  • Thrombocytopenia <100,00/uL
  • Haemolysis -
    
    • schistocytes or red cell fragments on blood film,
    • raised bilirubin,
    • raised lactate
    • dehydrogenase >600mIU/L
    • decreased haptogoblin
• Liver involvement
  
  • Raised serum transaminases
  • severe epigastric and/or right upper quadrant pain
• Neurological involvment
  
  • convulsions (eclampsia)
  • Hypereflexia with sustained clonus
  • persistent visual disturbance
    
    • photopsia
    • scotomata
    • cortical blindness
    • posterior reversible encephalopathy syndrome
    • retinal vasospasm
  • stroke
  • FGR

Question 3

Describe the pathophysiology of hypertensive disorders of pregnancy, risk factors and potential complications - Gestational Hypertension

Answer 3

• new onset of HTN Post 20 weeks
• without any maternal or fetal features of preeclampsia
• returns to normal BP within 3 months postpartum

Question 4

Describe the pathophysiology of hypertensive disorders of pregnancy, risk factors and potential complications - Chronic Hypertension

Answer 4

• includes essential hypertension as well as secondary htn to a range of conditions
  
  • essential 140/90 and unknown cause
• secondary to
  
  • chronic kidney disease - glomerulonephritis, reflux nephropathy, adult polycystic kidney disease
  • renal artery stenosis
  • systemic disease with renal involvement
    
    • diabetes mellitus
    • systemic lupus erythaematosus
  • Endocrine disorders
    
    • phaeochromocytoma
    • Cushing’s

Question 5

Explain the signs and symptoms of pre-eclampsia for both mother and fetus

Answer 5

maternal

• excess protein in urine (proteinuria)
• other kidney problems
• decreased levels of platelets in blood (thrombocytopenia) <1000
• increased liver enzymes that indicate liver problems
• severe headaches
• changes in vision
  
  • temp loss of vision
  • blurred vision
  • light sensitivity
• SOB caused by pulmonary oedema
• pain in upper right quadrant
• N&V
• spiral arteries involvment change is size

Fetus

• FGR
• preterm birth
• placental abruption
• HELLP syndrome - stands for hemolysis (the destruction of red blood cells)
  
  • elevated liver

Question 6

Incorporating a woman centred approach, explain the midwifery care for women with hypertensive disorders across the continuum, as part of the multi-disciplinary team

Answer 6

• monitor maternal and fetal well being
• to detect any deterioration in condition of both maternal and fetal
• to reduce maternal and fetal morbidity and mortality
• monitor bp
• Urinalysis
  
  • check for proteinuria
  • increasing vascular damage results in increasing protenuria
    
    • indicates the deterioration of maternal condition
• abdo palp
  
  • discomfort - placental abruption
  • HELLP syndrome (upper right quadrant pain)
• fetal movement
• fetal heart rate
• CTG
• antihypertensive therapy
• if preterm - corticosteroids
• COAGS
• FBE
• U&E
• Growth scan
• umi artery doppler studies

Question 7

Identify the medications used in the management of hypertensive disorders in pregnancy, describe indications for use, usual dose, therapeutic action and potential side effects

Answer 7

• Methyldopa
  
  • indications
    
    • Gestational hypertension
  • Dose
    
    • 250mg to 500mg
    • 250mg to 1000mg per day
  • side effects
    
    • headache
    • muscle weakness
    • upset stomach
    • vomiting
    • diarrhea
    • gas
    • dry mouth
    • rash
    • • Labetalol
  • dose
    
    • 100mg bd per day
    • 200 - 400mg bd not to exceed 2400mg per day
  • side effects
    
    • dizzines
    • tingling scalp or skin
    • lightheadedness
    • excessive tiredness’
    • heache
    • upset stomach
    • stuffy nose
• nifedipine
  *