8. Hypertensive disorders in pregnancy. Eclampsia. HELLP-syndrome

Question 1

what is the definition of chronic HTN (preexisting)

Answer 1

> 140/90 mmHg
Sustained; present before 20 w’
gestation, persists > 12 w’ after delivery

Question 2

definition of gestational HTN

Answer 2

> 140/90 mmHg
Sustained; present after 20 w’ gestation
resolves within < 12 w’ from delivery

Question 3

management of chronic and gestational HTN

Answer 3

1. Antihypertensive during pregnancy:
   - Hydralazine (short-term)
   - Labetalol (short-term)
   - α-methyldopa (long-term)
   - Nifedipine (long-term)
2. Frequent follow-up:
   - Fetal surveillance (NST, US)
   - Renal function and urinalysis
   - BP monitoring
3. Deliver at 37-39 w’ gestation
4. Low-dose aspirin (81 mg daily) may
   reduce the risk of preeclampsia in
   high-risk patients

Question 4

definition of preeclampsia

Answer 4

> 140/90 mmHg
Sustained; diagnosed after 20 w’ gestation
and Proteinuria > 0.3 g/L in 24-h’

Question 5

management of preeclampsia

Answer 5

> 37 w’ gestation → delivery
< 37 w’ gestation → close F/U, screen for alarm symptoms

Question 6

preeclampsia with severe features

Answer 6

> 140/90 mmHg
Sustained; diagnosed after 20 w’ gestation
and Proteinuria > 5 g/L in 24-h’
*BP > 160/110 mmHg
*PLT count < 100,000/μL
*Serum Cr > 1.1 mg/dL or doubling of baseline concentration in the absence of renal disease
*↑ ALT or AST (> 2x normal)
*Pulmonary edema
*New-onset headache (refractory to standard
analgesics)
*Visual symptoms

Question 7

management of preeclampsia with severe features

Answer 7

1. Magnesium sulfate (continue for 24 h’ after delivery – prophylaxis)
2. Delivery (urgently → induction or C-section)
3. BP control (IV hydralazine)

Question 8

Eclampsia management

Answer 8

1. Magnesium sulfate (abort seizure)
2. stabilization (ABC)
3. Delivery (emergent C-section)

Question 9

what occurs in eclampsia?

Answer 9

> 140/90 mmHg
Imposed on preeclampsia or gestational HTN
*any type of urinalysis- proteinuria or no
*Seizures (cannot be attributed to any other cause)

Question 10

what is Superimposed preeclampsia ?

Answer 10

preeclampsia in patients with preexisting chronic HTN; seen in up to 25% of patients with chronic HTN.

Question 11

what does diagnosis of HTN require ?

Answer 11

recording of elevated blood pressure (> 140/90 mmHg) on at least 2 occasions, at least 4 hours apart.

Question 12

Pathogenesis of preeclampsia/eclampsia

Answer 12

1. Inadequate placental implantation (cytotrophoblastic invasion of the spiral uterine arteries) → wide-spread vascular endothelial dysfunction and vasospasm → ischemia → release of toxins into the systemic circulation that further exacerbate endothelial dysfunction → systemic signs and symptoms.
2. Reduced placental synthesis of vasodilators prostaglandins.
   3.Increased placental synthesis of agents antagonizing VEGF and TGF-β.

Question 13

risk factors of preeclampsia/eclampsia

Answer 13

• Nulliparity
• Maternal age (> 35 years or < 15 years)
• Multiple gestation
• History of renal disease or chronic HTN
• History of preeclampsia/eclampsia
• Diabetes mellitus
• Obesity
• Antiphospholipid syndrome

Question 14

complications of preeclampsia

Answer 14

Placental abruption
Coagulopathy
AKI
HELLP syndrome
Eclampsia

Question 15

complication of eclampsia

Answer 15

• Stroke (hemorrhagic or thrombotic)
• ARDS
• AKI
• Hemorrhagic shock

Question 16

complications of HELLP syndrome

Answer 16

• DIC
• Hepatic subcapsular hematoma
• Hepatic rupture +/- hemorrhagic shock
• Placental abruption

Question 17

what are the consequences of seizure during pregnancy/delivery?

Answer 17

maternal acidosis, maternal and fetal hypoxia, CNS damage, ↑ risk of stroke.

Question 18

what is HELLP syndrome?

Answer 18

a severe form of preeclampsia plus Hemolysis, Elevated Liver enzymes, Low Platelets

**although do not have to have preeclampsia to have HELLP syndrome ? שנוי במחלוקת

Question 19

A patient with HELLP syndrome is more likely to be

Answer 19

multiparous, older than 25 years, and presenting at < 36 w’ gestation

Question 20

clinical presentation of HELLP syndrome

Answer 20

onset of symptoms is usually rapid, with patient complaining of 3rd trimester nausea/vomiting, and severe RUQ abdominal pain or epigastric pain (hepatic subcapsular hematoma).

Question 21

what is Tennessee classification?

Answer 21

criteria used to establish diagnosis for HELLP syndrome

Question 22

Tennessee classification

Answer 22

(1) Hemolysis (at least two of the following): peripheral smear with schistocytes, serum bilirubin ≥ 1.2 mg/dL, serum haptoglobin ≤ 25 mg/dL, serum LDH ≥ 2 times the upper level of normal, severe anemia.

(2) Elevated liver enzymes: AST or ALT ≥ x2 the upper limit of normal.

(3) Low platelets: < 100,000 cells/μL.

Question 23

imaging to assess HELLP syndrome

Answer 23

start with us
proceed with MRI

Question 24

what parameters are used in Mississippi classification (severity of HELLP syndrome)?

Answer 24

PLT count
AST/ALT
LDH >600
divided into 3 classes. 1 is the worse

Question 25

DD with HELLP syndrome

Answer 25

acute fatty liver of pregnancy,
thrombotic thrombocytopenic purpura (TTP), pregnancy-related hemolytic-uremic syndrome (HUS),
and SLE.

Question 26

management of HELLP syndrome

Answer 26

1. seizure prophylaxis (Magnesium-sulfate).
2. blood products if symptomatic anemia/thrombocytopenia
3. dexamethasone (questionable effect on liver function and platelet count)
4. eculizumab (complement C5 inhibitor)- experimental.
5. if stable–> delivery with a team experience in liver trauma surgery
6. hepatic bleeding–> volume replacement and blood
7. antihypertensives to control BP