Blood Pressure in Pregnancy

Question 1

How does blood pressure fluctuate throughout pregnancy?

Answer 1

Blood pressure changes in a normal and characteristic way during pregnancy
Reduced, at the start due to reduced vascular resistance from the effects of progesterone
Increased, after 24 weeks due to increase in stroke volume
Decreased after delivery but may peak 3-4 days post-partum

Question 2

What are the cut off values for hypertension in pregnancy?

Answer 2

Mild 140-149 systolic, 90-99 diastolic

Moderate 150-159 systolic 100-109 diastolic

Severe >160 systolic > 110 diastolic

Question 3

What is pregnancy induced hypertension?

Answer 3

Gestational hypertension or pregnancy induced hypertension = new onset hypertension diagnosed after 20 weeks without significant proteinuria or an increase above booking readings of > 30 mmHg systolic or > 15 mmHg diastolic. Both increase risk of PET.

Question 4

What is the definition for pre-existing hypertension?

Answer 4

A history of hypertension before pregnancy or an elevated blood pressure > 140/90 mmHg before 20 weeks gestation

No proteinuria, no oedema

Question 5

What is the definition of pre eclampsia?

Answer 5

Pregnancy-induced hypertension in association with proteinuria (> 0.3g / 24 hours)

Oedema may occur but is now less commonly used as a criteria.

Question 6

How should pre existing hypertension be managed during pregnancy?

Answer 6

Prior to conception (Essential/Chronic Hypertension)
• Need to be changed to a pregnancy friendly drug i.e. Labetalol
• Aspirin daily from 12 weeks to reduce risk of pre-eclampsia
• Growth pathway – increased risk of growth restriction
• Consultant lead care
• Smoking, diet weight, alcohol advice etc.
• Induced around due date

Question 7

How should pregnancy induced hypertension be managed?

Answer 7

• Aspirin daily to reduce risk of pre-eclampsia (depends on risk factors) if one high or two or more moderate risk factors for pre-eclampsia
• Delivery aimed for EDD
• Medication to treat hypertension

Question 8

What is the 1st line drug used for hypertension during pregnancy, list some common side effects and other important guidelines regarding it.

Answer 8

Labetalol (1st line)

Beta-blocker.

Scalp tingling, postural hypotension, fatigue, headache, nausea and vomiting, epigastric pain and liver damage.

Contraindicated in asthmatics and
DMT1 – removes palpitations which are a sign of hypos

Not effective in black, afro-Caribbean’s

Question 9

What is the 2nd line drug used for hypertension during pregnancy, list some common side effects and other important guidelines regarding it.

Answer 9

Nifedipine (MR)

Calcium channel blocker.

Inhibition of labour, peripheral oedema, dizziness, flushing, headache, constipation.

Avoid grapefruit juice

Nifedipine always given MR unless given stat to stop contractions

Question 10

What is the 3rd line drug used for hypertension during pregnancy, list some common side effects and other important guidelines regarding it.

Answer 10

Methyldopa

Alpha-agonist.

Depression, drowsiness, headache, oedema, GI disturbances, dry mouth, postural hypotension, bradycardia, hepatotoxicity.

Good for replacing ACE inhibitors

Avoid in severe depression and post-natally

Question 11

Should ACEi be used during pregnancy?

Can they be used postnatally?

Answer 11

Note: ACE-inhibitors are contra-indicated in pregnancy due to their association with congenital abnormalities.

Enalapril – ACE inhibitor. Used post-natal (not first line). Side effects: dry cough, dyspnoea and depression.

Safe in breastfeeding

Question 12

How would you treat a black afro-carribean lady, with asthma who’s throwing up and has severe HTN?

Answer 12

Hydralazine – useful in black Caribbean, asthmatic who’s throwing up with severe high BP.

Avoid in severe tachy, recent MI, idiopathic SLE or before 3rd trimester.

Side effects: tachycardia. Flushing and palpitations. IV infusion.

Safe in breastfeeding

Question 13

What is pre eclampsia?

Answer 13

Pathophysiology – mechanism unknown. Generally considered to be due to poor placental perfusion as a result of abnormal placentation. Normally muscles around the spiral arteries are destroyed during placentation meaning they can’t constrict = healthy blood supply. In Pre-eclampsia remodelling is incomplete creating a high resistance low flow system.

The resultant BP increase combined with hypoxia and oxidative stress leads to a systemic inflammatory response and endothelial dysfunction resulting in leak blood vessels.

Question 14

What are the high and moderate risk factors for PET?

Answer 14

High Risk
Hypertensive disease in previous pregnancy
Chronic kidney disease
Autoimmune disease e.g. lupus, antiphospholipid syndrome
Type 1 or 2 diabetes
Chronic hypertension

Moderate Risk 
First pregnancy 
Age 40 or older 
Pregnancy interval of more than 10 years 
BMI > 35
Family history of pre-eclampsia 
Multiple pregnancy

Question 15

When should aspirin be taken to prevent PET?

Answer 15

If one high risk factor or 2 or more moderate, then daily Aspirin from 12 weeks gestation until birth

Question 16

What are the maternal signs and symptoms of PET?

Answer 16

A woman greater than 20 weeks gestation
• Hypertension (140/90) on two occasions at least 4 hours apart
• Significant proteinuria >300mg in 24 hours or >30 urinary protein:creatinine (PCR)

May be asymptomatic
Visual disturbances
Headaches (usually frontal that won’t go away)
Epigastric pain/RUQ (hepatic capsule distention/infarction): comes, stays and won’t go away
Confusion
Sudden onset oedema
Uterine tenderness or vaginal bleeding from abruption
Hyper-reflexia

Urate, urea, LDH and creatinine usually raised

Question 17

What are the foetal symptoms of PET?

Answer 17

Reduce foetal movements
IUGR
Reduced liquor
Poor dopplers

Question 18

How should suspected PET be investigated?

Answer 18

Urine dipstick and BP, U&E and LDH

Monitor for organ dysfunction
• Mother: FBC, Urea and electrolytes, liver function tests and clotting
• Foetus: Umbilical artery doppler – look for end diastolic flow. Absent is better than reversed.

Question 19

Where should PET be managed?

Answer 19

Once substantial proteinuria then must be admitted and have high level monitoring of both maternal and foetal well being

Question 20

How should pre eclampsia be managed?

Answer 20

Only cure for pre-eclampsia
is delivery.

1. Hypertensive treatments – aim for <160/110 – Stat PO Nifedipine every 30 mins – if BP remains high after 3 doses then IV labetalol (methyldopa if asthmatic)
2. Prevention of VTE – fragmin
3. Magnesium sulphate is used stat to treat eclamptic fits
4. After 34 weeks gestation same day delivery may be considered
5. Epidurals will help to keep blood pressure down during labour
6. Strict fluid balance
7. Steroids if less than 34 weeks

Question 21

What are the indications for immediate delivery in a patient with PET

Answer 21

Indications for immediate delivery:
•	Worsening thrombocytopenia 
•	Worsening liver or renal function 
•	Severe maternal symptoms especially epigastric pain and poor LFTs 
•	HELLP pre-eclampsia 
•	Foetal distress

Question 22

Is there any risk after delivery indicated for PET?

Answer 22

Still high risk of eclamptic seizures post-partum so mother should be monitored for her blood pressure often in first 2 days post-partum then at least once a day 3-5 days post-partum. Reassess need for antihypertensives after these 5 days.

Question 23

What symptoms suggest a high risk of seizure and how should that be managed?

Answer 23

If high risk of a seizure: hyper-reflexia, symptomatic, severe hypertension, abnormal blood tests then give prophylactic magnesium sulphate IV infusion

Question 24

When treating PET with magnesium sulphate what should you be aware of?

Answer 24

Be aware of magnesium toxicity – respiratory depression, loss of patella reflexes, confusion, weakness, flushing, sweating, bradycardias/arrhythmia – STOP Magnesium sulphate. If toxic give calcium gluconate.

Question 25

What are the complications of pre eclampsia?

Answer 25

Maternal:
•	HELLP – haemolysis, elevated liver enzymes and low platelets
•	Eclampsia/Eclamptic fit 
•	AKI
•	DIC
•	ARDS
•	4-fold increased risk of hypertension postpartum
•	Cerebral haemorrhage
•	Death 

Foetal:
•	Prematurity 
•	IUGR
•	Placental abruption 
•	Intrauterine foetal death

Question 26

What is Eclampsia?

Answer 26

Eclampsia is defined as the development of tonic-clonic seizures in association with pre-eclampsia. Clinically it is a sign of severe disease, people die as a result of HELLP, intracranial haemorrhage and blood loss.

Question 27

How should eclampsia be treated?

Answer 27

Magnesium sulphate is used to both prevent seizures in patients with severe pre-eclampsia and treat seizures once they develop. Guidelines on its use suggest the following:
• Should be given once a decision to deliver has been made
• In eclampsia an IV bolus of 4g over 5-10 minutes should be given followed by an infusion of 1g / hour
• Urine output, reflexes, respiratory rate and oxygen saturations should be monitored during treatment
• Treatment should continue for 24 hours after last seizure or delivery (around 40% of seizures occur post-partum)
• If seizures repeat, consider diazepam
• General obs important as well as ABCDE – may need intubation
• Monitor urine output

Question 28

How should fluids be managed during treatment for PET or eclampsia?

Answer 28

Other important aspects of treating severe pre-eclampsia/eclampsia include fluid restriction to avoid the potentially serious consequences of fluid overload

Question 29

What is HELLP?

Answer 29

Severe variant of eclampsia manifesting with: Haemolysis, Elevated Liver enzymes and Low platelets. HELLP usually self-limiting but may lead to permanent liver or kidney damage. One up (LFTs), one down (low platelets) and one broken down (haemolysis).

Question 30

What are the symptoms of HELLP?

Answer 30

RUQ pain
N and V
Tea coloured urine due to haemolysis
Associated PET

Question 31

How should HELLP be managed?

Answer 31

Delivery indicated and Treat with magnesium sulphate