Ch 8 Hypertension And Pregnancy

Question 1

Abnormal bp during pregnancy is classified into categories based on predicting hypertension

Answer 1

Chronic hypertension - is seen increasingly in pregnancy and is associated with increased risk of maternal and neonatal morbidity

And
Gestational hypertension - caused by pregnancy
Liver injury is seen in a small percentage of patients with preeclampsia abs is associated with two diseases in pregnancy with high mortality: HELLP (hemolysis, elevated liver enzymes, low platelets)
AFLP (acute fatty liver of pregnancy)

Treatment is also delivery. These disorders r the leading cause of prematurity

Question 2

effects of preeclampsia: placental underperfusion resulting in polssible growth restriction and hypoxia.

Answer 2

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results in increased vascular permeability, activation of the coagulation cascade, microangiopathic hemolysis, and vasoconstriction manifesting clinically as HTN, proteinuria, and other clinical manifestations of the disease.

Question 3

FETAL complications of preeclampsia

Answer 3

acute uteroplacental insufficiency - placental infarct and/or abruption, intrapartum fetal distress, stillbirth (in severe cases)

chronic uteroplacental insufficiency - asymmetric and symmetric SGA fetuses , iugr

oligohydranios

Question 4

MATERNAL complications of preeclampsia

Answer 4

seizure
cerebral hemorrhage
DIC and thrombocytopenia
renal failure
hepatic rupture / failure
pulmonary edema

obstetric complications
Uteroplacental insufficiency
placental abortion
increased premature deliveries
increased c/s deliveries

Question 5

maternal complications asscoiated with preclampsia are related to generalized arteriolar vasoconstriction that affects the brain (seizure and stroke), kidneys (oligouria and renal failure),
lungs (pulmonary edema)
liver (edema and subcapsular hematoma)
and small blood vessels (thrombocytopenia and disseminated intravascular coagulation (dic)

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Question 6

10% of patients with preeclampsia with severe features develop HELLP syndrome - further subcategory of preeclampsia in which the patient presents with HEmolysis, elevated liver enzymes, and low platelets

HTN and proteinuria may be minimal or even absent in these patients. HELLP syndrome results in high rate of stillbirth 10-15%, and neonatal death 20-25%

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Question 7

when HTN is seen early in 2nd trimester (14-20)weeks, a hydatiform mole or previously undiagnosed chronic htn should be considered

Answer 7

hydatiform mole or previously undiagnosed chronic htn should be considered

Question 8

patient with HELLP syndrome is more likely to be less than 36 weeks gestation .

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Question 9

20% of HELLP syndrome have no previous hx of HTN before their diagnosis, and will present merely with symptomm of right upper quadrant RUQ pain. any patient who presents with RUQ pain , epigastric pain, nausea and vomiting in the 3rd trimester should be seen immediately to r/o HELLP syndmr

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Question 10

risk factors for preeclampsia:
chronic hTN
chronic renal disease
antiphospholipid antibody syndrome
collagen vascular disease (ex. sle)
pregestational diabetes
african american
maternal age <20 or >35

immunologic related:
nulliparity
previous preeclampsia
multiple gestation
abnormal placentation
new paternity 
mother of the father (MIL) had preeclampsia, the patient is at greater risk of developing preeclampsia.

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Question 11

gestational HTN: elevated systolic bp above 140 and/or diastolic bp above 90 on 2 occasions at least 4-6 hours apart after 20 weeks gestation

bp should always be taken in seated position to obtain most accurate rading.

patients with gestational HTNshould be delivered at 37 weeks gestation

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Question 12

preeclampsia without severe features:

elevated systolic bp above 140 and/or diastolic bp above 90 on 2 occasions at least 4-6 hours apart after 20 weeks gestation
**AND**********
proteinuria - >= 300mg/24h protein OR creatinine ratio >=0.3 OR dipstick reading of +1

OR
IN THE BASENCE OF PROTEINURIA AND SEVERE RANGE BLOOD PRESSURE, NEW ONSET HTN WITH NEW ONSET OF ANY OF THE FOLLOWING:

1. THROMBOCYTOPENIA (PLATELET COUNT <100,000
2. RENAL INSUFFICIENCY (SERUM CREATININE CONCEITRATIONS > 1.1 MGDL OR A DOUBLING OF SERUM BASELINE CREATININE CONCETRATION IN THE ABSENCE OF OTHER RENAL DISEASE
3. IMPAIRED LIVER FUNCTION ( ELEVATED BLOOD CONCETRATIONS OF LIVER TRANSAMINASES TO TWICE NORMAL CONCENTRATION
4. PULMONARY EDEMA
5. CEREBRAL/VISUAL SYMPTOMS

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Question 13

HELLP syndrome: hemolysis, elevated liver enzymes, low platelets
characteraized by rapid deteriorating liver function, evidence of hemolysis, and thrombocytopenia. in addition, a number will develop DIC.

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Question 14

dx of HELLP
elevated lactate dehydrogenase
elevated total bilirubin
elevated liver enzymes
increase in aspartate aminotransferase (AST)
increase in alanine aminotransferase (ALT)
low platelets
thrombocytopenia

Answer 14

HELLP, hemolysis, elevated liver enzymes, low platelet count

Question 15

acute fatty liver of pregnancy AFLP
more thna 50% of patients with aflp will also have hypertension and proteinuria
1/10,000 pregnancies and has high mortality rate

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Question 16

AFLP can be difficult to distinguish from HELLP syndrome, but typically women with AFLP exhibit evidence of liver failure, including elevated ammonia level, blood glucose < 50mg/dl, and markedly reduced fibrinogen and antithrombin III levels.
management involves maternal stabilization and prompt delivery of fetus regardless of gestational age.

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Question 17

aflp is associated with significant morbvidity including need for liver transplant and high maternal mortality rates

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Question 18

women with preeclampsia during first pregnancy will hve 25% to 33% recurrence in subsequent pregnancies.

pts with both chronic htn and preeclampsia , risk of recurrence is 70%

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Question 19

recommended that women with hx of preeclampsia, multiple gestations, chronic hTN, diabetes, renal disease, or autoimmune disease receive low dose aspirin after 12 weeks to help reduce risk of preeclampsia.

calcium supplementation also been associated with decreased rates of subsequent preeclampsia

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Question 20

eclampsia is occurrence of grand mal seizures in preeclamptic patient that cannot be attributed to other causes

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Question 21

complications of eclampsia include

Answer 21

cerebral hemorrhage, aspiration pneumonia, hypoxic encephalopathy, and thromboembolic events

Question 22

seizures in eclamptic patient are tonic-clonic and may or or may not preced by an aura. these seizures occur within the first 48 hrs after delivery, but will occasionally occur as late as several weeksa fter delivery. fetal bradycardia can also occur during and after eclamptic seizures.

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Question 23

treatment include seizures management, bp control, prophylaxis against further convulsions, seizures managemetn always start with ABCs (airway, breathing, circulation)

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Question 24

chronic hypertension, defined as HTN present BEFORE conception, before 20 weeks gestation, or persisting more than 6 weeks postpartum .

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Question 25

patients are at risk for other complciations of chronic HTN, baseline labs
cbc
complete metabolic panel
baseline 24 hour urine collection fo creatinine clearance and protein should be obtained. this will also help differentiate superimposed preeclampsia from chronic renal disease later in pregnancy
also important to get baseline ECG in pt with chronic HTN to ensure there is no current cardiac compromise requiring further evaluation. low dose asa should be initiated after 12 weeks to reduce risk of developing superimposed preeclampsia

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Question 26

1/3 of or more of patients with chronic HTN will develop superimposed preeclampsia.
because HTN is longstanding, complications such as IUGR and placental abruption are more common

dx of superimpsed preeclampsia can be made in patients with increasingly elevated BPs and new / worsening proteinuria.

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Question 27

if 24 hour urine protein becomes elevated > 300mg/24 hrs, diagnosis is clearly superimposed preeclampsia.

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Question 28

patients bmi, hx of gestational htn, and bp indicate patient most likely has diagnosis of chronic htn. chronic htn complicates up to 5% of pregnancies in the US. its prevalence varies depending on woman’s age, race and bmi.

in pregnant women, chronic hypertension is defined as HTN that is present before pregnancy, sustained HTN before 20 weeks’ gestation or HTN persisting more than 6 weeks postpartum

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Question 29

initial evaluation of women with chronic HTN includes assessing for presence of other medical complications and target end-organ damage associated with chronic HTN.

ab seline 24 hr urine collection should be done to assess protein and creatinine clearance. in addition to establishing a baseline, this will help to differentiate btwn chronic renal disease and superimposed preeclampsia later in the pregnancy.

ecg is important for basleine cardiac status

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Question 30

quad screen is a maternal blood screening test that looks at levels of

Answer 30

alpha fetoprotein
beta human chorionic gonadotropin
estradiol
inhibin A

to assess probability of potential genetic disorders.
15-18 weeks

Question 31

pregnnag women with chronic HTN are at increased risk of SUPERIMPOSED PREECLAMPSIA, placental abruption, preterm delivery, and small for gestational age.

1/3 will develop superimposed preeclampsia.
dx is worsening bps and presence of new onset or worsening proteinuria or evidence of end-organ damage after 20 weeks’ gestation .

also at increased risk of maternal complications such as pulmonary edema, cerebral hemorrhage, and acute renal failure

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Question 32

diagnosis of patients in severe preeclampsia:
thrombocytopenia, <100,000
serum creatinine >= 1.1
or double baseline creatinine, transaminitis of double normal
headache/visual disturbances
pulmonary edema.

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Question 33

management of preeclampsia with severe features:
keep bps <= 160/110 using labetalol / nifedipine
ultrasound to assess fetal growth
daily NST
lab tests (CBC, liver enzymes, basic metabolic panel, LDH, uric acid)
betamethasone should be given to facilitate fetal maturation, particularly in pulmonary system in women < 36wks

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Question 34

HELLP syndrome is hemolysis, elevated liver enymes, l and low platelets.

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