Chapter 13: HTN Disorders In Pregnancy Flashcards
HYPERTENSIVE DISORDERS IN PREGNANCY. You are a trainee intern at an antenatal booking clinic with Jackie, a 36-year-old G1P0 Pākehā woman at 18 weeks gestation. It is challenging measuring Jackie’s blood pressure as she has cerebral palsy with contractures in her limbs and is obese (BMI 33). From the following options, what describes best practice for accurately measuring her blood pressure in pregnancy with a stethoscope?
Have the middle of the cuff at the level of the heart
Have the woman seated or semi-recumbent
Use a cuff size that is appropriate for her weight
Place the stethoscope directly over the brachial artery
Record it to the nearest 2mm Hg
Do all of these
Do all of these
HYPERTENSIVE DISORDERS IN PREGNANCY. You are a trainee intern at an antenatal clinic with Sakiya, an obese 36 year old G1P0 Indonesian woman at 24 weeks gestation. Sakiya has a strong family history of pre-eclampsia and is anxious. She asks you when an antenatal blood pressure measurement is classed as significant. From the following options, what is the most important one in determining a diagnosis of hypertension in pregnancy?
Hypertension is a rise of systolic BP > 30 mm Hg over booking BP OR a rise of diastolic BP > 15 mmHg over booking BP
Hypertension is a systolic BP > 160 mm Hg OR a diastolic BP > 110 mmHg
Hypertension is a rise of systolic BP > 30 mm Hg over booking BP AND a rise of diastolic BP > 15 mmHg over booking BP
Hypertension is a systolic BP > 140 mm Hg OR a diastolic BP > 90 mmHg
Hypertension is a systolic BP > 140 mm Hg AND a diastolic BP > 90 mmHg
Hypertension is a systolic BP > 140 mm Hg OR a diastolic BP > 90 mmHg
HYPERTENSIVE DISORDERS IN PREGNANCY You are a trainee intern at an antenatal clinic with Karen, a 28 year old G2P1 Pākehā woman who is 28 weeks gestation. Her previous pregnancy, labour and birth two years ago was uncomplicated. This pregnancy has been uncomplicated so far. Karen’s booking blood pressure was 136/78. Routine urinalysis today was also normal with no proteinuria. Her weight is 70Kg. Her blood pressure on both occasions you take it during the 10 minute consultation, is 140/90 (using a standard sized cuff). Abdominal examination showed a fundal height consistent with dates. Karen has no oedema and feels well - you check that she has no specific symptoms of preeclampsia. You request Karen has “pre-eclampsia bloods” taken – FBC, U&Es, LFTs and uric acid. Which of the following management options is most appropriate?
Advise routine review in two weeks
Repeat the blood pressure measurement on the other arm
Repeat the blood pressure measurements within 2-3 days
Repeat the blood pressure measurement using a larger sized cuff
Advise routine review in four weeks
Advise review in 10 days
Repeat the blood pressure measurements within 2-3 days
HYPERTENSIVE DISORDERS IN PREGNANCY. You are a trainee intern seeing Kirsten, a 40 year old G2P0 Pākehā woman who is 32 weeks pregnant. She has been referred by her midwife after her BP was 150/95 at a routine antenatal check. Kirsten’s booking BP at 10 weeks was 125/76. Kirsten has no headache nor visual disturbances nor epigastric pain and her baby is active. She has + oedema of her legs. When you recheck Kirsten’s BP it is 145/95. Kirsten has ++ of proteinuria. From the following options, what is the most likely management?
Start oral labetalol and review in 2 days
Start oral bendrofluazide and review in 2 days
Review in 2 days
Start oral cilazapril and review in 2 days
Admit for observation and further fetal and maternal assessment
Admit for observation and further fetal and maternal assessment
HYPERTENSIVE DISORDERS IN PREGNANCY. You are a trainee intern in an antenatal clinic seeing Leanne, a 38-year-old G3P2 Pākehā woman for her booking visit at 10 weeks gestation. She has a blood pressure of 150/100. Leanne has been on labetalol 100mg bd for hypertension for two years. She has no proteinuria. Which of the following options is the most important blood investigation to organise now, so that it is available for later reference should Leanne develop preeclampsia with proteinuria and/or oliguria in the third trimester?
WCC
Hb and PCV
Creatinine
Group and antibody
Platelets
Creatinine
HYPERTENSIVE DISORDERS IN PREGNANCY. You are a trainee intern admitting Naomi, a 32 year old G1P0 woman of Indian ethnicity to the antenatal ward. Naomi is 32 weeks gestation and has had increasingly severe epigastric pain, nausea and vomiting for the past 8 hours. She has not had any vaginal bleeding. Her pregnancy has previously been uneventful and was last seen 10 days ago when she was well and had normal clinical findings. On admission today her blood pressure was 146/104 mmHg, and urinalysis showed: leucocytes+, protein+++. As the TI going to admit her, which of the following possible differential diagnoses of the cause of her pain would you consider most likely?
Acute degeneration of a fibroid
Placental abruption
Torsion of an ovary
HELLP syndrome
Pancreatitis
Pyelonephritis
Appendicitis
HELLP syndrome
HYPERTENSIVE DISORDERS IN PREGNANCY. You are a trainee intern admitting Moana, a 30 year old G4P3 wahine Māori, to the antenatal ward. Moana is 30 weeks pregnant. At a routine LMC appointment today Moana’s blood pressure was noted to be 172/112 and she had proteinuria +++. (Her booking blood pressure was 116/68.) Moana’s previously pregnancies have been uncomplicated normal vaginal births 11, 9 and 5 years ago. This is her new partner’s first child. When you admit Moana her BP is 165/110. You note both ankle and abdominal wall oedema. The baby is presenting as a breech, and the liquor volume appears reduced as the fetal parts are easily felt. Her partner anxiously asks you “what is likely to happen now?” Which of the following options is the most appropriate management?
Continued hospitalisation with induction of labour via a foley balloon catheter, probably within the next two weeks
Continued hospitalisation with medical induction of labour with prostaglandins, probably within the next two weeks
Continued hospitalisation with delivery by caesarean section, probably within the next two weeks
Discharge home when her blood pressure and proteinuria resolve
Administration of nifedipine (or an IV antihypertensive), stabilise on oral antihypertensive and discharge once blood pressure <160/100
Continued hospitalisation with delivery by caesarean section, probably within the next two weeks
HYPERTENSIVE DISORDERS IN PREGNANCY. You are a trainee intern admitting Aiko, a 32 year old G1P0 Japanese woman who is 38 weeks pregnant. Aiko’s blood pressure has increased from 138/84 to 146/112 over the last 2 weeks. She has proteinuria +++ and has gained 4kg in weight. She has no headache or visual disturbances or epigastric pain. On examination there is oedema ++ but no hyper – reflexia. On abdominal examination the fundal height is 38 cm, the lie is longitudinal and the head is deeply engaged with 1/5 of the head palpable abdominally. On vaginal exam, the cervix is soft, three cms dilated and fully effaced with bulging membranes. A CTG shows a normal trace. The registrar has prescribed Aiko a stat dose of oral labetalol. Which of the following management options is the most likely?
A caesarean section
Induction of labour with an artificial rupture of membranes (ARM)
Commence regular labetalol and discharge when the blood pressure is stabilised
Induction of labour with prostaglandins
Strict fluid balance chart, with fluid restriction if oliguria <500mls/24hrs while awaiting spontaneous labour
Induction of labour with an artificial rupture of membranes (ARM)
HYPERTENSIVE DISORDERS IN PREGNANCY. You are a trainee intern in an antenatal clinic seeing Olive, a 35 year old primigravid NZ European woman who is 34 weeks pregnant. Olive’s blood pressure has increased from 110/70 at booking to 146/102 today. She has ++ of proteinuria (new today). She has gained 4kg in weight over the last 4 weeks. She feels well. On examination she has oedema ++. Abdominal examination is normal for 34 weeks gestation. Which of the following diagnoses do you consider to be the most likely cause of her hypertension, proteinuria and oedema?
A phaeochromocytoma
Gestational hypertension
Essential hypertension with renal involvement
Preeclampsia
Nephrotic syndrome
Preeclampsia
HYPERTENSIVE DISORDERS IN PREGNANCY You are a trainee intern in antenatal clinic seeing Prue, a 36-year-old G1P0 New Zealand European woman who is 35 weeks pregnant. Prue’s blood pressure is 146/102 (booking BP 110/70) and she has proteinuria ++++. Prue did not have proteinuria when she was last seen 2 weeks ago. Prue has no headaches, visual disturbances or epigastric pain. When examining Prue you note oedema ++. Abdominal examination is consistent with 35 weeks gestation. Prue has no abdominal tenderness. She has normal reflexes and no clonus. You diagnose Prue with pre-eclampsia. Which of the following organs is the most severely affected by her pre-eclampsia?
Kidneys
Uterus
Skin and peripheral vasculature
Liver
Heart
Brain
Kidneys
HYPERTENSIVE DISORDERS IN PREGNANCY. You are a trainee intern in an antenatal clinic, seeing Hine, a 30-year-old primigravid wahine Māori who is 34 weeks pregnant. Hine’s blood pressure is 145/100 (booking BP 116/72) and she has +++ proteinuria on urine dipstick. Hine has no symptoms of pre-eclampsia. On examination there is oedema ++. Abdominal examination reveals a fundal height of 34 cm. There is no right upper quadrant or uterine tenderness. Hine’s reflexes are normal and she has no clonus. Which of the following blood tests is most likely to be abnormal.
Hb and/or PCV
Plasma albumin and/or globulin
Liver enzymes
Creatinine
Platelet count
Creatinine
HYPERTENSIVE DISORDERS IN PREGNANCY. You are a trainee intern on the antenatal ward admitting Pania, a 24-year-old primigravid wahine Māori who is 34 weeks’ gestation. Pania has raised blood pressure (150/105) and proteinuria +++. In the last hour Pania has developed an increasingly severe frontal headache and some blurring of vision. On examination she has hyperreflexia and clonus. Of the following options, which would be your most immediate management?
Administer an antihypertensive agent IV
Arrange immediate induction of labour
Administer magnesium sulphate intravenously
Administer an oral antihypertensive agent
Arrange emergency caesarean section
Administer magnesium sulphate orally
Administer magnesium sulphate intravenously
HYPERTENSIVE DISORDERS IN PREGNANCY. You are a trainee intern on the antenatal ward admitting Sarah, a 24-year-old G1P0 Pākehā woman who is 34 weeks pregnant and has raised blood pressure (150/105) and proteinuria +++. In the last hour Sarah has developed a severe frontal headache and some blurring of vision. You undertake an examination. Which of the following findings would confirm to you that an IMMEDIATE intervention is required?
Epigastric tenderness
Abdominal wall oedema
Pitting ankle oedema
Hyperreflexia and clonus
Loin tenderness
Petechiae and bruising
Hyperreflexia and clonus
HYPERTENSIVE DISORDERS IN PREGNANCY. You are a trainee intern on the birthing suite admitting Robyn, a 24 year old G2P1 Pākehā woman who is 37 weeks pregnant. She has a 4 year old son who was a NVD at term, to a different partner. Currently Robyn has hypertension (150/98) and proteinuria ++. She woke up this morning with some abdominal pains and now has some light vaginal bleeding. She is now having contractions every 5 minutes. She is being placed on the CTG now. You insert an IV line and send bloods to the lab. Fifteen minutes later the midwife comes to update you. Which of the following scenarios would require an immediate intervention?
Robyn also complains of epigastric tenderness. She has abdominal wall and tibial oedema +++.
Robyn’s cervix is closed on vaginal examination. Her CTG is abnormal with late decelerations
Robyn has abdominal wall oedema and brisk reflexes, but no clonus
Robyn is 7cm dilated on vaginal examination. Her CTG is reassuring
On vaginal examination Robyn’s cervix is closed. Her CTG is currently reassuring.
Robyn is 3cm dilated on vaginal examination. Her membranes have ruptured. Her CTG is normal.
Robyn’s cervix is closed on vaginal examination. Her CTG is abnormal with late decelerations
HYPERTENSIVE DISORDERS IN PREGNANCY. You are a trainee intern on the birthing suite admitting Natalie, a 24 year old G2P1 Pākehā woman who is 38 weeks gestation and has raised blood pressure (146/95) and proteinuria ++. Natalie had a normal vaginal birth at term 2 years ago. Currently, Natalie has some right upper quadrant pain, but is otherwise asymptomatic. On examination you confirm the hypertension and also note petechiae and bruising on Natalie’s limbs. She has no uterine or abdominal tenderness. The fundal height measures 36cms with the fetus lying longitudinally, with a deeply engaged head. On vaginal examination, her cervix is 3 cms dilated, fully effaced and you can feel bulging membranes. The head is at the level of the ischial spines. Urgent blood tests showed Hb of 110g/L (normal) a platelet count of 60 x109/L (N>150), and schistocytes on the blood film. Her hepatic enzymes were elevated. A CTG is normal. Magnesium Sulphate has been commenced Which of the following options is the most appropriate management plan?
Induce labour by performing an ARM (artificial rupture of the membranes)
Deliver by emergency caesarean section under spinal anaesthetic
Treat the hypertension and observe in hospital until Natalie goes into labour
Induce labour with a Foley balloon catheter
Give a platelet transfusion, fresh frozen plasma and cryoprecipitate before planning delivery
Induce labour medically with prostaglandins
Induce labour by performing an ARM (artificial rupture of the membranes)
