Gestational Hypertension

Question 1

Pathophysiology of Gestational Hypertension (TISARUA)

Answer 1

decreased trophoblastic invasion into decidua and myometrium.

Narrow vascular lumen of maternal spiral arteries.

Increased resistance to flow in the uterine artery leading to chronic placental ischemia and oxidative stress

Question 2

Risk Factors to gestational hypertension

Answer 2

Risk Factors: previous preeclampsia, nulliparity, new partner, advanced maternal age >40years old, multifetal gestation, obesity, pre-existing medical conditions (chronic hypertension, renal disease, pregestational DM, autoimmune conditions), assisted reproductive technologies, family history of preeclampsia, blck, hispanic and asian descent.

Question 3

which ethnicities are risk factors for gestational hypertension

Answer 3

blck, hispanic and asian descent.

Question 4

1. Explain the classification of hypertension in pregnancy depending on if person had chronic hypertension or if they were normotensive when non-pregnant

Answer 4

Pre-eclampsia Definition if patient was normotensive when non-pregnant: Hypertension >20 weeks, New proteinuria ≥1 adverse condition ≥1 severe complication –> one of these! You do not need proteinuria to diagnose pre-eclampsia. You basically just need hypertension + one other adverse condition

Pre-eclampsia definition if chronic hypertension: Resistant hypertension New or worsening proteinuria ≥1 adverse condition ≥1 severe complication

Question 5

symptoms of preeclampsia

Answer 5

high blood pressure symptoms

Symptoms: persistent and/or severe headache, visual abnormalities (photophobia, blurred vision), upper abdominal, retrosternal, or epigastric pain, edema (rapid weight gain), new onset nausea, altered mental status, dyspnea or orthopnea

Question 6

pre-eclampsia requires >1 adverse condition to be present to make the diagnosis. what are some examples of adverse conditions?

Answer 6

Adverse Conditions

▪ MATERNAL:

▪ CNS: Headache, visual disturbances

▪ CV/Resp: Chest pain / dyspnea

▪ Hematologic: Thrombocytopenia (>50 x 109/L)

▪ Renal: Elevated creatinine, elevated uric acid

▪ Hepatic: Nausea/vomiting, RUQ or epigastric pain, elevated ALT

▪ FETAL:

▪ IUGR

▪ Oligohydramnios

▪ Abnormal fetal Doppler studies on ultrasound

Question 7

pre-eclampsia requires >1 severe complication condition to be present to make the diagnosis. what are some examples of severe complications?

For maternal, what CNS, CV/Resp, hematologic, renal or hepatic problems are happening)?

Answer 7

▪ MATERNAL:

▪ CNS: Eclampsia, PRES, GCS < 13, stroke/TIA

▪ CV/Resp: Uncontrolled severe HTN, O2 sat < 90%, pulmonary edema, MI

▪ Hematologic: Thrombocytopenia (<50 x 109/L), need for transfusion

▪ Renal: Acute kidney injury, (Cr >150 µmol/L), need for dialysis

▪ Hepatic: INR > 2, hepatic hematoma or ruptur

▪ FETAL:

▪ Placental abruption

▪ Critically abnormal fetal Doppler studies (reverse A-wave of the ductus venosus) on ultrasound

▪ Stillbirth

Question 8

examplsia

Answer 8

a severe complication fo pre-eclampsia complicated by generalized tonic-clonic convulsions. occurs in 2-3% of women with severe preeclampsia who are not receiving anti-seizure prophylaxis

Question 9

prophylaxis for eclampsia

Answer 9

mag sulphate

Question 10

treatment for eclampsia

Answer 10

also mag sulphate

Question 11

eclampsia is an indication for___

Answer 11

delivery

Question 12

HELLP syndrome presentation

Answer 12

hemolysis, elevated liver enzymes, low platelets.

Question 13

3. List the investigations required to evaluate a patient with hypertension in pregnancy.

Answer 13

Investigations: BP, Lab studies (CBC, LDH, Creatinine, Urate, liver chemistries, quantitative urinary protein determination, Pr:cr ratio, 24 hour urine collection), coagulation studies (prothrombin time, partial thromboplastin time, fibrinogen).

Fetal evaluation: NST, biophysical profile.

Significant proteinuria: >0.3g/d in 24 hour collection, >30mg/mmol in spot sample.

*proteinuria does not predict short-term adverse outcomes nor long term renal prognosis.

*in LOW RISK normotensive women, don’t perform routine urinalysis

Question 14

T/f the presence of proteinuria can predict how the preeclampsia will impact outcome in the shortterm

Answer 14

false.*proteinuria does not predict short-term adverse outcomes nor long term renal prognosis.

Question 15

management of gestational hypertension

Answer 15

1. icnreased surveillance: more prenatal visits, home blood pressure monitoring, serial lab work
2. DELIVERY!!!

Question 16

target for mild-moderate hypertension in a pregnant person

Answer 16

target of BP is 130-155/80-105 without co-morbid ocndiitons, and 130-139/80-89 with co-morbid conditions

Question 17

medical management for mild-moderate hypertension (not preclampsia)

Answer 17

don’t give mad sulphate unless actual preclampsia

• give labetalol, nifedipine or methyldopa. No ACE or ARBS.

Question 18

medical management for severe hypertension

Answer 18

aim for a lower blood press re <160/ Mag sulphate prophylaxis against eclampsia.

• also give labetalol, nifedipine or methyldopa

Question 19

Post partum care of gestational hypertension

In future pregnancies, there is a __-___% risk of recurrence. Evidence for use of ___ in women at high risk of preeclampsia. Current recommendation is 162mg at bedtime, optimally started <16 weeks GA

Answer 19

In future pregnancies, there is a 15-20% risk of recurrence. Evidence for use of ASA in women at high risk of preeclampsia. Current recommendation is 162mg at bedtime, optimally started <16 weeks GA