Gestational Hypertension And Preeclampsia

Question 1

Prevelance of pre-eclampsia globally

Answer 1

2-8%

Question 2

Most cases of pre-eclampsia occur in healthy nulliparous women.. true or false?

Answer 2

True

Question 3

What are the severe features of pre-eclampsia?

Answer 3

BP more than 160/110
Thrombocytopenia (less than 100K)
Elevated liver enzymes (twice upper limit.of normal)
Sever RUQ pain
Renal insufficiency (creatinine more than 1.1)
Pulmunary edema
New onset severe headache
Visual disturbance

Question 4

Risk factors for pre-eclampsia

Answer 4

Nulliparity
Multifetal gestation
History if pre-E
Chronic HTN
Pregestational diabetes
Thrombophilia
SLE
BMI 30
APS
Age older than 35
Kidney disease
ART
Sleep apnea

Question 5

Diagnostic criteria for pre-E

Answer 5

BP: more than 140 systolic or more than 90 diastolic in more than 2 occasions at least 4hs apart after 20 weeks of gestation given that initially BP was normal
PLUS
Proteinuria (300mg/24h urone collection or protein/crea 0.3 or dipstick +2)
Or any of the severe pre-E features

Question 6

Gestational hypertension and pre-E are different entities with pre-E being more concerning than gestational HTN
True or false?

Answer 6

False
Both conditions are considered as the same spectrum of disease with both disease treated similarly and with the same caution.
They are both also undistinguishable in terms of long term cardiovascular risks including chronic HTN

Question 7

What percentage of gestational hypertension will eventually develop pre-E?

Answer 7

50%
This progression is more likely when the diagnosis is made before 32w.

Question 8

Diagnostic criteria for HELLP syndrome

Answer 8

LDL more than 600
AST and ALT twice the normal value
Platelets count less than 100K
Most cases in the 3rd trimester
30% early prenancy or postpartum

Question 9

Eclapmsia

Answer 9

Significant cause of maternal death
Usually no sequalea
1/4 of patients may demonstrate white matter loss on MRI without any clinical significance
When seizure happens while patient is on magnesium consider other conditions

Question 10

What % of pre-eclamptic patients develop eclampsia?

Answer 10

1.9% of pre-E
3.2% of severe pre-E

Question 11

Eclampisa always develops from a severe pre-eclampsia that follows pre-E… True or false?

Answer 11

False
20-40% of eclampsia can develop with no prior documentation of HTN or proteinuria

Question 12

What are the vascular changes seen in pre-E

Answer 12

Lack of hypervolemia with hemoconcentration
Interaction of prostacyclin, thromboxane A2, nitric oxide and endothelins resulting in severe vasospasm
Aggressive IV fluids to pre-E patients fails to correct these pathologies and reaults in elevation of pulmanary capillary wedge pressure and pulmunary edema.

Question 13

What differs the hepatic changes of pre-E from the other parenchymal liver disease?

Answer 13

In pre-E, AST is elevated more than ALT ( due to periportal necrosis)

Question 14

In the context of pre-E, when are LDH, billirubin, PT, PTT and fibrinogen tested?

Answer 14

LDH, billirubin, PT PTT and fibrinogen are only tested when platelets are less than 150K, there is a significant liver dysfunction or in cases of abruption.

Question 15

What are the renal changes in pre-E?

Answer 15

Non-selective proteinuria
Decreased urinary calcium due to reabsorption
In severe pre-E, oliguria
A greater increase in uric acid levels

Question 16

What are the screening tests used to predict the development of pre-E?

Answer 16

Low risk women screening is associated with low PPV (up to 33% only)
Intervention is unlikely to improve maternal or fetal outcome
Markers used in this setting are: uterine arteries doppler, aoluble fms-like tyrosine kinase angigenic factor (sFlt-1) placental geowth factor, soluble endoglin)

Question 17

What measures can be used ro decrease the risk of pre-E

Answer 17

No intervention has been proven extremely effective up to date
Nutritional interventions ( Vit C, D and E, fish oil, garlic supplement, folic acid and low salt) innefficient evidence
Data does not support bed rest
Ca supplementation in developing countries was found to be helpful but not in the developed ones

Question 18

Mechanism of action of aspirin in the prevention of pre-E

Answer 18

It blocks thromboxane A2 and hence restores balance between thromboxane A2 and prostacyclin

Question 19

When to treat patients with Aspirin for pre-E prevention?

Answer 19

1 High risk factors: History of pre-E, multiple gestation, renal disease, diabetes, HTN)
Or 2 Moderate risk factors:first pregnancy, maternal age more than 35, BMI more than 30, family history, sociodermographic characteristics, and personal history factors)
Low dose aspirin (81 g) received between 12 and 28 weeks (preferably before 16 weeks) continued untill delivery

Question 20

Are there other medications (other than aspirin) to be used to prevent pre-E?

Answer 20

Metformin, statins and sindenafil are all experimental drugs and should not be recommended outside this scope.

Question 21

What is the best time to deliver a gestational hypertensive/pre-E without severe feature?

Answer 21

37 weeks
More than this will increase the chance of morbidity to mother and baby (severe symptoms, eclampsia, HELLP..)
Before this period more chances of prematurity related complications

Question 22

After the diagnosis of pre-E, is it valuable to continue monitoring proteinuria?

Answer 22

No value in doing so, since quantitative level is not of prognostic value and does not affect management in anyway.

Question 23

Will pre-E with severe feature progression happens slower in gestational hypertension compared to pre-E without severe feature?

Answer 23

Yes.
Average of 3 weeks versus 3 days

Question 24

When should we deliver pre-E with sever features after 34 weeks?

Answer 24

Immidiatly
Should not be delayed to give steroid at thos stage

Question 25

When should we deliever pre-E with sever features before 34 weeks?

Answer 25

Immidiatly
Expectant management can be considered in a well equiped setting. 1 to 2 weeks of delivery delay can be achieved without compromising maternal or fetal health as long as good logistics exist.
Conditions precluding expectant managment:
Uncontrolled BP
Persistant headache
Epigastric pain requiring meds
Stroke MI eclampsia and HELLP
Worsening renal function
Pulmonary edema.
Placental abruption suspicion
Fetal causes:
Abnormal testing
Fetus with fetal anomaly aw unable to sirvive
Reversed end diastolic umbilical artery flow

Question 26

In pre-E, what are the monitoring modalities used?

Answer 26

Fetal US: every 3-4 weeks
NST: once or twice weekly
Maternal labs: weekly
Once weekly assesment of proteinuria in GHTN
Clinic visit weekly

Question 27

Number needed to treat pre-E with Mg to prevent 1 eclampsia?

Answer 27

36 if symptomatic
129 of asymptomatoc

Question 28

Contraindication to MgSO4 treatment

Answer 28

Myestenia gravis
Hypocalcemia
Moderate to severe renal failure
Cardia ischemia
Heart block
Myocarditis

Question 29

What is the therapeutic dose/toxic dose of MgSO4?

Answer 29

Therapeutic: 4.8 topp 9.6
But even lower levels achieved with 1g/h Mg can be beneficial

Question 30

Magnesium sulfate dosage and frequency

Answer 30

4-6g loading dose then 1-2g/h
If no IV access: 5 m in each buttock then 5g q4hs alternating (should be moxed with xylocain)
Risk of advert effects higher in IM group
If renal impairment: adjust the dose
Adverse effects: reflex loss at level 9
Respiratoty depression at 12
Cardiac arrest at 30 mch
In this case, calcium gluconate plus furosemide IV

Question 31

What are the treatment options for hyoertensive diseases in pregnancy?

Answer 31

Hydralazine, labetalol and oral nifedipine.
They are all equal in efficacy and anyone if them can serve as 1st line treatment.
Initial treatment can be oral labetalol 200mg q12h (max dose 2400 per day). If BP not controlled then add nifedipine.

Question 32

Antihypertensive dosage during pregnancy

Answer 32

Labetalol: 10 to 20 mg IV ( then double till reaching 80mg every 10 to 30min). Max cumulative dose of 300 or constant 1-2mg/min IV drip
Hydralazine: 5mg IV or IM, then 5-10 mg IV every 20-40 min to max dose of 20 mg or constant infusion 0.5-10 mg/h
Nifedipine 10 to 20 mg orally repeated in 20 min if needed then q2-6h max daily dosage of 180 mg

Question 33

Common contraindications and side effect of antihypertensive drugs used in pre-E

Answer 33

Labetalol: avoid in asthmatic, hx of MI, low cardiac function, heart block and bradycardia

Hudralazine:bmaternal hypotensio, headaches and abnormal fetal heart rate tracings.

Nifedipin: reflex tachycardia and headaches

Question 34

What to do in case of eclampsia while.on MgSO4?

Answer 34

2 to 4 additional grams can be goven and wait.
Then in case of refractory seizure despite this (20 min), consider phenytoin amobarbital and thiopental shojuld be considered along with intubation. Head imaging is also needed

Question 35

How to manage HELLP syndrome?

Answer 35

Delivery at any gestational age
Using high dose steroid was not ahown to be beneficial
Labs every 12hs
AST more than 2000 and LDH more than 3000 suggest increased mortalility
Platelets count tends to drop 40% daily
Lowest platelets count 23hs post delivery
Should not keep progressing after 4 days postpartum, otherwise diagnosia should be questioned
90% of patients will improve markedly on day 7 with only supportive measure and even sometimes rebound increase in plts

Question 36

What is the cardio-vascular risk for patients with a history of pre-E?

Answer 36

Double odds.
HTN, MI, CHF, CVA, PAD, and cardiovascular mortality later on in life

Question 37

What is the cardiovascular risk for a patient with history of pre-E

Answer 37

Double odds.
HTN, MI, CHF, CVA, PAD and CV mortality.
To note the recurrent pre-E or early pre-E increases the risk 4 to 8 times.
HTN is 5 times more likely in this population

Question 38

Can NSAID be used in the postpartum phase for a pre-E patient?

Answer 38

Yes NSAID is still used preferentially over opoids