HTN and Diabetes in Pregnancy

Question 1

What is considered HTN in pregnancy?

Answer 1

Two blood pressure measurements six hours apart of greater than 140/90 mm Hg is considered diagnostic of hypertension in pregnancy.

Question 2

What is considered pre-Eclampsia?

Answer 2

In pregnancy:
HTN
Proteinuria
Edema

Question 3

What 3 things are abnormal on PE in a patient with pre-Eclampsia?

Answer 3

1. Hyperreflexia (normal in pregnancy but more pronounced in pre-Eclampsia)
2. Headaches
3. Visual Changes

Question 4

What causes epigastric pain in pre-Eclampsia?

Answer 4

Increased abdominal pressure from expanding uterus and the HTN causes a backup of fluid in the liver and portal system. This stretches the capsule around the liver causing pain.

Question 5

How does pre-Eclampsia cause IUGR?

Answer 5

The HTN can cause fibrosis and calcification in the placenta vessels which can lead to thrombosis. This compromises blood supply to the growing fetus and impairs growth.

(IUGR can also be called fetal growth restriction or FGR)

Question 6

What are the 3 types of pre-Eclampsia?

Answer 6

1 Mild

2. Severe
3. HELLP syndrome

Question 7

What is HELLP syndrome?

Answer 7

Condition in pregnancy with Hemolysis, Elevated Liver enzymes, and Low Platelets. Can occur in both mild or severe pre-Eclampsia. If present in either mild or severe it indicates a much poorer prognosis.

Question 8

What is Eclampsia?

Answer 8

Pre-Eclampsia with convulsions

Question 9

What 3 tests are run to monitor patients with Eclampsia?

Answer 9

1. Blood tests: CBC, clotting tests
2. Renal Tests: BUN, creatinine
3. LFT tests: AST, ALT, bilirubin

Question 10

What 3 tests are run to monitor the fetus in patients with Eclampsia?

Answer 10

1. NST
2. CST
3. BPP

Question 11

What is the treatment strategy for patients diagnosed with mild pre-Eclampsia?

Answer 11

1. Rest and Observation
2. BPP and NST 2x per week to assure fetal well being
3. Deliver if:
   - 38+ weeks gestation
   - signs and symptoms get worse
   - evidence of fetal compromise exists

Question 12

What is the treatment strategy for patients diagnosed with severe pre-Eclampsia?

Answer 12

If less than 32 weeks gestation:

• remain hospitalized until deliver
• control bp
• steroids for lung maturity and preventing fetal inctracranial hemorrhage

If more than 32 weeks gestation:
-stabilize and deliver

Question 13

What two medications are used as seizure prophylaxis during deliver in a severe pre-Eclampsia patient?

Answer 13

1. IV Magnesium Sulfate

2. IV Labetalol

Question 14

How is blood pressure managed in pregnant patients regardless of Eclampsia status?

Answer 14

Medications: IV hydralazine, IV labetalol
Correct BP to 140/90, any less and there is a risk of hypoperfusing the placenta and fetus.

Never use diuretics because blood volume must be maintained.

Question 15

What is gestational HTN?

Answer 15

HTN after 20 weeks gestation without proteinuria

Question 16

What is Chronic HTN in pregnancy?

Answer 16

Known HTN before pregnancy or development of HTN prior to 20 weeks gestation.

Question 17

Which 2 medication classes should be avoided in treatment of chronic HTN?

Answer 17

Beta Blockers: can cause IUGR

ACE Inhibitors: can cause congenital defects

Question 18

What type of complication is present in pregnant patients with pre-existing diabetes vs. gestational diabetes.(GD).

Answer 18

Pre-existing diabetic patients can have the fetus develop congenital anomalies:

1. Cardiac
2. Neural Tube
3. Sacral Agenesis

Question 19

What is the reason congenital anomalies are not present in gestational diabetes?

Answer 19

GD usually doesn’t arise until the 3rd trimester. By this time the chance of congenital anomalies is very low.

Question 20

What is the screening test for GD and how is it interpreted?

Answer 20

1 hour 50g Glucola Test

• patients drinks 50g glucola and 1 hour later blood sugar is measured
• if above 140, the 3-hour glucose tolerance test (GTT) is performed

Question 21

What is the diagnostic test for GD and how is it interpreted?

Answer 21

3 hour GTT
-FBS is measured
-patient drinks 100g glucose solution
-blood sugar measured after 1hr, 2hrs, 3hrs
-Diagnosis of GD is confirmed if at least 2 of the measured levels are higher than these:
FBS: 95
1hr: 180
2hrs: 155
3hrs: 140

Question 22

What is the White Classification?

Answer 22

Classifies Diabetic Patients during pregnancy.
A1: GD patients that can control blood sugar with exercise and diet
A2: GD patients that need insulin for blood sugar control
B,C,D,R,F,G,H,T: pre-existing diabetic patients

Question 23

What is the treatment for GD?

Answer 23

1st line: diet exercise

2nd line: if non-responsive to 1st line, then insulin

Question 24

What are the 4 serial tests to measure fetal well being in diabetic pregnant patients?

Answer 24

NST
CST
BPP
Cord Doppler Study

Question 25

What is the postpartum management for both GD and pre-existing diabetic patients?

Answer 25

GD: almost always resolves and no more insulin is required after deliver

• do a 3 hour 75g GTT
• yearly screening of FBS b/c these patients are at risk of developing diabetes later in life

Pre-existing: insulin requirements drop for a couple days but then regular diabetic therapy continues