HTN and Pre-eclampsia Flashcards
What is the definition of gestational HTN?
Defined by blood pressure (BP) >140/90 mmHg on 2 occasions (at least 4 hours apart) during pregnancy after 20 weeks’ gestation in a previously normotensive patient, without the presence of proteinuria or other clinical features suggestive of pre-eclampsia (thrombocytopenia, impaired renal or kidney function, pulmonary oedema, or new-onset headache).
Which monitoring function is required in patients with gestational HTN?
Patient requires regular monitoring of BP and urinalysis during the pregnancy to exclude pre-eclampsia and gestational diabetes.
When should induction of labour be considered?
> 37 weeks’ gestation
What is the proposed aetiology of gestational HTN?
It is thought that insulin resistance may mediate the clinical onset of HTN in pregnancy.
Which condition should you be worried about when a pregnant woman is diagnosed with gestational HTN?
Pre-eclampsia. Aligns gestational hypertension closely with pre-eclampsia; the management of gestational hypertension and that of pre-eclampsia without severe features is similar in many aspects, and both require enhanced surveillance.
What are the risk factors for gestational HTN?
Nulligravidity Black or Hispanic ethnicity Multiple pregnancies Obesity Mother herself being born small for gestational age
When should a diagnosis of gestational HTN be made?
A diagnosis of gestational hypertension should be made only after two readings ≥140/90 mmHg, spaced at least 4 hours (but no more than 7 days) apart.
Which investigations are required at each antenatal visit for women with gestational HTN?
Urinalysis: Because patients are at increased risk of pre-eclampsia, a urine dipstick test is recommended on each visit.
FBC: baseline test to screen for pre-eclampsia at diagnosis
LFTs: baseline test to screen for pre-eclampsia at diagnosis
Differentials of gestational HTN
Pre-eclampsia
Eclampsia
HTN, essential
Treatment of gestational HTN less than 37 weeks gestation that is non-severe
Lifestyle mediation
Induction of labour
Anti-hypertensive- labetalol (200mg) or nifedipine
What are the indications of proceeding to immediate delivery in women with gestational HTN?
Labour or rupture of membranes Abnormal foetus testing IUGR Development of pre-eclampsia Eclampsia Evidence of end-organ damage (e.g. neurological, hepatic or renal dysfunction)
Treatment of severe HTN in ladies who are less than 37 weeks pregnant
Antihypertensive treatment (labetalol) Lifestyle modification Induction of delivery
Treatment in women who are more than 37 weeks pregnant
Induction of labour
Complications of gestational HTN
Pre-eclampsia
CVD in the mother
Foetal or neonatal complications
What is pre-eclampsia?
A disorder of pregnancy associated with new-onset hypertension (defined as a blood pressure ≥140 mmHg systolic and/or ≥90 mmHg diastolic), which occurs most often after 20 weeks of gestation and frequently near term.
What is the cause of pre-eclampsia?
Pre-eclampsia is associated with a failure of normal invasion of trophoblast cells leading to maladaptation of maternal spiral arterioles, and is associated with hyperplacentation disorders such as diabetes, hydatidiform mole, and multiple pregnancy
What is the diagnostic criteria for pre-eclampsia?
BP is 140-159 mmHg systolic and/or 90-109 mmHg diastolic and proteinuria is ≥300 mg/24 hours; or dipstick reading ≥2+ (use only if other quantitative methods not available); or protein: creatinine ratio is ≥0.3 mg/dL.
Can pre-eclampsia be diagnosed in the absence of proteinuria?
BP is 140-159 mmHg systolic and/or 90-109 mmHg diastolic and, in the absence of proteinuria, any of the following is present:
Thrombocytopenia, platelets count <100,000/microlitre.
Serum creatinine ≥1.1 mg/L or a doubling of the serum creatinine concentration in the absence of other renal disease.
Impaired liver function, elevated blood concentrations of liver transaminases to twice normal concentration.
Pulmonary oedema.
New-onset headache unresponsive to medication and not accounted for by alternative diagnoses or visual symptoms.
What are the severe features of pre-eclampsia?
BP is ≥160 mmHg systolic and/or ≥110 mmHg diastolic (on two occasions at least 4 hours apart, unless antihypertensive therapy is initiated before this time.
Thrombocytopenia, platelets count <100,000/microlitre.
Serum creatinine ≥1.1 mg/L or a doubling of the serum creatinine concentration in the absence of other renal disease.
oImpaired liver function, elevated blood concentrations of liver transaminases to twice normal concentration, and severe persistent right upper quadrant or epigastric pain unresponsive to medication and not accounted for by alternative diagnoses.
Pulmonary oedema.
New-onset headache unresponsive to medication and not accounted for by alternative diagnoses
Visual disturbances.
Symptoms of pre-eclampsia
Occur in women after 20 weeks’ gestation.
BP >140mmHg systolic and/or >90mmHg diastolic and previously normotensive.
Headache
Upper abdominal pain
Reduced fetal movement
FGR
Oedema
Risk factors for pre-eclampsia
Primiparity Pre-eclampsia in previous pregnancy FHx of pre-eclampsia BMI>30 Maternal age >40 years Multiple (twin) pregnancy Sub-fertility Gestational HTN Pre-existing diabetes PCOS Autoimmune disease Renal disease Pre-existing CVD and chronic HTN
Investigations for pre-eclampsia
Urinalysis Foetal ultrasound Umbilical artery Doppler velocimetry Amniotic fluid assessment Foetal cardiotocography FBC LFTs Serum creatinine
Differentials of pre-eclampsia
Chronic HTN Gestational HTN Epilepsy HUS TTP Renal disease Liver disease Gallbladder disease Pancreatic disease
What is the treatment of pre-eclampsia?
Before delivery: o Hospital admission and monitoring o Decision regarding delivery o Corticosteroid o Severe HTN- labetalol 20mg IV, hydralazine 5-10 mg o Magnesium sulphate (seizures) After delivery: o Close monitoring of fluid balance o Continue antihypertensives and magnesium sulfate
