HTN and Pre-eclampsia

Question 1

What is the definition of gestational HTN?

Answer 1

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).

Question 2

Which monitoring function is required in patients with gestational HTN?

Answer 2

Patient requires regular monitoring of BP and urinalysis during the pregnancy to exclude pre-eclampsia and gestational diabetes.

Question 3

When should induction of labour be considered?

Answer 3

> 37 weeks’ gestation

Question 4

What is the proposed aetiology of gestational HTN?

Answer 4

It is thought that insulin resistance may mediate the clinical onset of HTN in pregnancy.

Question 5

Which condition should you be worried about when a pregnant woman is diagnosed with gestational HTN?

Answer 5

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.

Question 6

What are the risk factors for gestational HTN?

Answer 6

Nulligravidity 
Black or Hispanic ethnicity 
Multiple pregnancies 
Obesity 
Mother herself being born small for gestational age

Question 7

When should a diagnosis of gestational HTN be made?

Answer 7

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.

Question 8

Which investigations are required at each antenatal visit for women with gestational HTN?

Answer 8

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

Question 9

Differentials of gestational HTN

Answer 9

Pre-eclampsia
Eclampsia
HTN, essential

Question 10

Treatment of gestational HTN less than 37 weeks gestation that is non-severe

Answer 10

Lifestyle mediation
Induction of labour
Anti-hypertensive- labetalol (200mg) or nifedipine

Question 11

What are the indications of proceeding to immediate delivery in women with gestational HTN?

Answer 11

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)

Question 12

Treatment of severe HTN in ladies who are less than 37 weeks pregnant

Answer 12

Antihypertensive treatment (labetalol)
Lifestyle modification
Induction of delivery

Question 13

Treatment in women who are more than 37 weeks pregnant

Answer 13

Induction of labour

Question 14

Complications of gestational HTN

Answer 14

Pre-eclampsia
CVD in the mother
Foetal or neonatal complications

Question 15

What is pre-eclampsia?

Answer 15

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.

Question 16

What is the cause of pre-eclampsia?

Answer 16

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

Question 17

What is the diagnostic criteria for pre-eclampsia?

Answer 17

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.

Question 18

Can pre-eclampsia be diagnosed in the absence of proteinuria?

Answer 18

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.

Question 19

What are the severe features of pre-eclampsia?

Answer 19

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.

Question 20

Symptoms of pre-eclampsia

Answer 20

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

Question 21

Risk factors for pre-eclampsia

Answer 21

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

Question 22

Investigations for pre-eclampsia

Answer 22

Urinalysis
Foetal ultrasound
Umbilical artery Doppler velocimetry
Amniotic fluid assessment
Foetal cardiotocography
FBC
LFTs
Serum creatinine

Question 23

Differentials of pre-eclampsia

Answer 23

Chronic HTN
Gestational HTN
Epilepsy
HUS
TTP
Renal disease
Liver disease
Gallbladder disease
Pancreatic disease

Question 24

What is the treatment of pre-eclampsia?

Answer 24

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

Question 25

Complications of pre-eclampsia

Answer 25

Intrauterine growth restriction
Eclampsia
Pulmonary oedema
Pregnancy-associated stroke
Placental abruption
Renal failure
Stillbirth

Question 26

What is the pre-pregnancy advice given to hypertensive women?

Answer 26

Advise women who take ACEi or ARBs or Thiazide:
• that there is an increased risk of congenital abnormalities if these drugs are taken during pregnancy
• to discuss alternative antihypertensive treatment with the healthcare professional responsible for managing their HTN, if they are planning pregnancy
• to discuss alternative treatment with the healthcare professional responsible for managing their condition, if ACE inhibitors or ARBs are being taken for other conditions such as renal disease.

Question 27

Which medications shouldn’t be used to prevent hypertensive disorders during pregnancy?

Answer 27

nitric oxide donors
progesterone
diuretics
low molecular weight heparin.

Question 28

Which medication should be offered to women with more than 1 risk factor for pre-eclampsia?

Answer 28

Advise pregnant women with more than 1 moderate risk factor for pre-eclampsia to take 75-150 mg of aspirin1 daily from 12 weeks until the birth of the baby. Factors indicating moderate risk are:
• first pregnancy
• age 40 years or older
• pregnancy interval of more than 10 years
• BMI of 35 kg/m2 or more at first visit
• family history of pre-eclampsia
• multi-pregnancy.

Question 29

When should you start offering USS for women with pre-eclampsia

Answer 29

28-30 weeks.

Carry out an ultrasound for fetal growth and amniotic fluid volume assessment and umbilical artery doppler velocimetry starting at between 28 and 30 weeks (or at least 2 weeks before previous gestational age of onset if earlier than 28 weeks) and repeating 4 weeks later in women with previous:
• Severe pre-eclmapsia
• pre-eclampsia that resulted in birth before 34 weeks
• pre-eclampsia with a baby whose birth weight was less than the 10th centile
• intrauterine death
• placental abruption.

Question 30

Should you offer a delivery before 37 weeks for a woman whose BP is lower than 160/110?

Answer 30

No.

Do not offer planned early birth before 37 weeks to women with chronic hypertension whose blood pressure is lower than 160/110 mmHg, with or without antihypertensive treatment, unless there are other medical indications.

Question 31

Which medications are uterine stimulants?

Answer 31

Prostin, oxytocin, misoprostol, endothelin, ergometrine

Question 32

Which medications are uterine relaxants?

Answer 32

Nitric oxide, relaxin, indomethacin, atosiban, magnesium, nifedipine, terbutaline

Question 33

Blood loss in a soiled sanitary towel

Answer 33

30 ml

Question 34

Blood loss in a soaked sanitary towel

Answer 34

100 ml

Question 35

Blood loss in a small soaked swab

Answer 35

60 ml

Question 36

Blood loss in an incontinence pad

Answer 36

250 ml

Question 37

Blood loss in a large soaked swab

Answer 37

350 ml

Question 38

Blood loss in a 100 cm diameter floor spill

Answer 38

1500 ml

Question 39

Blood loss from a PPH on bed only

Answer 39

1000 ml

Question 40

Blood loss from PPH spilling to floor

Answer 40

2000 ml

Question 41

Blood loss in a full kidney dish

Answer 41

500 ml