HTN in Pregnancy

Question 1

What is the Definition of Pre-eclampsia?

Answer 1

• a syndromic definition
  
  • HTN >140/90 or >30/15 above baseline (less used) + something else
    
    • Proteinuria
      
      • >300mg/24hrs - 150mg/24hr max in normal, but pregnancy increases flow
      • 3 principles of DDx
        
        • artefact (leukorrhea) - contamination from vaginal discharge
        • UTI
        • pre-eclampsia
    • generalised oedema
      
      • especially in face
      • normal to have increased body water.
    • Multisystem organ dysfunction
      
      • growth restricted baby e.g.

Question 2

What are some complications of pre-eclampsia?

Answer 2

• CVD
  
  • pulmonary oedema
  • severe HTN
• renal
  
  • oliguria
  • renal failure
• haematological
• neurological main reason for death
  
  • cerebreal haemorrhage
  • cerebral oedema
  • eclmapsia
• hepatic (rupture)
• uteroplacental
  
  • FGR
  • abruption
  • fetal distress/death

Question 3

What are some RFs for Pre-eclampsia?

Answer 3

• FHx
• extremes of age
• first pregnancy/new paternity
• period of sexual cohabitation
  
  • briefer = increased risk
  • especially if barrier contraception
  • theory of reduced immune tolerance
• assisted reproduction
• predisposing medical conditions (association vs causation)
  
  • thrombophilias
  • chronic HTN
  • renal/DM
  • autoimmune
• predisposing pregnancy conditions
  
  • multiple pregnancies
  • gestational DM
  • GTBD
  • hydrops
  • trisomy 13

Question 4

What is the presentation of Pre-eclampsia?

Answer 4

• latter half of pregnancy
• asymptomatic
  
  • majority of women
  • symptoms are a late feature
  • mild symptoms generally attributed to normal pregnancy.
• progression

Question 5

What are the stages of progression of pre-eclampsia?

Answer 5

Stage 1

• HTN of 2weeks - 3 mths. (no proteinuria, symptoms)
• admission is elective

Stage 2

• HTN + Proteinuria (no eclampsia/symptoms)
• 2-3weeks
• admit - deliver after 34-36 weeks

Stage 3

• 2hr-3days
• delivery once stabilised, immediate retrieval.
• Red Flags:
  
  • symptoms:
    
    • HTN,
    • Neuro: headache, papilloedema, visual disturbance, upper abdo pain, hyperreflexia
    • renal: oliguria, proteinuria, pul. oedema
  • thrombocytopenia
  • increased LFTs

Question 6

What is the Management of a women with pre-eclampsia?

Answer 6

Assess:

• Ix - maternal FBE, renal, LFTs. foetal CTG, US.
• BP

Admission:

• stabilisation (BP control, fluid balance, surviellance)
• seizure prophylaxis
• multidisciplinary care

HTN treatment:

• LMN (used because safety profile, no one wants to test on pregnant ladies) L - lebetalol, methyldopa, nifedipine
• labetalol - most common, combined alpha/beta blocker.
• can use hydralazine in acute.
• diazoxide rarely used
• ACEI/ARBS - kill the baby in 3rd trimester.

Neuronal stablisation:

• Magnesium sulfate
  
  • monitor - respiration (depressed) reflexes (decreases with administration, serum levels, antidote is CaCL

Question 7

What is the treatment of eclampsia?

Answer 7

• general aims
  
  • airway,
  • control convulsion
  • injury herself
  • review maternal/foetal state
  • expedite delivery
• Epilepsy or pre-eclampsia?
  
  • gum hypertrophy if chronic (phenytoin)
  • medication with her
  • bracelet/hx
• 15-30% post-partum - cured by delivery not at delivery.

Question 8

What is the rough explanation of the cause of pre-eclampsia?

Answer 8

• thought to be associated with poor placentation
• spiral arteries grow into uterine decidua + replace muscular coat with cells.
• In PE
  
  • limited invasion of trophoplasts
• chemical signals from placental cause of maternal vasocontriction
• maternal vasospasm.

Question 9

What is HELLP syndrome?

Answer 9

• may not be HTN - not major feature
• pathognomonic features:
  
  • Haemolysis
  • Elevated Liver enzymes
  • Low Platelet count
• systemic symptoms - non-specific:
  
  • malaise
  • epigastric pain
  • RUQ tender
  • nausea +/- vomiting
  • headache
  • oedema
• Dx - FBE + LFT - high index of suspicion
• DDx - much rare in pregnancy

Question 10

Prevention of preeclampsia?

Answer 10

• Calcium 1500mg helps - particularly calcium deplete reduces
• low dose aspirin can reduce the risk
• having a good lifestyle pre-pregnancy - diet, exercise.

Question 11

A patient presents at 38 weeks with a BP of 170/105mmHg. Her Symphyseal-fundal height is 32cm. What are 3 focused history questions you want to ask?

Answer 11

• is there a family history of pre-eclampsia?
• do you have any symptoms for instance upper abdominal pain, headache or swelling?
• any predisposing conditions for instance HTN, chronic renal disease, DM, autoimmune diseases or thrombophilias?