HTN in Pregnancy B&B

Question 1

how is gestational HTN defined?

Answer 1

elevated BP developing after 20 weeks of pregnancy with no proteinuria or evidence of preeclampsia

Question 2

which 4 HTN drugs are safe during pregnancy?

Answer 2

1. Hydralazine
2. alpha-methyldopa
3. labetalol (beta1/2+alpha1 blocker)
4. nifedipine (Ca2+ channel blocker)

Hypertensive (Hydralazine) Moms (Methyldopa) Love (Labetalol) Nifedipine

Question 3

what are the components of preeclampsia? (3)

Answer 3

multi-system disorder of pregnancy

1. HTN
2. proteinuria
3. end-organ dysfunction

Question 4

what is the pathogenesis behind the development of preeclampsia?

Answer 4

disorder of placenta in which trophoblasts do not invade/transform into spiral arteries normally (remain narrow)

leads to placental under-perfusion which causes release of circulating factors that induce diffuse maternal endothelial dysfunction (how other organs become involved) —> vasospasm and coagulation

resolves with delivery once placenta is removed

Question 5

what will a placental biopsy show in a patient with preeclampsia?

Answer 5

fibrinoid necrosis of blood vessels due to ischemia and under-perfusion of the placenta because the spiral arteries are abnormally narrow

seen as pink material accumulating in the wall of the vessels

Question 6

how and when does preeclampsia typically present?

Answer 6

new onset HTN during the 3rd trimester (when baby is getting bigger and needs more blood flow, and abnormally narrow spiral arteries cannot keep up)

also requires proteinuria or end-organ damage for diagnosis

Question 7

A pregnant woman in the 3rd trimester of her first pregnancy presents to her OBGYN with complaint of headache and visual changes. BP is 160/95 on first reading and again 15 minutes later. Blood is drawn which shows elevated AST and ALT. A urinalysis is positive for protein. What is most likely going on?

Answer 7

preeclampsia: disorder of placenta in which trophoblasts do not invade/transform into spiral arteries normally (remain narrow)

leads to placental under-perfusion which causes release of circulating factors that induce diffuse maternal endothelial dysfunction (how other organs become involved) —> vasospasm and coagulation

resolves with delivery once placenta is removed

Question 8

what is the difference between preeclampsia and eclampsia

Answer 8

preeclampsia = HTN + proteinuria AND/OR end-organ dysfunction

eclampsia = HTN + proteinuria AND/OR end-organ dysfunction + seizures

Question 9

how is eclampsia treated?

Answer 9

eclampsia = preeclampsia (HTN + proteinuria AND/OR end-organ dysfunction) + tonic-clonic seizures

anti-convulsive DOC: magnesium sulfate (also given for prevention in patients with preeclampsia)

definitive treatment is to deliver the baby - pre/eclampsia originates in placental dysfunction of spiral arteries

Question 10

magnesium sulfate is the anti-convulsive drug of choice for which patients?

Answer 10

tonic-clonic seizures due to eclampsia in pregnant women

can also be given as prevention of eclampsia in patients with preeclampsia

eclampsia = preeclampsia (HTN + proteinuria AND/OR end-organ dysfunction) + tonic-clonic seizures

Question 11

HELLP Syndrome

Answer 11

severe form of preeclampsia:
Hemolysis
Elevated Liver enzymes
Low Platelet count

due to coagulation activation and liver infarction

[preeclampsia = HTN + proteinuria AND/OR end-organ dysfunction]

Question 12

A woman in the third trimester of her first pregnancy presents to her OBGYN feeling unwell. She states she has been experiencing frequent headaches, but denies seizures. PMH includes antiphospholipid syndrome. Her BP is elevated on 2 separate measurements, and bilateral edema is noted in both shins. Blood is drawn, which shows elevated AST, ALT, and bilirubin, and low haptoglobin and platelet count. Urine is 2+ for protein. What is likely going on, and what do you expect to see in a peripheral blood smear?

Answer 12

HELLP Syndrome: severe form of preeclampsia characterized by Hemolysis + Elevated Liver enzymes + Low Platelets

peripheral smear will show schistocytes due to microangiopathic hemolytic anemia

consumption of platelets causes thrombocytopenia

treatment is to delivery the baby, because the pathogenesis originates in the abnormal spiral arteries of the placenta!

[Lupus/antiphospholipid syndrome is risk factor for preeclampsia]