Hypertension and Pre-eclampsia

Question 1

Pre-eclampsia

Answer 1

New hypertension in pregnancy with end-organ dysfunction

+ proteinuria

Occurring after 20 weeks gestation

Question 2

When is pre - eclampsia classed after 20 weeks gestation

Answer 2

This is when the spiral arteries of the placenta form abnormally, leading to a high vascular resistance in these vessels

Question 3

Risk of pre - eclampsia

Answer 3

Can lead to:

• Maternal organ damage
• Fetal growth restriction
• Eclampsia - seizures
• Early labour

Question 4

Pre - eclampsia triad

Answer 4

Hypertension
Proteinuria
Oedema

Question 5

Chronic hypertension

Answer 5

Hypertension that exists before the 20 weeks of gestation and long standing

Question 6

Gestational hypertension

Answer 6

Hypertension occurring after 20 weeks gestation, without proteinuria

Question 7

High-risk factors for pre - eclampsia

Answer 7

Pre-existing hypertension

Previous hypertension in pregnancy

Existing autoimmune conditions (e.g. systemic lupus erythematosus)

Diabetes

Chronic kidney disease

Question 8

Moderate-risk factors for pre - eclampsia

Answer 8

Older than 40 yo

BMI > 35

More than 10 years since previous pregnancy

Multiple pregnancy

First pregnancy

Family history of pre-eclampsia

Question 9

Pre - eclampsia prophylaxis

Answer 9

Aspirin from 12 weeks gestation until birth

Question 10

When is pre - eclampsia prophylaxis given

Answer 10

If 1+ high risk factor

If 2 + moderate risk factors

Question 11

Symptoms of pre - eclampsia

Answer 11

Headache

Visual disturbance or blurriness

Nausea and vomiting

Upper abdominal or epigastric pain (this is due to liver swelling)

Oedema

Reduced urine output

Brisk reflexes

Question 12

How to diagnose pre - eclampsia

Answer 12

Systolic blood pressure > 140 mmHg
Diastolic blood pressure > 90 mmHg

PLUS any of:

Proteinuria (1+ or more on urine dipstick)

Organ dysfunction (e.g. raised creatinine, elevated liver enzymes, seizures, thrombocytopenia or haemolytic anaemia)

Placental dysfunction (e.g. fetal growth restriction or abnormal Doppler studies)

Question 13

Proteinuria

Answer 13

Urine protein:creatinine ratio - above 30mg/mmol

Or

Urine albumin:creatinine ratio - above 8mg/mmol

Question 14

Investigations for pre - eclampsia

Answer 14

Blood pressure 
Urine dipstick 
Test reflexes 
Blood glucose - diabetes 
Placental growth factor tests (low in pre eclampsia)

Bloods:

• FBC - haemolysis, low platelets
• LFTs - Elevated liver enzymes
• U+Es

Question 15

Management of pre - eclampsia

Answer 15

Aspirin
Labetalol first line
Nifedipine second line

Scoring systems are used to determine whether to admit the woman (fullPIERS or PREP‑S)

Blood pressure is monitored closely (at least every 48 hours)

Urine dipstick testing is not routinely necessary (the diagnosis is already made)

Ultrasound monitoring of the fetus, amniotic fluid and dopplers is performed two weekly

Question 16

Management of gestational hypertension

Answer 16

Treating to aim for a blood pressure below 135/85 mmHg - labetalol

Admission for women with a blood pressure above 160/110 mmHg

Urine dipstick testing at least weekly

Monitoring of blood tests weekly (full blood count, liver enzymes and renal profile)

Monitoring fetal growth by serial growth scans

PlGF testing on one occasion

Question 17

Medical management options for pre - eclampsia

Answer 17

Labetolol - first-line
Nifedipine - second-line
Methyldopa - third-line (needs to be stopped within two days of birth)

IV hydralazine may be used as an antihypertensive in critical care in severe pre-eclampsia or eclampsia

IV magnesium sulphate is given during labour and in the 24 hours afterwards to prevent seizures

Fluid restriction used during labour in severe pre-eclampsia or eclampsia, to avoid fluid overload

Question 18

Early birth planning

Answer 18

May be necessary if BP cannot be controlled

Corticosteroids given

Question 19

Treatment of pre - eclampsia after birth

Answer 19

The blood pressure will steadily normalise however medical management is given:

• Enalapril (first-line)
• Nifedipine or amlodipine (first-line in black African or Caribbean patients)
• Labetolol or atenolol (third-line)

Question 20

Eclampsia

Answer 20

Seizures associated with pre - eclampsia

Question 21

How to manage eclampsia

Answer 21

IV magnesium sulphate

Escalate to senior

Question 22

HELLP Syndrome

Answer 22

Complication of pre - eclampsia

• Haemolysis
• Elevated Liver enzymes
• Low Platelets