Hypertension and Pre-Eclampsia

Question 1

Define the following: pre-gestational hypertension?

Answer 1

BP of greater than 140/90mm/hg before 20 weeks gestation

Question 2

Define the following: gestational hypertension?

Answer 2

BP persistently greater than 140/90 which develops after 20 weeks gestation.

Or an increase of 30/20 from booking BP

Question 3

Describe the different stages of gestational hypertension?

Answer 3

Mild: 140/90
Moderate: 150/100
Severe: 160/110

Question 4

What BP should be aimed for in pregnancy?

Answer 4

120/80

Question 5

What are the risks due to pre-gestational HTN in pregnancy?

Answer 5

Increased risk of:

• Pre-eclampsia
• IUGR
• Placental abruption
• Still birth

Question 6

How should pre-gestational HTN be managed?

Answer 6

DO NOT USE:
ACE inhibitor or Diuretics

Treat with:
-Labetalol (beta blocker)
OR
-Nifedipine (Ca antagonist)

Treat with low dose aspirin to reduce pre-eclampsia risk
Monitor BP and urine dip more frequently screen with uterine aa doppler

Question 7

What is pre-eclampsia?

Answer 7

A placental disease characterised by suboptimal uteroplacental perfusion associated with a maternal inflammatory response and maternal vascular endothelial dysfunction.

Question 8

What are the diagnostic criteria for pre-eclampsia?

Answer 8

Hypertension of greater than 140 systolic OR 90 diastolic and proteinuria in the second half of pregnancy.

With or without oedema.

Question 9

Who is at risk of developing pre-eclampsia?

Current pregnancy, past pregnancy, PMH, FH

Answer 9

Nulliparous
PMH of pre-eclampsia

Afro-carribean
FH of pre-eclampsia

Chronic HTN
Chronic renal disease
Antiphospolipid syndrome 
Collegen vascular disease
Diabetes 

Pregnancy in young or old (less than 15 older than 35)
Multiple pregnancy

Question 10

What is the proposed pathophysiology of pre-eclampsia?

Answer 10

Incomplete invasion of spiral aa into the trophoblasts (this usually leads to vasodilation).

This leads to reduced uteroplacental blood flow.

This causes the placenta to become ischaemic which may cause an exagerated maternal inflammatory response causing widespread endothelial damage.

This causes vasoconstriction, increased vascular permeability (oedema) and clotting dysfunction.

Question 11

What are the symptoms of pre-eclampsia?

Answer 11

Usually asymptomatic.

Note presence of symptoms suggests severe pre-eclampsia

Symptoms can include:

• Headache
• Visual disturbances (blurred/scotomas)
• Drowsiness
• Nausea and vomiting (late stage complication)
• Epigastric pain
• Breathlessness secondary to pulmonary oedema

Question 12

What are the maternal complications of pre-eclampasia in pregnancy?

Answer 12

1. Eclampsia (treat with MgSO4)
2. Cerebrovascular haemorrhage
3. HELLP syndrome
4. Renal failure
5. Pulmonary oedema (O2, furosemide and fluid restriction to treat)

Question 13

What is HELLP syndrome?

Answer 13

It is a complication of severe pre-eclampsia characterised by:

Haemolysis

Elevated Liver enzymes (ALT*)

Low Platelets

Can cause DIC, needs many blood products + give MgSO4 to prevent eclampsia

*Note ALP is produced by the placenta and therefore is always raised in pregnancy

Question 14

What are the fetal complications of pre-eclampsia?

Answer 14

Increased mortality

IUGR (pre-term delivery is often required)

Placental abruption (risk of mortality)

Question 15

How should you manage a patient that is at risk of pre-eclampsia?

Answer 15

More frequent BP and urine monitoring.

Prophylactic aspirin 75mg from 12 weeks

Question 16

What tests should be done when confirming pre-eclampsia?

Answer 16

BP

MSU and urine protein measurement

Question 17

What are the criteria for mild, moderate and severe pre-eclampsia?

Answer 17

Mild:
Proteinuria and mild-moderate HTN (150/100)

Moderate:
Proteinuria and severe HTN (160/110)

Severe:
Proteinuria and HTN before 34 weeks Or any maternal complications

Question 18

How should you monitor a pre-eclamptic patient in hospital?

Answer 18

If pre-eclampsia patient needs admission.

4hrly BP
Catheterise and daily urinalysis
Daily CTG
Regular bloods: FBC and LFTs

Question 19

How and when should you manage blood pressure in hypertension or pre-eclampsia?

Answer 19

When BP reaches 150/100

Treat with labetalol and nifedipine

IV labetalol can be given in severe hypertension/pre-eclampsia.

Hydralasine can be used as an alternative

Question 20

What is magnesium sulphate used for?

Answer 20

Used in treatment of eclampsia and in prevention in severe pre-eclampsia.

Note: toxicity is severe including respiratory depression, hypotension and loss of deep tendon reflexes (check for these)

Question 21

What is the definitive treatment of pre-eclampsia?

Answer 21

Delivery of the foetus

Question 22

When should you aim for delivery in mild, moderate and severe pre-eclampsia?

Answer 22

Mild deliver by 37 weeks

Moderate-severe deliver between 34-36 weeks

If maternal complications deliver at any point if necessary

Question 23

When are steroids indicated in pre-eclampsia?

Answer 23

Before 34 weeks in moderate/severe pre-eclampsia as helps lung maturation if pre-term delivery is indicated

Question 24

What is the post natal care protocol for a pre-eclamptic mother?

Answer 24

Keep in hospital for ~5days

Monitor BP, UO
Bloods: FBC, LFTs, U&E’s

Important as may still fit post natally

Question 25

In magnesium sulphate toxicity what is the treatment?

Answer 25

Calcium glutamate