Hypertension in pregnancy

Question 1

Outline the types of HTN in pregnancy

Answer 1

Gestational HTN: New onset HTN after 20wks gestation. No features of PET.

Chronic HTN: Pre-existing HTN of HTN detected at <20wks gestation. Essential or secondary HTN (normal, non-pregnancy causes).

Pre-eclampsia (PET): New onset HTN at >20wks gestation with involvement of one or more organ systems.

Chronic HTN with superimposed pre-eclampsia: Pre-existing HTN with features of PET arising after 20wks.

Question 2

What multi-system issues can be seen in pre-eclampsia along with HTN?
Think about what organs malfunction and what can go wrong with them.

Answer 2

There are 7

1. Renal
   - proteinuria
   - oliguria
   - Inc creatinine
2. Liver
   - Inc AST, ALT
   - RUQ pain
   - dec plts
3. CNS
   - headaches
   - visual disturbance
   - hyper-reflexia
   - clonus
   - convulsions (if eclampsia)
   - stroke
4. Haem
   - dec plts
   - DIC
   - haemolysis (HELLP)
5. Foetal compromise: oligohydramnios.
6. Pulm oedema
7. Placental abruption

Question 3

List symptoms of pre-eclampsia

Answer 3

Headache
Visual disturbance
RUQ pain
Nausea and vomiting
Swelling of face and sacrum

Question 4

What are the signs of pre-eclampsia

Answer 4

HTN (>140/90)
Sacral and facial oedema
Abdo tenderness RUQ
Hyper-reflexia
Clonus (>3 beats)
Papilloedema

Question 5

Risk factors for pre-eclampsia

Answer 5

PMHx pre-eclampsia
Primigravid
<18y or >35yo
FHx PET
Obesity
GDM
PMHx: DM, HTN, renal disease.
Ethnicity
Multiple pregnancy

Question 6

Investigations to order for PET and findings

Answer 6

Urine dipstick
Urine PCR (>30)
FBC (dec plts)
Coags if thrombocytopenic
LFTs (inc AST, ALT)
UEC (creatinine)
Uric acid (inc)

Question 7

?PET in antenatal clinic - what is your management

Answer 7

Sent to MAU for BP monitoring.
CTG.
Measure fundal height.
Urine dipstick and PCR
Order FBC, EUC, LFTs, uric acid

Question 8

What is the significance of hyperuricemia in PET?

Answer 8

It is a marker of PET but NOT and indication to deliver.

Question 9

Management for PET

Answer 9

Anti-hypertensive:
-Labetolol
- Methyldopa
- Nifedipine
- Hydralazine
Magnesium sulfate (seizure prophylaxis)
Glucocorticoids if <34wks
Delivery: IOL from 37 wks, earlier via CS if HELLP or eclampsia.

Question 10

What are the benefits of corticosteroids in pregnancy?

Answer 10

Surfactant production.
Dec risk ARDS
Dec risk necrotising enterocolitis
Dec risk perinatal death
Dec risk intraventricular haemorrhage

Question 11

List 2 contraindicated anti-hypertensives for PET

Answer 11

ACE inhibitors –> IUGR, foetal death, foetal renal failure.

Diuretics –> plasma volume is already low.

Question 12

Prevention strategies for PET

Answer 12

Low dose aspirin at 12-16wks (100mg)
Calcium supplements
Weight loss of obese

Question 13

What is the most common cause of death in PET patients? (mum)

Answer 13

Pulmonary oedema.

Question 14

List the complications of PET

Answer 14

Maternal:

• HELLP syndrome
• DIC
• stroke
• ARDS
• eclampsia (seizures)
• pulm oedema
• death

Foetal:

• IUGR
• prematurity
• ARDS
• Intrauterine death
• placental abruption