Hypertension in pregnancy

Question 1

25% of antenatal admissions occur as a result of hypertension. true/false?

Answer 1

True

Question 2

Pre-eclampsia affects what % of primigravida women?

Answer 2

Mild pre-eclampsia affects 10% of primigravida women

Severe pre-eclampsia affects 1% of primigravida women

Question 3

Meaning of primigravida?

Answer 3

Woman pregnant for the first time

Question 4

What is pre-eclampsia?

Answer 4

new high blood pressure (hypertension) in pregnancy with end-organ dysfunction, notably with proteinuria (protein in the urine). It occurs after 20 weeks gestation

Question 5

What cardiovascular changes occur in pregnancy?

Answer 5

Plasma volume
Cardiac output
Stroke volume
Heart rate
peripheral vascular resistance

Question 6

What is regarded as hypertension in pregnancy?

Answer 6

> / = 140/90 mmHg on 2 occasions, 4 hrs apart

or

> 160/110 mm Hg once

or

A rise of 30/15 mm Hg compared to first trimester

Question 7

What 3 groups can pregnancy hypertension be grouped into?

Answer 7

Mild
Moderate
Severe

Question 8

Range for mild hypertension?

Answer 8

Systolic: 140-149 mmHg

and/or

Diastolic: 90-99 mmHg

Question 9

Range for moderate hypertension?

Answer 9

Systolic: 150-199 mmHg

and/or

Diastolic: 100-109 mmHg

Question 10

Range for severe hypertension?

Answer 10

Systolic >/= 160mmHg

Diastolic >/= 110mmHg

Question 11

Types of hypertension that can be present in pregnancy?

Answer 11

pre-existing/chronic hypertension
- Essential
- Secondary

Gestational hypertension (GH)

Pre-eclampsia (PET)

Question 12

Chronic/pre-existing hypertension features?

Answer 12

• Diagnosis prior to pregnancy
• This is likely if hypertension is present in the first part of pregnancy
• Exists before 20 weeks gestation and is longstanding. Not caused by dysfunction in the placenta and is not classed as pre-eclampsia.

Question 13

What is essential hypertension?

Answer 13

Aka primary hypertension. High blood pressure with no known cause. It is the most common type and gradually develops over years.

Question 14

What is secondary hypertension?

Answer 14

high blood pressure that occurs from underlying causes.

Causes can include:
- Cushing’s
- Pheochromocytoma
- Conn’s
- Renal/cardiac

Question 15

What is gestational hypertension features?

Answer 15

• Presents after 20 week gestation
• NO signs of proteinuria or other features of of pre-eclampsia
• Has better outcomes than pre-eclampsia
• Up to 25 % progression to pre-eclampsia (is dependant on gestation)
• Recurrence rate is HIGH

Question 16

Main features of pre-eclampsia?

Answer 16

• Hypertension
• Proteinuria (UPCR > 30mg/mmol)
• Oedema

Absence doesn’t exclude diagnosis

Question 17

Pathogenesis of pre-eclampsia?

Answer 17

• Genetic/environmental pre-disposition
• Stage 1 - abnormal placental perfusion. Placental ischaemia.
• Stage 2 - maternal syndrome - an antiangiogenic state associated with endothelial dysfunction

Question 18

What increases risk of pre-eclampsia?

Answer 18

If mother and sister also have pre-eclampsia

Question 19

High risk factors for pre-eclampsia?

Answer 19

Pre-existing hypertension
Previous hypertension in pregnancy
Existing autoimmune conditions (e.g. systemic lupus erythematosus)
Diabetes
Chronic kidney disease

Question 20

Moderate risk factors for pre-eclampsia?

Answer 20

Older than 40
BMI > 35
More than 10 years since previous pregnancy
Multiple pregnancy
First pregnancy
Family history of pre-eclampsia

Question 21

Complication symptoms of pre-eclampsia?

Answer 21

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 22

How is diagnosis of pre-eclampsia confirmed?

Answer 22

Systolic blood pressure above 140 mmHg
Diastolic blood pressure above 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 23

How is proteinuria quantified?

Answer 23

Proteinuria can be quantified using:

Urine protein:creatinine ratio (above 30mg/mmol is significant)
Urine albumin:creatinine ratio (above 8mg/mmol is significant)

Question 24

Medical management of pre-eclampsia?

Answer 24

Labetolol is first-line as an antihypertensive

Nifedipine (modified-release) is commonly used second-line

Methyldopa is used third-line (needs to be stopped within two days of birth)

Intravenous 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 is used during labour in severe pre-eclampsia or eclampsia, to avoid fluid overload

Question 25

When gestational hypertension (without proteinuria) is identified, what is done for management?

Answer 25

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

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 foetal growth by serial growth scans

Question 26

What is eclampsia?

Answer 26

refers to the seizures associated with pre-eclampsia.

IV magnesium sulphate is used to manage seizures associated with pre-eclampsia.

Question 27

What is HELLP syndrome?

Answer 27

HELLP syndrome is a combination of features that occurs as a complication of pre-eclampsia and eclampsia. It is an acronym for the key characteristics:

Haemolysis
Elevated Liver enzymes
Low Platelets