Hypertension in Pregnancy

Question 1

Chronic HTN:

Answer 1

Before conception, < 20 wks EGA, or > 6 wks postpartum

Big risk for PEC.

Question 2

Management of cHTN

Answer 2

Treat with antiHTN (usually labetalol / nifedipine) meds.

Get baseline ECG / 24h for Cr / protein to help with PEC dx later.

Question 3

Superimposed PEC on cHTN

Answer 3

Often dx’d with >30/15 increase (either or) in BP + 24h urine elevation
Uric acid > 6.0-6.5 also used, more controversial

Question 4

Gestational HTN:

Answer 4

Blood pressure > 140/90 x 2 occasions 4-6h apart, seated.

Question 5

Severe HTN

Answer 5

> 160 systolic or > 105 diastolic

Goal DBP 90-100 (prevent stroke / abruption w/o compromising uterine perfusion

Question 6

Severe HTN Rx

Answer 6

Hydralazine or labetalol are first choices

Question 7

Mild Preeclampsia

Answer 7

BP 140/90 x 2 and proteinuria > 300 mg / 24h (roughly 2+) and nondependent edema (face/hands)

Can get urine protein/Cr ratio, although not official, for spot check

Question 8

Risk factors for preeclampsia

Answer 8

cHTN, renal dz, also nullip, young or old mom, hx PEC with same dad, living with dad < 1yr

Question 9

Contraindications to expectant management remote from term (<32 wks) in PEC

Answer 9

thrombocytopenia (plt < 100,000), inability to control BP with max doses of 2 antiHTN meds, non-reassuring fetal survellance,
LFTs > 2x ULN, eclampsia, persistent CNS sx, oliguria - need to deliver now!

Question 10

Treatment for preeclampsia

Answer 10

Tx: Mag sulfate during L&D stay, and 12-24h after.

Question 11

Mag levels (mEq/L):
● 4-7: 
● 7-10: 
● > 12: 
● >15:

Answer 11

4-7: therapeutic
7-10: lose DTRs
> 12: respiratory depression
>15: cardiac arrest

Question 12

Management of Mag overdose

Answer 12

If overdose, give calcium (CaCl / Ca gluconate) for cardiac protection

Question 13

Severe PEC:

Answer 13

> 160 systolic or 110 diastolic x 2 occasions 6h apart; proteinuria > 5g/24h

Can have mild PEC by BP / proteinuria but becomes severe if altered consciousness, H/A or visual changes, epigastric / RUQ pain, impaired liver fxn (2x nL), oliguria (<400mL/24h), pulmonary edema, thrombocytopenia (<100)

Question 14

Treatment of severe PEC

Answer 14

Tx: need to deliver immediately if > 32 wks or mother crashing.
If you can wait, try BMZ & check lung
maturity. “Delivery is the cure”

Question 15

Eclampsia management:

Answer 15

ABCs, stabilize mom; Mag sulfate → lorazepam → phenytoin → phenobarb; Lower HTN with hydralazine
Deliver only when mom has stopped seizing (best for fetus too)

Question 16

HELLP syndrome Dx

Answer 16

Rapidly deteriorating liver fxn (AST/ALT increases), thrombocytopenia < 100, hemolysis (schistocytes on peripheral smear, elevated LDH, elevated total bili)

Question 17

HELLP Sx

Answer 17

RUQ pain (liver capsule distention), nausea, vomiting → can lead to hepatic rupture!

Question 18

Acute fatty liver of pregnancy (AFLP)

Answer 18

vs HELLP, see elevated ammonia, hypoglycemia (glc < 50), reduced
clotting factors (fibrinogen &amp; antithrombin III) in AFLP (fulminant liver failure!)