Hypertension in Pregnancy

Question 1

briefly describe the physiology of BP in pregnancy

Answer 1

-Pregnancy causes vasodilation
it falls in early pregnancy
then steadily rises after 22-24 wks until term
BP will fall after delivery and then rises and peaks 3-4 days PN

Question 2

how is hypertension defined in pregnancy? (3)

Answer 2

> 140/90 on 2 occasions
DBP> 110mmHg
ACOG- >30/15 mmHg compared to booking BP

Question 3

Pre-existing hypertension

• when detected?
• what else should be considered?
• give 3 assoc complications of pregnancy?

Answer 3

• consider if high BP in early pregnancy
• secondary causes e.g. renal, cardiac, Cushing’s, Conn’s, phew
• PET, IUGR, abruption

Question 4

Pregnancy induced hypertension (PIH)

• occurs & resolves when?
• features (1)

Answer 4

-second half of pregnancy
resolves within 6/52 post delivery

-NO proteinuria or other features of pre-eclampsia

Question 5

Pre-eclampsia

• definition?
• risk factors? (7)
• symptoms? (5)
• signs? (8)
• investigations? (8)
• Management? (3)

Answer 5

-Hypertension + Proteinuria + Oedema causing:
Diffuse vascular endothelial dysfunction widespread circulatory disturbance
Renal / Hepatic / Cardiovascular / Haematology / CNS / Placenta

-Maternal age
Maternal BMI
Fam hx
parity 
Multiple preg
Previous PET
molar pregnancy or triploidy 
\+ pre-existing renal disease/ hypertension/ DM, connective tissue disease
Thrombophilias

-Headache
Visual disturbance
Epigastric/RUQ pain 
Nausea/vomiting
rapidly progressive oedema 

-Hypertension 
Proteinuria 
oedema
abdominal tenderness
disorientation 
SGA
IUD
hyper-reflexia, involuntary movement, clonus 

-Us&Es
serum urate
LFTs
FBC
coagulation screen
UPCR
CTG
US- biometry, AFI, doppler

-antenatal screening (BP, Urine, MUAD)
treat hypertension
surveillance

Question 6

Describe the pathogenesis of Pre-eclampsia:

• predisposing factors
• stages? (2)
• The process by which the disease occurs?

Answer 6

-Genetic predisposition

stage 1- abnormal placental perfusion
Stage 2- maternal syndrome

-abnormal placentation and trophoblastic invasion causes failure of normal vascular remodelling
spiral artery fail to adapt to become high capacitance, low resistance vessels
Placental Ischaemia causes endothelial damage and dysfunction
endothelial activation leads to: inc capillary permeability
inc expression of CAM
inc prothrombotic factors
inc platelet aggregation
Vasoconstriction

Question 7

Name the CNS disease associated with pre-eclampsia? (5)

Answer 7

hypertensive encephelopathy 
intracranial haemorrhage 
Cerebral oedema
Cortical blindness
CN palsy

Question 8

State the markers of real disease in pre-eclampsia? (5)

-causes what?

Answer 8

GFR (dec)
Proteinuria 
serum pic acid (inc)
creatinine, k, urea (inc)
oliguria/anuria

-Acute renal failure

Question 9

Liver disease in pre-eclampsia

• presentation? (3)
• causes what? (1)

Answer 9

-Epigastric/ RUQ pain
Abnormal liver enzymes
Hepatic capsule rupture

-HELLP syndrome
H-haemolysis
E&L- elevated liver enzymes
L&P- Low platelets

Question 10

Give the 4 steps leading to haematological disease in pre-eclampsia and the resulting condition?

Answer 10

-Reduced plasma vol
heamo-concentration
thrombocytopenia
haemolysis
DIC

Question 11

what 2 forms of CV and resp disease can occur in pre-eclampsia?

Answer 11

Pulmonary oedema leading to ARDS

PE

Question 12

placental disease causes what 3 complications?

Answer 12

-IUGR
placental abruption
Intrauterine death

Question 13

Screening

• what finding on a MUAD would raise suspicion?
• When should mother be referred? (4)
• When should mother be admitted? (6)
• inpatient assessment involves what?

Answer 13

-a notch

-BP> 140/90
(++) proteinuria
lots of oedema
persistent headache

-BP >170/110 OR >140/90 with (++) proteinuria
Significant symptoms - headache / visual disturbance / abdominal pain
Abnormal biochemistry
Significant proteinuria - UPCR >30mg/mmol
Need for antihypertensive therapy
Signs of fetal compromise

-BP 4 hourly
urinalysis daily 
input/output fluid chart
UPCR
Bloods- FBC, U&Es, Urate, LFTs
\+foetal movement 
CTG daily 
US- biometry, amniotic fluid index, umbilical artery doppler

Question 14

When should hypertension be treated?

-what 4 drugs are used? and what are their MOA?

Answer 14

-if MAP over 150/100 mmHg

-Methyldopa (centrally acting alpha agonist)
Labetolol (alpha and beta agonist)
Nifedipine (Ca channel antagonist)
Hydralazine (Vasodilator)

Question 15

Treatment of pre-eclampsia?

• indications for treatment?
• why are steroids used? when administered?

Answer 15

• only cure is delivery + steroids ( 12mg betamethasone IM x2 in 24 hrs)
• term gestation, inability to control BP, rapidly deteriorating biochem, eclampsia, other crisis, foetal compromise

-they promote foetal lung surfactant production to reduce neonatal RDS
administer 24-48hrs before delivery up to 36 weeks

Question 16

Eclampsia 
-definition?
-associated with what?
-management of: 
BP? (2)
seizure? (4)

Answer 16

• tonic-clonic (grand mal)seizure occurring with features of pre-eclampsia
• ischaemia/vasospasm

-Control BP
(IV labetolol and IV hydrazine)

stop/prevent seizure
Mg sulphate 4g IV over 5 min
then IV infusion 1g/hr
further seizure: 2g Mg sulphate
diazepam 10mg IV 

fluid balance
fluid challenges potentially dangerous so safer to run patient dry

Delivery

Question 17

How should delivery be managed?

• mode of delivery?
• anasthesia?
• monitering?
• what should be avoided?

Answer 17

-aim for vaginal delivery
Control BP
epidural anaesthesia 
continuous electronic fetal monitering 
avoid ergometrine

Question 18

what can be used for prophylaxis?

-when commenced?

Answer 18

• 75mg Aspirin used in high risk women

- commence before 12 weeks, safe in pregnancy