Hypertension in Pregnancy

Question 1

Definition of Gestational Hypertension

Answer 1

New onset hypertension presenting after 20 weeks gestation without proteinuria

Question 2

Diagnosis of Pre-Eclampsia

Answer 2

BP >140/90 mmHg

AND

Proteinuria >0.3g/24h (which is equal to protein:creatinine ratio >30mg/nmol)

Traditionally collected urine for 24 hours
Protein:Creatinine Ratio (PCR) used as faster and easier

Question 3

Staging of Pre-Eclampsia

Answer 3

Mild
140/90 - 149/99 mmHg
Proteinuria with mild/moderate HTN

Moderate
150/100 - 159/109 mmHg
Proteinuria and severe HTN with no maternal complications

Severe
>160/110mmHg
Proteinuria and HTN <34 weeks
OR
with maternal complications

Question 4

Risk Factors for Pre-Eclampsia

Answer 4

FRANTIC OP

Family Hx of PET

Renal Disease

Autoimmune Disease

Nulliparity

Twin pregnancy

Increased Maternal Age

Chronic HTN

Obscenity

Previous Hx of PET (15% recurrent rate) (up to 50% if there has been previous severe pre-eclampsia before 28 weeks)

Question 5

Symptoms to screen for in Pre-Eclampsia

Answer 5

VENDH

Visual disturbances

Epigastric Pain

Nausea and Vomiting

Drowsiness

Headache

Question 6

Examinations performed for suspected Pre-Eclampsia

Answer 6

Blood pressure

Abdominal examination –> epigastric pain sign of maternal complications

Urine dipstick (if positive, rule out UTI)

Neurological exam (reflexes, eye movements)

Check for oedema

Fundoscopy (hypertensive retinal changes)

Question 7

Complications of Pre-Eclampsia

Answer 7

Maternal
Eclampsia - grand mal seizure due to cerebrovascular spasm (Tx: Mag Sulphate)

Cerebrovascular haemorrhage due to hypertension

Liver & Coagulation
HELLP
DIC
Liver failure / rupture
Women have peigastric pain
Dark urine indicative of haemolysis

Renal failure

Pulmonary oedema from fluid overload (give oxygen and furosemide)

ARDS

Fetal
Stillbirth (5% of stillbirths –> pre-eclampsia)
Preterm delivery (10% of preterm –> pre-eclampsia)
If <34 weeks –> IUGR & Preterm delivery often required
Placental Abruption

Question 8

Monitoring in Pre-Eclampsia

Answer 8

Maternal Monitoring

Urate (becomes daranged before U&Es)
Increased Hb
Low platelets --> HELLP
Increased ALT --> HELLP
Increased LDH with liver disease and haemolysis

Fetal Monitoring

USS to estimate fetal weight and growth
Doppler of umbilical artery
CTG

Question 9

Management of Pre-Eclampsia

Answer 9

Screening
Regular BP and urinalysis checks
Uterine artery doppler at 23 weeks
Prevention in high-risk pregnancy with 75mg daily aspirin before 16 weeks

Hypertension (Mild/Moderate) in absence of proteinuria
Manage as outpatient
BP check twice weekly
USS every 2-4 weeks

ADMISSION - Symptoms, proteinuria 2+, or 0.3g/24h, BP >160/110mmHg, suspected fetal compromise

Labetalol given if BP >150/100mHg

If severe add nifedipine

Aim for 140/90mmHg

Steroids given for fetal lung maturity

Question 10

Management of Delivery in Pre-Eclampsia

Answer 10

Gestational HTN –> IOL at 40 weeks

Mild PET –> IOL by 37 weeks

Moderate/Severe PET –> Delivery 34-36 weeks

Severe PET with any maternal or fetal complications –> deliver at any time

Method of delivery:
<34 weeks –> C-section
>34 weeks: can perform IOL with prostaglandins and epidural analgesia to reduce BP
Avoid pushing if BP >160/110mmHg

Before 34 weeks conservative management in specialist unit with neonatal facilities

Steroid prophylaxis

Fetal surveillance

CTG

Fluid balance, frequent blood tests

Question 11

Post-natal care of Pre-Eclampsia

Answer 11

Takes 24 hours post delivery for reduction in BP
HTN may worsen in this time

Bloods: LFTs, Platelets, Renal function

Fluid Balance: Pulmonary oedema and respiratory failure risk - CVP monitoring if low urine output

Long-term HTN managed by GP

persistent proteinuria or HTN –> refer to renal

Question 12

Management of pre-existing HTN in Pregnancy

Answer 12

Pre-existing = When BP treated or exceeds 140/90mmHg before 20 weeks

Have higher risk of HTN later in life
Increased risk of PET

Inx
measure urine catecholamines to rule out phaeochromocytomas
Renal USS
Renal Function
Rule out PET

Mx
Labetolol
Nifedipine 2nd line
ACEi are teratogenic

Low dose aspirin
Deliver by 40 weeks