Hypertension in Pregnancy

Question 1

What is hypertension with proteinuria?

Answer 1

Pre-eclampsia

Question 2

What is the primary defect of pre-eclampsia?

Answer 2

The primary defect is failure of trophoblastic invasion of spiral arteries, leaving them vasoactive

Question 3

When does pre-eclampsia develops? And when will it resolve?

Answer 3

Pre-eclampsia develops after 20 weeks gestation and usually resolves within 10 days of delivery

Question 4

What is eclampsia?

Answer 4

Eclampsia occurs when the pregnant mother develops fits

Question 5

What are the high risk factors of pre-eclampsia?

Answer 5

Diabetes Mellitus, Chronic hypertension, Hypertension in previous pregnancies, chronic kidney disease, autoimmune diseases (SLE, thrombophilia)

Question 6

What are the moderate risk factors of pre-eclampsia?

Answer 6

first pregnancy, >40yo, FHx of pre-eclampsia, multiple pregnancy

Question 7

What medication is given to help prevent pre-eclampsia?

Answer 7

Aspirin 75MG OD PO from 12 weeks pregnancy until delivery

Question 8

Define severe pre-eclampsia.

Answer 8

BP>160/110 with proteinuria, or

BP>140/90 with proteinuria plus Seizures/visual disturbances/headache or epigastric pain/papilloedema

Question 9

What are the signs and symptoms of pre-eclampsia?

Answer 9

Usually asymptomatic but can present with drowsiness, headache, N&V, epigastric pain/liver tenderness, visual disturbances.
Hypertension is a sign that is absent until later stages.

Question 10

List the moderate risk factors for pre-eclampsia.

Answer 10

Maternal age >/-40
First pregnancy
Multiple pregnancies
Family history of pre-eclampsia
BMI >/- 35 at time of presentation.
10 years or more since last pregnancy

Question 11

List the high risk factors for pre-eclampsia.

Answer 11

History of pre-eclampsia, eclampsia or hypertension in previous pregnancies.
Current medical condition: Current hypertension, CKD, DM, autoimmune diseases (SLE, thrombophilia)

Question 12

What is HELLP syndrome in pre-eclampsia?

Answer 12

HELLP is a mnemonic:
Haemolysis
Elevated Liver enzymes
Low Platelets

Question 13

What are the complications of pre-eclampsia to the foetus?

Answer 13

Hypoxia
Intrauterine Growth restriction
Preterm birth
Placental abruption

Question 14

What are the complications of pre-eclampsia on the mother?

Answer 14

Eclampsia - Grand-mal seizures
DIC
Fluid overload, resulting in pulmonary oedema or Acute respiratory distress syndrome
Liver failure or liver rupture
Renal failure
Cerebral haemorrhage: due to failure of autoregulation of cerebral blood flow at mean arterial pressures >140mmHg
HELLP syndrome: Patient presents with N&V, headache and upper right abdominal pain

Question 15

How is proteinuria determined?

Answer 15

There is proteinuria if it is +2 or more on dipstick, or if there is an increase in more than 0.3g after a 24 hour collection: 0.3g/24hours
OR a Protein: Creatinine Ratio (PCR) or >30mg/mmol

Question 16

Which anti-hypertensive medication is indicated in pre-eclampsia?

Answer 16

Labetalol (oral/IV),

Nifedipine (only in oral form), alpha-Methyldopa and IV hydralazine.

Question 17

Who should Labetalol be contraindicated in?

Answer 17

Labetalol is contraindicated in asthmatic patients.

Question 18

Is smoking protective against pre-eclampsia?

Answer 18

Yes

Question 19

Define hypertension in pregnancy and pre-eclampsia.

Answer 19

Hypertension in pregnancy is when BP is >140/90mmHg in 2 readings done 4 hours apart.

Pre-eclampsia is defined as new onset hypertension with new onset proteinuria (>0.3g/24 hour)

Question 20

What is HELLP syndrome?

Answer 20

HELLP Syndrome is a life-threatening liver disorder that develops from severe pre-eclampsia.
H - Haemolysis
EL - Elevated liver enzymes
LP - Low Platelet count

Question 21

What is Magnesium sulphate used for?

Answer 21

Magnesium sulphate is taken to prevent eclampsia

Question 22

What reflex is usually done in the examination of patients suspected of pre-eclampsia?
What is the finding from the examination?

Answer 22

Patella reflex.

Hypertension usually results in hyper-reflexia

Question 23

What are the management steps in those with pre-eclampsia?

Answer 23

Giving MgSO4, anti-hypertensives such as Labetalol, and steroids (betamethasone and dexamethasone)

Question 24

Why are steroids given?

Answer 24

Steroids are given if it is likely to deliver before 34 weeks.
Steroids helps fetal lung development as it increase surfactant production.
steroids also helps prevent ARDS, decrease risk of bleed in fetal brain and decrease risk of necrotising enterocolitis

Question 25

Which anti-hypertensive is not suitable for severe eclampsia? Explain.

Answer 25

alpha-Methyldopa, as it is a long-acting anti-hypertensive

Question 26

When is Labetalol contraindicated?

Answer 26

In pregnant ladies who are asthmatic

Question 27

What is given if toxicity is suspected after giving Magnesium Sulphate?

Answer 27

10mL of 10% Calcium Gluconate if toxicity is suspected

Question 28

What medications are avoided antenatally even though it is known to help with lowering BP? Why?

Answer 28

ACE inhibitors and Angiotensin II Receptor antagonists.
ACE inhibitors can cause IUGR and increased incidences of CVS and CNS congenital anomalities.
Angiotensin II receptor antagonists and ACE inhibitors can also cause renal dysfuntion, neonatal anuria, and oligohydramnios.