Hypertension in Pregnancy

Question 1

What happens to vessels during pregnancy?

Answer 1

Vasodilation

Question 2

Is blood pressure high or low in early pregnancy?

Answer 2

Low

Question 3

Is blood pressure high or low in late pregnancy?

Answer 3

High

Question 4

When is the lowest blood pressure in pregnancy?

Answer 4

22-24 weeks

Question 5

What are the parameters/criteria for diagnosing hypertension in pregnancy?

Answer 5

Greater than 140/90 on 2 occasions

Greater than 160/110 once

Question 6

What is the most common cause of prematurity during pregnancy?

Answer 6

Preclampsia

Question 7

If hypertension persists within 3 months of delivery of a baby, what is the likely diagnosis?

Answer 7

Pre-existing (undiagnosed) hypertension

Question 8

If hypertension occurs in early pregnancy, what is the differential diagnosis?

Answer 8

Pre-existing hypertension

Question 9

List some secondary causes of pre-existing hypertension

Answer 9

Renal
Cardiac
Cushings
Conns
Phaechromocytoma

Question 10

If hypertension occurs in second half of pregnancy, what are the differential diagnoses?

Answer 10

Pregnancy-induced hypertension

Preclampsia

Question 11

When should pregnancy-induced hypertension resolve by?

Answer 11

6 weeks following delivery

Question 12

There is a high recurrence rate of pregnancy-induced hypertension. True/ False?

Answer 12

True

Question 13

What is the triad of features present in pre-eclampsia?

Answer 13

Hypertension
Proteinuria
Oedema

Question 14

Absence of symptoms excludes diagnosis of pre-eclampsia. True/ False?

Answer 14

False

Often asymptomatic at 1st presentation

Question 15

How much proteinuria meets the criteria for pre-eclampsia?

Answer 15

0.3 g/l or more
0.3 g or more in 24 hour period
2+ on dipstick

Question 16

How is pre-eclampsia classified?

Answer 16

Early (<34 weeks)

Late (>34 weeks)

Question 17

Describe the pathogenesis of pre-eclampsia

Answer 17

Abnormal placental perfusion and failure of trophoblast invasion cause spiral arteries to stay as high resistance/low flow vessels, leading to placental endothelial damage and thrombosis

Question 18

Preclampsia is a multi-system disorder. List the most common crisis’s found in preclampsia

Answer 18

Eclampsia
HELLP syndrome
Pulmonary Oedema
Placental Abruption
Cerebral Haemorrhage
Cortical Blindness
Disseminated Intravascular Coagulation
Acute Renal Failure
Hepatic Rupture

Question 19

What is the most common clinical sign of liver pathology in preclampsia?

Answer 19

Epigastric/ RUQ pain

Question 20

Pulmonary oedema, as a complication of preclampsia, can result in which emergency condition?

Answer 20

ARDS

Question 21

What syndrome related to liver disease are women with pre-eclampsia at risk of?

Answer 21

HELLP syndrome

Question 22

What are the clinical features of HELLP syndrome?

Answer 22

Haemolysis
Elevated Liver enzymes
Low platelet count

Question 23

What effect - vasodilation or vasoconstriction - does hypertension have on the placenta?

Answer 23

Vasoconstriction

Question 24

List symptoms of pre-eclampsia

Answer 24

Headache
Visual disturbance
Epigastric/RUQ pain
Nausea/vomiting
Rapidly progressiv oedema

Question 25

List clinical signs of pre-eclampsia

Answer 25

``` Hypertension/ Proteinuria/ Oedema Abdominal tenderness Disorientation SGA IUD Hypereflexia ```

Question 26

List investigations used in the diagnosis of preclampsia

Answer 26

``` U+Es/ Serum urate/ LFTs FBC Coag screen Urine PCR CTG Ultrasound biometry, doppler ```

Question 27

List risk factors for preclampsia

Answer 27

``` Maternal age >40 yrs Maternal BMI >30 FHx Parity (1st pregnancy) Multiple pregnancy Previous PE Birth interval > 10 yrs Molar pregnancy Pre-existing hypertension Thrombophilia Pre-existing renal disease, DM, CTD ```

Question 28

What is the indication for aspirin in the management of preclampsia?

Answer 28

Prophylactic dose of 75mg aspirin for high risk women - renal disease, DM, APS, multiple pregnancy, Hx PET

Question 29

What is the mode of action of aspirin in the management of preclampsia?

Answer 29

Inhibits cyclo-oxygenase | Prevents TXA2 synthesis

Question 30

How can pre-eclampsia be screened for/predicted?

Answer 30

Maternal uterine artery doppler to assess blood flow at 20-24 weeks - if poor flow (notching) then high risk

Question 31

What blood pressure is aimed for in the treatment of hypertension during pregnancy?

Answer 31

140-150/90-100 mmHg

Question 32

What medication is used for hypertension in pregnancy 1st line? State the drug class for each

Answer 32

1. Labetolol - alpha and beta blocker 2. Nifedipine - Ca channel blocker 3. Methyldopa - alpha agonist

Question 33

Labetolol is contraindicated in...

Answer 33

Asthma

Question 34

Methyldopa is contraindicated in...

Answer 34

Depression

Question 35

What medication is used for hypertension in pregnancy 2nd line? State the drug class for each

Answer 35

Hydralazine - vasodilator | Doxazocin - alpha antagonist

Question 36

Which hypertensive drug class should be stopped in pregnancy?

Answer 36

ACEI/ARB

Question 37

List methods used in surveillance of the fetus in preclampsia

Answer 37

Fetal movements CTG daily Ultrasound

Question 38

What is the only cure for pre-eclampsia?

Answer 38

Delivery of baby | Most women deliver within 2 weeks of diagnosis

Question 39

When should a baby aim to be delivered if there is pre-eclampsia?

Answer 39

37 weeks

Question 40

What medication is administered during labour to manage preclampsia?

Answer 40

Steroids | Dexamethasone

Question 41

What is eclampsia?

Answer 41

Tonic-clonic (grand mal) seizure occurring with pre-eclampsia features

Question 42

Is eclampsia more common antepartum, intrapartum or postpartum?

Answer 42

Postpartum

Question 43

What medications are used to control hypertension in severe preclampsia or eclampsia?

Answer 43

IV labetolol | IV hydralazine

Question 44

What should be given to treat seizures in eclampsia? If there is persistance of seizure, what other medication should be considered?

Answer 44

Magnesium sulphate IV | Diazepam IV

Question 45

When managing fluid balance in eclampsia, it's safer to let patients run dry. True/ False?

Answer 45

True | Main cause of maternal death is pulmonary oedema from fluid overload

Question 46

What is the regime for IV fluids in eclampsia?

Answer 46

80ml/hr

Question 47

Eclampsia should always be managed with c-section. True/False?

Answer 47

False | Aim for vaginal birth

Question 48

Why is epidural anaesthesia useful in delivery in eclampsia?

Answer 48

It's a vasodilator - helps to reduce blood pressure

Question 49

List aspects of post-partum management for eclampsia

Answer 49

``` Breastfeeding Contraception BP management Counselling on future risk Long term CVD risk ```

Question 50

Eclampsia is more common in which group of women?

Answer 50

Teenagers