Hypertension in pregnancy

Question 1

What are the main types of hypertension in pregnancy?

Answer 1

White coat hypertension.
Non-proteinuric hypertension.
Pre-eclampsia.
Superimposed pre-eclampsia (= pre-eclampsia hos kvinner som fra før har hypertensjon).

Question 2

How should blood pressure be measured?

Answer 2

Appropriate apparatus, correct cuff size etc.
Sitting position, non-dominant arm.
Adequate rest prior to blood pressure measurement.
Disappearance of sounds indicates diastolic blood pressure if manual measurement is used.
Use validated automated machines.

Question 3

What is the cure for pre-eclampsia?

Answer 3

Delivery is the only cure.

Question 4

Explain the basic pathophysiology of pre-eclampsia.

Answer 4

The pathohysiology is poorly understood.

Endothelial injury causes abnormal permeability
(and proteinuria), swelling, and activation of coagulation system (which in turn results in low platelets).

Vasospasm causes hypertension, oliguria, and abnormal renal and liver functions.

Question 5

What are risk factors of pre-eclampsia?

Answer 5

First pregnancy.
Family history.
Multiple pregnancy.
Pre-existing hypertension.
Renal disease.
Diabetes.
Anti-phospholipid syndrome.

Question 6

What are signs and symptoms of pre-eclampsia?

Answer 6

The condition can be asympomatic.
Symptoms include: Headaches, flashing lights, epigastric pain, nausea/vomiting and confusion.
Signs include: Hypertension, proteinuria and brisk jerks.

Question 7

How is pre-eclampsia diagnosed?

Answer 7

Rise of blood pressure: DBP > 90 mmHg in 2 measurements > 4 hours apart. (Or a rise in DBP > 15 mmHg in women with pre-existing hypertension.)

Proteinuria: 24-hours proteinuria > 300 mg, or 2 dipstick tests > ++ for proteins (or a spot protein-creatinine-ratio > 30 mg/mmol.)

Question 8

What are maternal effects of pre-eclampsia?

Answer 8

Cerebral oedema (Eclampsia). 
Vasospasm (hypertension, renal failure).
Endothelial injury (low platelets, DIC).
Albumin leakage (proteinuria, pulmonary oedema).

Question 9

What are fetal effect of pre-eclampsia?

Answer 9

Growth restriction.
Prematurity.
Placental abruption.
Fetal death.

Question 10

How is pre-eclampsia treated/managed?

Answer 10

Antihypertensives, magnesium sulphate (MgSO4), monitoring of mother and fetus, and delivery through induction of labor in pregnancies after week 37.

Question 11

What is eclampsia? When is the risk of eclampsia highest?

Answer 11

Presence of convulsions in a woman with pre-eclampsia.

The risk is highest immediate post-partum.

Question 12

What types of antihypertensives are used to treat (pre-)emclapsia?

Answer 12

Labetalol, Nifedipine, and Hydrallazine.

Question 13

What are drugs to avoid when treating (pre-)eclampsia?

Answer 13

Diazepam, diuretics, ACE-inhibitors and atenalol.

Question 14

True or false: If hypertension or proteinuria persists

6 weeks postnatally further investigation is required.

Answer 14

True. An assessment of BP and proteinuria by
the general practitioner at the 6 weeks
postnatal check, and such a finding would be abnormal.

Question 15

True or false: In women with pre-existing hypertension early delivery is required.

Answer 15

False. Early delivery not required if no superimposed pre-eclampsia.

Question 16

True or false: PLGF levels are high in pre-ecplampsia.

Answer 16

False. Levels are low

in pre-eclampsia.

Question 17

Are levels of sFLT increased or decreased i pre-eclampsia?

Answer 17

Increased.

Question 18

What biochemical markers can be used to evaluate the risk of pre-eclampsia?

Answer 18

PLGF and sFLT.