hypertension in pregnancy

Question 1

Classification of HTN

Answer 1

mild 140/149 90/99
moderate 150/159 -100/109
severe >160 >110

Question 2

What are the three types of hypertension in pregnancy

Answer 2

gestational hypertension (non-proteinuric)
chronic hypertension
pre-eclampsia

Question 3

what is gestational HTN

Answer 3

new HTN that arises after 20 weeks

non-proteinuric

Question 4

chronic HTN

Answer 4

women who have confirmed HTN in first half of pregnancy - can put you at risk of pre-eclampsia

Question 5

What is pre-eclampsia

Answer 5

Hypertension recorded on 2 separate occasions 4 hour apart
w/ 3OOmg protein in 24 hour urine collection
that commences after 20 weeks and resolves 6 weeks post-partum

Question 6

what renal lesion is seen in P-E

Answer 6

glomeruloendotheliosis (leads to selective protein loss - albumin and transferrin)

Question 7

What is HELLP

Answer 7

Haemolytic anaemia (fibrin deposition)
Elevated liver enzymes (fibrin messes up liver)
Low PLatelets (deposition of PLT due to vascular damage)

Question 8

What is eclampsia

Answer 8

tonic-clonic seizures in woman with P-E

Question 9

Classical symptoms of P-E

Answer 9

frontal headache
Visual disturbance
Epigastric pain
non-specific flu-type stuff

Question 10

Tx for P-E

Answer 10

Have to reduce BP or they will get intracerebral bleed
Give labetalol (alpha-blocker)
Give MgSO4 if woman has features of P-E and birth planned in next 24 hours

Question 11

What medication is contraindicated in P-E

Answer 11

ERGOMETRINE (it can raise BP)

Question 12

Birth advice for people with P-E?

Especially when to deliver

Answer 12

If severe HTN get to 34 weeks and deliver
If mild 34-37
If moderate and after 37 weeks deliver within 24-48 hours
Adivce:
deliver on labour ward
Epidural is good to control BP
NO ERGOMETRINE

Question 13

Mx for P-E mild HTN (140/149)

Answer 13

Admit, don’t treat, monitor 4x a day (check kidneys, electorlytes, FBC)

Question 14

Mx for P-E moderate HTN (150/59)

Answer 14

Admit, give oral labetalol to keep SBP <150 and DBP 80-100, monitor 4x a day and check kidneys, electrolytes, FBC

Question 15

Mx for P-E severe HTN (160/69)

Answer 15

Admit, give oral labetalol aim for SBP <150, DBP 80-100, monitor more than 4x a day check kidney electrolytes, FBC

Question 16

When would you give anticonvulsants for P-E

Answer 16

if in intensive care with previous fit or severe HTN
If they’re symptomatic (liver, visual disturbance, headache)
If they have severe HTN w/ proteinuria

Question 17

Which antihypertensives are teratogenic

Answer 17

ARB
ACEi
atenolol

Question 18

Mx mild (<150/100) chronic HTN

Answer 18

No treatment needed
Monitor growth w/ serial growth scan between 28-36 weeks
low dose aspirin from week 12

Question 19

Mx if BP >150/100 chronic HTN

Answer 19

Do not admit
Antihypertensive to maintain BP <150/100-80
Measure BP twice a week
Blood tests not essential

Question 20

Causes of FGR

Answer 20

Foetal -
chromosomal abnormalities (aneuploidy)
structural abnormalities (renal agenesis)
intrauterine infection (CMV)
Maternal - Undernutrition (malnutrition
hypoxia
drugs (fags, alcohol, coke)
PLacental
reduced utero-placental perfusion (inadequate trophoblast invasion, sickle cell)
reduced foetoplacental transfusion (TTTTS, single umbilical artery)

Question 21

Two types of FGR

Answer 21

symmetrical (implies a problem in something directly impacting foetal growth)
asymmetrical (uteroplacental insufficiency - head gets all the blood so develops normally while the liver and kidneys don’t - associated w/ oligohydramnios)

Question 22

how to asses gestational age

Answer 22

CRL <13+6

Head circumference 13+6-20

Question 23

Who are at high risk of P-E?

Answer 23

Hypertensive disease during previous pregnancy
CKD
DM
Autoimmune conditions
chronic HTN

Question 24

what do you give for P-E prophylaxis

Answer 24

prophylactic aspirin from 12 weeks daily

Question 25

antenatal medical mx for gestational HTN

Answer 25

Antihypertensives:
1st line: labetalol
2nd line: nifedipine
3rd line: methyldopa
aim for 135/85

Question 26

Postnatal mx of gestational HTN

Answer 26

Monitor BP daily for first 2 days, then once between days 3-5
Continue taking antihypertensive (but change methyldopa to something else postpartum)
Hypertension should resolve within 6 weeks

Question 27

Postnatal mx of P-E

Answer 27

keep under observation for at least 24 hours
monitor BP 4x a day while inpatient, then 1-2 days a week til no HTN
F/U w/ GP after 2 weeks if still on antihypertensive
F/U at 6 weeks to ensure HTN has resolved

Question 28

mx of eclampsia

Answer 28

ABCDE 
MgSO4 4g loading dose then 1g/hour
Complications: resp depression and arrhythmias
Give 10ml 10% calcium glauconate
antihypertensives 
expedite delivery

Question 29

Intrapartum and postpartum management in pre-existing chronic HTN

Answer 29

if <160/110 don’t offer induction at 37 week

postpartum measure BP for 2 days, then once between day 3-5 and GP follow up at 2 weeks

Question 30

What are high risk factors for P-E

Answer 30

HTN in previous disease

pre-existing maternal disease (chronic HTN, renal disease, DM, AI disease)

Question 31

What are moderate risk factors for P-E

Answer 31

First pregnancy
Age >40
BMI >35
Pregnancy interval >10
multiple pregnancy 
FH of P-E

Question 32

Who do you give P-E prophylaxis to?

Answer 32

1 major risk factor

2 minor

Question 33

What is P-E prophylaxis

Answer 33

75mg aspirin daily from 12 weeks

Question 34

What are the indications for admission to antenatal ward with pre eclampsia

Answer 34

Severe HTN >160
Headaches or other signs of late stage disease
Biochemical abnormalities (elevated liver enzymes, deranged U+E)
Low platelets
SIGNS OF FOETAL COMPROMISE

Question 35

What is antenatal monitoring for woman with P-E?

Answer 35

BP every 2 days
Bloods 2x a week (FBC, LFT, U+E)
Serial growth scans every 2 weeks

Question 36

what do you look for on serial growth scan

Answer 36

UA doppler flow, growth, liquor

Question 37

antenatal monitoring for gestational HTN

Answer 37

Lifestyle modification (reduce salt)
Monitor BP weekly if poorly controlled and every 2 weeks if well controlled
Serial growth scans every 4 weeks from 28-36 weeks