hypertension in pregnancy

Question 1

what advise is given to women who have HTN wanting to get pregnant

Answer 1

if they are taking ACE inhibitors or ARBs it can increase the risk of congenital abnormalities

same goes for thiazide or thiazide like diuretics

Question 2

what should not be used to lower BP

Answer 2

nitric oxide donors
progesterone
diuretics
low molecular weight heparin.

magnesium
folic acid
antioxidants (vitamins C and E)
fish oils or algal oils
garlic.

Question 3

which women at high risk of pre-eclampsia

Answer 3

• hypertensive disease during a previous pregnancy
• chronic kidney disease
• autoimmune disease such as systemic lupus erythematosus or antiphospholipid syndrome
• type 1 or type 2 diabetes
• chronic hypertension.

Question 4

if women is at high risk of preclampsia what medication is given as precautionary and when

Answer 4

75-150 mg of aspirin1 daily from 12 weeks until the birth of the baby.

if they have one high risk factor

if they have more than one moderate risk factor

Question 5

moderate risk of factors of pre-eclampsia

Answer 5

• first pregnancy
• age 40 years or older
• pregnancy interval of more than 10 years
• BMI of 35 kg/m2 or more at first visit
• family history of pre-eclampsia
  multi-fetal pregnancy.

Question 6

at what BP should one stop treatment

Answer 6

SBP <90

DBP <70

the woman has symptomatic hypotension.

target - 135/85mmHg

Question 7

Mx for HTN in pregnant women

Answer 7

1ST LINE - LABETALOL
- oral or iV
SEs - bradycardia, confusion, depression, dry eye, heart failure
CI - bronchospasm

nifedipine
SEs - abdo pain, dizzy, flushing, headache, nausea, angioedema, gingivial hyperplasia
CI - diabetes, elderly, ischaemic pain

methyldopa - stop within 2 days of birth
SEs - abdo distension, amenorrhoea, angioedema
CI- depression, acute porphyria, phaeochromocytoma

also provide aspirin 75-150mg once daily from 12 weeks

Question 8

what test can be done to rule out pre-eclampsia between 20 weeks and up to 35 weeks of pregnancy

Answer 8

PIGF placetnal growth factor

Question 9

what lifestyle and diet advise can be given to the pregnant woman

Answer 9

weight management
exercise
healthy eating
lowering the amount of salt in their diet.

Question 10

No of antenatal appointments if women has chronic HTN

Answer 10

weekly appointments if hypertension is poorly controlled

appointments every 2 to 4 weeks if hypertension is well-controlled.

Question 11

what additional fetal monitoring is done in women with chronic HTN and when

Answer 11

ultrasound for fetal growth and amniotic fluid volume assessment, and umbilical artery doppler velocimetry at 28 weeks, 32 weeks and 36 weeks.

Question 12

which women need additional fetal monitoring

Answer 12

• severe pre-eclampsia
• pre-eclampsia that resulted in birth before 34 weeks
• pre-eclampsia with a baby whose birth weight was less than the 10th centile
• intrauterine death
• placental abruption.

Question 13

during labour when do you measure BP HTN women

Answer 13

hourly, in women with hypertension

every 15-30 minutes until blood pressure is less than 160/110 mmHg in women with severe hypertension.

Question 14

when to measure BP after giving birth with HTN women

Answer 14

daily for the first 2 days after birth

at least once between day 3 and day 5 after birth

as clinically indicated if antihypertensive treatment is changed after birth.

Question 15

what advise to give if women choses to breastfeed while taking antihypertensives

Answer 15

consider monitoring the blood pressure of babies, especially those born preterm, who have symptoms of low blood pressure for the first few weeks

when discharged home, advise women to monitor their babies for drowsiness, lethargy, pallor, cold peripheries or poor feeding.

Question 16

Mx of HTN in postnatal period

Answer 16

enalapril - monitor of maternal renal function and maternal serum potassium.

africa or carribean
- nifedipine

amlodipine

Question 17

protein:creatinine ratio quantity to diagnose pre-eclampsia

Answer 17

use 30 mg/mmol as a threshold for significant proteinuria

Question 18

albumin:creatinine ration quantity to diagnose pre-eclampsia

Answer 18

use 8 mg/mmol as a diagnostic threshold

Question 19

when will and what additional fetal monitoring done in gestational HTN

Answer 19

ultrasound for fetal growth and amniotic fluid volume assessment and umbilical artery doppler velocimetry at diagnosis and if normal repeat every 2 to 4 weeks, if clinically indicated.

Question 20

when to carry out CGT cardiotocography

Answer 20

pre-eclampsia or severe gestational HTN

Question 21

If conservative management of pre-eclampsia or severe gestational hypertension is planned, carry out all the following tests at diagnosis:

Answer 21

ultrasound for fetal growth and amniotic fluid volume assessment
umbilical artery doppler velocimetry.

Question 22

when to repeat CTG

Answer 22

the woman reports a change in fetal movement
vaginal bleeding
abdominal pain
deterioration in maternal condition.

Question 23

what is and features of symphysis pubis dysfunction

Answer 23

Ligament laxity increases in response to hormonal changes of pregnancy
Pain over the pubic symphysis with radiation to the groins and the medial aspects of the thighs. A waddling gait may be seen

Question 24

uterine rupture features

Answer 24

Ruptures usually occur during labour but occur in third trimester
Risk factors: previous caesarean section
Presents with maternal shock, abdominal pain and vaginal bleeding to varying degree

Question 25

Mx of pre-eclampsia

Answer 25

reduce BP >160/110 - Labetolol is first-line as an antihypertensive - Nifedipine (modified-release) is commonly used second-line - Methyldopa is used third-line (needs to be stopped within two days of birth) EMERGENCY CONTROL OF SEVERE HTN IV 1. Labetalol 2. Intravenous hydralazine may be used as an antihypertensive in critical care in severe pre-eclampsia or eclampsia IV magnesium sulphate is given during labour and in the 24 hours afterwards to prevent seizures - steroids for lung maturation if preterm - deliver - strict fluid balance - HDU care after switching Enalapril (first-line) Nifedipine or amlodipine (first-line in black African or Caribbean patients) Labetolol or atenolol (third-line)

Question 26

when to think about delivery before 37 weeks

Answer 26

``` cant control BP after use of 3 drugs sats <90 deterioration of organs eclampsia placental abruption ```

Question 27

Ix of preeclampsia

Answer 27

high bP protein Maternal - FBC- thrombocytopenia - U&Es -> raised urea and creatinine uric acid - elevated -> LFTs - reduced albumin, deranged liver enzymes Protienuria -> 24hr urinary protein - >0.5g in 24 hours, PCR DIC (coagulation profile in severe cases or thrombocytopenia Fetal: - Growth velocity (fetal growth ultrasound) - Fetal wellbeing (CTG, amniotic fluid volume, fetal Doppler)

Question 28

Pre-eclampsia complications maternal

Answer 28

CNS Eclampsia Intracranial haemorrhage/Stroke Cortical blindness Renal Renal tubular necrosis (Acute kidney injury) Respiratory Pulmonary oedema Liver HELLP Syndrome (Haemolysis, elevated liver enzymes, low platelets) Liver capsule haemorrhage Liver rupture Haematological DIC VTE Placenta Placental abruption FETUS - stillbirth - small for gestational age - prematurity

Question 29

Pathophysiology of pre-eclampsia

Answer 29

Failed trophoblastic invasion & adaptation of spiral arteries Reduced placental perfusion and placental ‘ischaemia’ ® oxidative stress ® endothelial dysfunction - High levels of circulating pro-inflammatory cytokines -> Endothelial dysfunction -> Increased capillary permeability -> Release of vasoconstrictive substances such as thromboxane A2 and endothelin Decrease in prostacyclin synthesis NOT NORMAL AS PROGESTRONE SHOULD RELAX NAD BP SHOULD BE LOW ``` Increased ECF volume secondary to endothelial damage raised filtration pressure (BP) low colloid oncotic pressure and capillary leakage No increase in COP or blood volume ­­ systemic vascular resistance ```

Question 30

Symptoms of pre-eclampsia

Answer 30

``` Headache Visual disturbance Sudden increase in swelling Generally unwell Vomiting Reduced fetal movements Abdominal pain Bleeding ```

Question 31

signs of pre-eclampsia

Answer 31

``` HypertensionProteinuria Non dependent oedema Hyperreflexia/clonus Fetal growth restriction Oligohydramnios Abnormal fetal Doppler ```

Question 32

what factors determine if you van delay or deliver???

Answer 32

gestation -> >37w deliver - severity of maternal disease - speed of progression (fulminating pre-eclampsia) - Presence of Complications (HELLP etc) - Fetal wellbeing

Question 33

define eclampsia

Answer 33

Seizures occurring in pregnancy or within 10 days of delivery and with at least two of the following features documented within 24 hours of the seizure: - Hypertension  - Proteinuria one “plus” or at least 0.3 g/24 h - Thrombocytopenia less than 100 000/μl - Raised transaminases

Question 34

Mx of eclampsia

Answer 34

ABCDE - IV Access - Bolus of 4g Magnesium Sulphate Continuous infusion of Magnesium Sulphate 1g/h over 24hrs - Control hypertension - If antenatal- plan for delivery by most appropriate route - Fluid balance - HDU care

Question 35

postnatal Mx

Answer 35

may require Mx for 6-12 weeks increased risk of VTE, PET - bloods contraception before discharge

Question 36

BP targets

Answer 36

systolc <150 | diastolic 80-100