Hypertensive disorders

Question 1

What is the definition of pre-eclampsia?

Answer 1

Blood pressure above 140/90
Recorded twice over a 4 hour period
In the presence of 300mg of protein in urine
Occurring after 20th week gestation
Resolving after 6th week post partum

Question 2

What is HELLP syndrome?

Answer 2

A form of severe eclampsia:

Haemolysis
Elevated Liver (enzymes)
Low Platelets

Women typically present with epigastric pain and nausea

Associated with high foetal loss rate

Question 3

What is eclampsia?

Answer 3

Presence of tonic-clonic seizures in a woman with pre-eclampsia in the absence of other identifiable causes

Question 4

What are the signs/symptoms of pre-eclampsia?

Answer 4

First sign is hypertension
Protein in urine
Frontal headaches
Epigastric pain
Vague "flu-like" symptoms
Visual disturbances
Rapidly progressive oedema of face and hands

In severe pre-eclampsia:
Drowsiness
Haemorrhagic stroke
Placental abruption
HELLP syndrome
Pappiloedema
Clonus
Hyperreflexia

Question 5

What is the management of mild pre-eclampsia?

Answer 5

BP = 140/90 mmHg

Admit to hospital - For monitoring

Measure blood pressure at least 4 times a day
Twice a week, check kidney function, electrolytes, FBC, transaminases & bilirubin (LFT)

Question 6

What is the management of moderate pre-eclampsia?

Answer 6

BP = 150/100 mmHg

Admit to hospital for treatment

Oral labetalol aiming to keep BP below 150/100

Measure blood pressure at least 4 times a day
3 times a week: Check kidney function, electrolytes, FBC, transaminases & bilirubin (LFT)

Question 7

What is the management of severe pre-eclampsia?

Answer 7

BP = 160/110 mmHg

Admit to hospital for treatment

Oral labetalol aiming to keep BP below 150/100

Measure blood pressure more than 4 times a day
3 times a week: Check kidney function, electrolytes, FBC, transaminases & bilirubin (LFT)

Question 8

What drugs are available for hypertension treatment and what are their contraindications?

Answer 8

Labetalol (CI: Asthma)
Nifedipine (CI: Aortic Stenosis)
Methyldopa (CI: Depression)
Hydralazine (CI: Kidney disease)

Question 9

When should magnesium sulphate be prescribed?

Answer 9

Patient with severe hypertension
Planning preterm delivery (for neuroprotection)
Patient suffering from eclampsia

Question 10

How do you treat a patient suffering from eclampsia?

Answer 10

4g IV Magnesium sulphate stat

1g/hour maintenance

Question 11

How often should blood pressure be measured postnatally in a woman who has had pre-eclampsia/gestational hypertension?

Answer 11

At least 4/day whilst an inpatient
At least once on days 3 and 5
On alternate days thereafter if the results aren’t normal on days 3/5

NOTE: if blood pressure remains > 150/100, start an anti-hypertensive

Question 12

When should further scans to assess the foetus be carried out in women with hypertensive disease in pregnancy?

Answer 12

28-30 weeks

Repeat at 32-34 weeks if severe pre-eclampsia

Question 13

What does magnesium sulphate toxicity cause and how is it treated?

Answer 13

Respiratory depression

Treatment: calcium gluconate

Question 14

How long should magnesium sulphate be continued for in a woman with pre-eclampsia?

Answer 14

For 24 hours after the last seizure or until 24 hours after delivery

Question 15

What should be monitored whilst giving magnesium sulphate treatment?

Answer 15

Reflexes
Respiratory rate
Oxygen saturation
Urine output

ECG monitoring is required during and for 1 hour after loading dose

Question 16

When is delivery recommended in women with pre-eclampsia?

Answer 16

If pre-eclampsia develops >37 weeks = Delivery within 24-48 hours

If mild/moderate pre-eclampsia = Offer delivery 34-37 weeks depending on maternal/foetal condition

If severe pre-eclampsia = Offer delivery after 34 weeks following a course of corticosteroids

Question 17

What groups are at high risk of developing pre-eclampsia? How should they be managed?

Answer 17

Hypertensive disease during previous pregnancy
Chronic hypertension
CKD
Autoimmune disease (SLE)
Diabetes Mellitus

75mg OD aspirin from 12 weeks

Question 18

What is the management of women with chronic hypertension in pregnancy?

Answer 18

Stop taking ACEi, chlorothiazides and Angiotensin-II receptor blockers (ARB) for first half of pregnancy as they are teratogenic
Reduce salt intake
Aim is to keep BP below 150/100

Question 19

What is the management of women with gestational hypertension?

Answer 19

Mild (>140/90 mmHg) = Measure BP at most once a week, test urine for protein at each antenatal appointment

Moderate (>150/100 mmHg) = Treat with oral labetalol. Measure BP twice a week. Test urine for protein at each antenatal appointment. Blood test for kidney function, liver function, FBC, electrolytes

Severe (>160/110 mmHg) = ADMIT (until BP is less than 160/110). Treat with oral labetalol. Measure BP four times a week. Test urine for protein at each antenatal appointment. Blood test for kidney function, liver function, FBC, electrolytes

Question 20

What management is required with regards to delivery of a woman with pre-eclampsia?

Answer 20

○ Iatrogenic premature delivery is often required
○ Deliver after 34 weeks
○ Deliver before 34 weeks only if severe hypertension refractory to treatment, or foetal/maternal wellbeing deteriorates
○ Delivery before term is usually by C-section
○ Usually at HIGH RISK of VTE, give prophylactic SC heparin and anti-thromboembolic stockings
○ In spontaneous or induced labour (if clotting studies are normal), epidural anaesthesia is indicated as it helps control blood pressure
○ Ergometrine should be AVOIDED as it significantly increases blood pressure
○ Post-natally, blood pressure and proteinuria should resolve within 6 weeks
○ If it fails to resolve, consider chronic hypertension or renal disease