Hypertensive Disorders in Pregnancy Flashcards
What is PIH?
new-onset hypertension, developing after 20 weeks gestation.
What does PIH stand for?
Pregnancy-Induced HTN
When does PIH develop?
After 20 weeks gestation
What causes PIH?
Systemic reaction to abnormally invasive placenta
Presentation of PIH?
asymptomatic, headaches, blurred vision
Initial investigation for Hypertensive disease in pregnancy?
BP + Urinanalysis + sFLT: PIGF ratio
What BP reading would indicate hypertensive disease in pregancy?
140/90mmHg, +30/+15 in pre-existing hypertension
What Urinanalysis results would indicate hypertensive disease in preganancy?
protein 2+ on dipstick, >30mg/mmol protein-creatinine ratio
What sFLT : PIGF ratio results would indicate hypertensive disease in pregnancy?
> 85 is diagnositic
Name further investigations for hypertensive disease in pregancy?
Bloods, USS, Umbilical artery doppler velocimetry, cardiotocography, auscultation of foetal heart
Which Bloods are requested as part of further investigation of hypertensive disease in pregnancy?
FBC, U+E, LFT
How often are blood requested as part of further investigation of hypertensive disease in pregnancy?
Twice weekly
What is the Ultrasound scan used for as part of further investigation of hypertensive disease in pregnancy?
To assess foetal growth and AFI
How often is an USS completed as part of further investigation of hypertensive disease in pregnancy?
2 weekly
What is the umbilical artery doppler velocimetry used for as part of further investigation of hypertensive disease in pregnancy?
assess placental perfusion
How often is the umbilical artery doppler velocimetry done as part of further investigation of hypertensive disease in pregnancy?
2 weekly
What is cardiotocography used for as part of further investigation of hypertensive disease in pregnancy?
upon diagnosis, + if RFM, PV bleed, abdo pain, deterioration
How often is auscultation of foetal heart completed as part of further investigation of hypertensive disease in pregnancy?
offered at every appointment
What is given for prevention of Hypertensive disease in pregnancy?
75mg aspirin OD from 12/40 onwards
First Line treatment for Hypertensive disease in pregnancy
labetalol (beta blocker)
Second Line treatment for Hypertensive disease in pregnancy
nifedipine
Third Line treatment for Hypertensive disease in pregnancy
methyldopa
for Hypertensive disease in pregnancy Consider early delivery at…..
37 weeks
Name some complications of Hypertensive disease in pregnancy
Eclampsia, HELLP syndrome, Placental Abruption, Disseminated intravascular coagulation
What is gestational hypertension?
Hypertension diagnosed after 20 weeks of pregnancy without significant proteinuria or signs of preeclampsia.
Defined as systolic BP ≥ 140 mmHg or diastolic BP ≥ 90 mmHg.
How is gestational hypertension diagnosed?
Blood pressure ≥ 140/90 mmHg measured on two occasions at least 4 hours apart.
No evidence of proteinuria or systemic features (e.g., organ dysfunction).
What are the risk factors for gestational hypertension?
First pregnancy.
Advanced maternal age (>35 years).
Obesity.
Family or personal history of hypertension or preeclampsia.
Multiple pregnancy.
Pre-existing conditions (e.g., diabetes, renal disease).
Gestational hypertension develops after __________ weeks of pregnancy without significant proteinuria.
20
What are the clinical features of gestational hypertension?
Elevated blood pressure (≥140/90 mmHg).
No proteinuria.
No symptoms of end-organ damage (e.g., headache, visual changes, epigastric pain).
What investigations are performed for gestational hypertension?
Urinalysis: Rule out proteinuria.
Blood tests: Assess renal function, liver function, and platelets.
Ultrasound: Monitor fetal growth.
Blood pressure monitoring: Regular checkups to detect progression to preeclampsia.
True/False
Q: Proteinuria is a diagnostic feature of gestational hypertension.
false.
What are the key principles of managing gestational hypertension?
Regular BP monitoring.
Assess for progression to preeclampsia.
Antihypertensive medications if BP ≥ 140/90 mmHg.
Monitor fetal growth and wellbeing.
Plan delivery at term if stable.
Which antihypertensive medications are safe in pregnancy?
Labetalol (first-line).
Nifedipine (if labetalol is contraindicated).
Methyldopa.
When is delivery recommended in gestational hypertension?
Around 37–39 weeks if there are no complications or earlier if the condition worsens.
What are the complications of untreated gestational hypertension?
Progression to preeclampsia.
Placental abruption.
Preterm birth.
Fetal growth restriction (FGR).
Stillbirth.
Labetalol is the first-line antihypertensive for __________ hypertension.
Gestational
What is the prognosis for gestational hypertension?
Typically resolves postpartum.
Increased risk of preeclampsia and long-term cardiovascular disease.
How is gestational hypertension monitored postpartum?
BP checks until normalization, usually by 6 weeks postpartum.
Assess for development of chronic hypertension.
A 28-year-old woman at 30 weeks gestation is found to have a BP of 145/95 mmHg on two occasions. No proteinuria is detected. What is the likely diagnosis, and how should it be managed?
Likely diagnosis: Gestational hypertension.
Management:
Start antihypertensive medication (e.g., labetalol).
Regular BP monitoring.
Monitor for signs of preeclampsia.
Plan for delivery around 37 weeks if stable.
What defines Pre-eclampsia?
new-onset hypertension associated with proteinuria or systemic features*, developing after 20 weeks gestation.
Presentation of Pre-Eclampsia?
asymptomatic, headaches, upper abdominal pain, blurred vision, reduced foetal movements // brisk reflexes, systemic hypertension
Eclampsia symptoms
tonic-clonic seizures in presence of pre-elcampsia
Managment of Eclampsia
intravenous magnesium sulphate, emergency delivery via LSCS
What are the 3 diagnostic criteria of severe pre-eclampsia requiring urgent hospital admission?
- Systolic BP > 160 mmHg 2. Severe headaches, visual scotomate, N+V, oliguria, epigastric pain, pulmonary oedema 3. Rising Creatinine, elevated liver enzymes, thrombocytopenia
What causes defective remodeling of maternal spiral arteries in pregnancy?
Inadequate invasion of extravillous trophoblast cells after week 10 leads to insufficient oxygenation of trophoblastic tissue and oxidative stress.
How does oxidative stress affect the maternal body during pregnancy?
Oxidative stress causes stressed trophoblasts to release pro-inflammatory cytokines and other factors, including sFLT, into maternal circulation.
What is the role of pro-inflammatory cytokines in pregnancy-related pathophysiology?
They disrupt maternal endothelium, causing systemic inflammatory response and reduced blood flow to maternal organs.
How does hypertension develop in pregnancy due to defective spiral artery remodeling?
Impaired renal blood flow and reduced glomerular filtration, along with elevated sFLT (which binds to and impairs VEGF), contribute to hypertension.
What causes proteinuria in pregnancy-related endothelial dysfunction?
Proteinuria results from glomerular changes, including disruption of the basement membrane and podocytes, though the exact mechanism is not fully understood.
How does defective remodeling of maternal arteries impact fetal development?
It leads to placental hypoperfusion, which reduces nutrient delivery to the fetus, potentially causing intrauterine growth restriction (IUGR).
What systemic effects arise from maternal endothelial dysfunction in pregnancy?
Endothelial dysfunction leads to vasodilatation and can affect maternal organs similarly to hypovolemic shock.
Why do seizures occur in eclampsia?
Seizures in eclampsia are thought to occur due to cerebral vasospasm.
What is the estimated worldwide incidence of pregnancy-related hypertensive disorders?
It is estimated to affect 4.6% of pregnancies globally.
What are some risk factors for hypertensive disorders in pregnancy?
Risk factors include nulliparity, previous pre-eclampsia, family history, BMI >30, age >40, multiple pregnancy, and subfertility.
What is HELLP syndrome?
syndrome of Haemolysis, Elevated Liver enzymes, Low Platelets
Management of HELLP syndrome
Intravenous magnesium, LSCS, plus expedite delivery
What does HELLP syndrome stand for?
H: Hemolysis
EL: Elevated Liver enzymes
LP: Low Platelets
Is HELLP syndrome considered a form of preeclampsia?
Yes, HELLP syndrome is a severe variant of preeclampsia.
When does HELLP syndrome most commonly occur during pregnancy?
Typically occurs in the third trimester, but it can develop postpartum.
What causes HELLP syndrome?
Hemolysis: Breakdown of red blood cells due to microangiopathy.
Elevated liver enzymes: Hepatocellular damage from ischemia and necrosis.
Low platelets: Increased platelet consumption and destruction.
What are the main symptoms of HELLP syndrome?
Right upper quadrant (RUQ) or epigastric pain.
Nausea and vomiting.
Headache.
Malaise or fatigue.
Symptoms of preeclampsia (e.g., hypertension, proteinuria).
True/False
Q: HELLP syndrome can occur without hypertension or proteinuria.
True.
What are the complications of HELLP syndrome?
Disseminated intravascular coagulation (DIC).
Placental abruption.
Acute kidney injury (AKI).
Pulmonary edema.
Liver hematoma or rupture.
Fetal complications: Preterm birth, growth restriction, stillbirth.
What laboratory findings are diagnostic of HELLP syndrome?
Hemolysis:
Abnormal peripheral smear (schistocytes).
Elevated lactate dehydrogenase (LDH).
Elevated liver enzymes:
Aspartate transaminase (AST) or alanine transaminase (ALT) > 70 U/L.
Low platelets: Platelet count < 100 × 10⁹/L.
HELLP syndrome is characterized by hemolysis, elevated liver enzymes, and low __________.
Platelets
What investigations should be performed in suspected HELLP syndrome?
Full blood count (FBC): Low platelets, hemolysis markers.
Liver function tests (LFTs): Elevated AST/ALT.
Coagulation profile: Rule out DIC.
Renal function tests: Elevated creatinine if AKI.
Fetal ultrasound: Assess fetal wellbeing.
What are the main principles of managing HELLP syndrome?
Stabilize the mother.
Expedite delivery if the pregnancy is ≥34 weeks or earlier if severe.
Treat complications (e.g., DIC, hypertension).
Monitor both mother and fetus closely.
What medications are used in HELLP syndrome management?
Antihypertensives: Labetalol, nifedipine.
Magnesium sulfate: For seizure prophylaxis.
Corticosteroids: For fetal lung maturity if preterm delivery is required.
When is delivery indicated in HELLP syndrome?
Immediate delivery if ≥34 weeks or if maternal/fetal condition is deteriorating.
Consider delay if <34 weeks and maternal/fetal condition is stable.
True/False
Q: The definitive treatment for HELLP syndrome is delivery.
True.
A 30-year-old woman at 32 weeks presents with RUQ pain, nausea, and hypertension. Lab results show elevated AST, low platelets, and elevated LDH. What is the diagnosis, and how should she be managed?
Likely diagnosis: HELLP syndrome.
Management:
Admit to hospital.
Administer antihypertensives and magnesium sulfate.
Stabilize and prepare for delivery if maternal or fetal condition deteriorates.
What is the prognosis for HELLP syndrome?
Maternal outcomes: Risk of complications such as DIC, liver rupture, and pulmonary edema.
Fetal outcomes: Risk of preterm birth and associated complications.
In HELLP syndrome, AST/ALT levels are typically elevated above __________ U/L.
70
