Hypertensive Disorders in Pregnancy

Question 1

What is chronic or essential HTN?

Answer 1

HTN that presents at booking or before 20 weeks gestation.

Question 2

What is gestational or Pregnancy induced HTN?

Answer 2

New HTN presenting after 20 weeks without proteinuria or signs of organ dysfunction
OR within 48-72 hours of delivery and resolves by 12 weeks post partum
* Note diagnosis can only ever be made in retrospect when there has been no protein/symptoms and BP returns to normal before the 12th week postpartum

Question 3

What is Pre-Eclampsia

Answer 3

new onset HTN and proteinuria OR symptomatic hyptertension (Blurred vision, RUQ pain, Headache) after 20 weeks gestation
OR
- Thrombocytopenia, DIC, elevated transaminases, elevated serum creatinine, pulmonary edema

Question 4

What is Eclampsia?

Answer 4

Presence of new-onset grand mal seizures in a woman with preeclampsia that cannot be attributed to other causes

Question 5

What is HELLP syndrome?

Answer 5

A variant of severe pre-eclampsia with a higher associated mortality and morbidity

• Hemolysis
• Elevated Liver enzymes
• Low Platelets

Question 6

What is the blood pressure cut off to determine if a pt is hypertensive? How many readings are needed?

Answer 6

• Systolic >140
• Diastolic >90
• Two readings are required at least 4 hrs apart

Question 7

During pregnancy, blood pressure decreases to a nadir around how many weeks?

Answer 7

• 22-24 weeks
• Following BP increases during third trimester to reach pre-pregnancy levels
• Due to decrease in systemic vascular resistance

Question 8

HTN due to pre-eclampsia typically resolves within how many weeks following delivery?

Answer 8

• 6 weeks

Question 9

What are the cutoff values for proteinurea? How is it screen and quantified if screen +?

Answer 9

• Screen by urine dip (1+ or higher is cutoff)
• If screen +, a 24 hour urine should be obtained (>300mg is positive)
  OR a protein:creatinine ration >0.3

Question 10

Which anti-hypertensive drugs are commonly used in pregnancy?

Answer 10

• Methyldopa
• Labetalol
• Nifedipine
• Hydralazine

Question 11

Which anti-hypertensive drugs are contraindicated in pregnancy and why?

Answer 11

• Diuretics
• ACE inhibitors
• ARBS

Due to renal effects

Question 12

How can pre-eclampsia be diagnosed in a patient with chronic hypertension

Answer 12

• Detection of new-onset proteinuria OR the development of signs of severe pre-eclampsia after 20 weeks gestation

Question 13

What is the classic triad associated with preeclampsia?

Answer 13

1) New onset hypertension
2) Proteinuria
3) Edema in the latter half of pregnancy

Question 14

How would you manage gestational hypertension?

Answer 14

• Close monitoring

- Significant percentage will go on to develop preeclampsia

Question 15

Is preeclampsia more common in primigravidas or mulligravida women?

Answer 15

• Primigravida women

- HELLP syndrome is more common in multigravida women

Question 16

What should you rule out if a patient presents with preeclampsia early in the second trimester (14-20 weeks)

Answer 16

• Molar pregnancy

- Choriocarcinoma (trophoblastic cancer)

Question 17

Why is there proteinuria in preeclampsia?

Answer 17

• vasoconstriction of the afferent (entering glomerulus) arteriolar system
• Can eventually lead to damage to glomerular membranes
• This increases permeability to proteins