Hypertensive disorders in pregnancy

Question 1

When and what do you expect to happen to the blood pressure during pregnancy?

Answer 1

2nd trimester - ↓ 30/15 compared to normal.

Expect to return to normal by term

Question 2

Whats the implication of having pre-existing hypertensive disorder before pregnancy?

Answer 2

6x ↑ of pre-eclampsia

Question 3

What are the pregnancy induced hypertensive disorders?

Answer 3

Pre-eclampsia

Gestational hypertension

Question 4

Pt presents with BP of 150/108 but no proteinuria. What condition is this?

Answer 4

Gestational hypertension

• Pre-eclampsia: BP >140/90 >20w gestation + proteinuria (>0.3g/24h) ± oedema
• Gestational hypertension: BP >140/90 >20w gestation, w/o proteinuria

Question 5

What is the classification of hypertension in pregnancy? What would 143/95 be?

Answer 5

Mild

• Mild: BP 140/90 – 144/99 mmHg
• Moderate: BP 150/100 – 159/109 mmHg
• Severe: BP >160/100 mmHg

Question 6

What %age of nulliparous women get pre-eclampsia

Answer 6

6% with a 15% recurrence

Therefore 2.5x more likely to get pre-eclampsia if already had before

Question 7

What are the other main risk factors for getting pre-eclampsia? Is multiple gestations one?

Answer 7

Yes

Multiple gestations
1st pregnancy
Mother >35

Diabetes
Obesity
FH

Highest risk factors:

Prev HTN in pregnancy
HTN, CKD, Autoimmune disease

Question 8

Briefly outline the pathophysiology of pre-eclampsia?

Answer 8

↓Uroplacental blood flow
Endothelial damage
Inflammation
Everything else

Question 9

Pre-Eclampsia

Signs and Symptoms?

Answer 9

Usually asymptomatic

First signs

+ve urine dip for protein
Sudden Oedema
HTN

Later signs

Neuro - Headache, drowsiness, visual disturbances
Gastro - N&A, epigrastic pain

Epigastric tenderness of a sign of impending complication

Question 10

If left untreated, what are the possible complications for the MOTHER?

Answer 10

Neuro - eclampsia (grand mal seizures), haem stroke
Lungs - Pulmonary oedema
Kidneys - Renal failure
Liver failure - HELLP Syndrome

Question 11

If left untreated, what are the possible complications for the FOETUS?

Answer 11

IUGR (<34/40)
Preterm birth
Placental abruption
Hypoxia

Question 12

What BP would indicate that you’d book for pre-eclampsia?

Answer 12

140/90

Question 13

If BP>140/90, what investigations would you perform to confirm the Dx

Answer 13

Confirm Dx

• BP + urine dipstick at bedside
• MSU (culture exclude infection)
• Urine protein quantification (protein:creatinine ratio [PCR]/24h collection)

Pre-eclampsia: BP >140/90 >20w gestation + proteinuria (>0.3g/24h) ± oedema

Question 14

If the diagnosis of pre-eclampsia is confirmed, what do you do? Would you admit?

Answer 14

Yes, admit all and run investigations and monitoring

Maternal

BP
FBC, uric acid
LFT, LDH (signs of liver)
U&E, Creatinine (sign of renal)

Foetal

USS foetal growth and amniotic fluid volume (↓in pre-eclampsia)
Umbilical artery doppler
CTG

Question 15

Management - mild Pre-eclampsia <150

Answer 15

Continue monitoring mother and foetus

Delivery by 37 weeks

Question 16

Management - moderate pre-eclampsia <160

Answer 16

Continue monitoring and foetus

Labetalol - Target BP <150/80-100
Delivery by 37 weeks

Question 17

Management - severe pre-eclampsia <170

Answer 17

Continue monitoring and foetus

Labetalol - Target BP <150/80-100
IV MgSO4
Delivery by 34 weeks +- steroids

Question 18

Management - severe + complications pre-eclampsia

Answer 18

Refer to ITU

Antihypertensives - Labetalol, methyldopa, nifedipine
- Target BP <150/80-100

IV MgSO4

Continual BP measurement
Foetal monitoring

Delivery ASAP

Question 19

Magnesium Sulphate - indication and assessment?

Answer 19

Severe hypertension

Give loading dose (4g in 5mins) followed by IV infusion (1g/hr)

Toxicity:

Test patellar reflexes regularly (loss = toxicity)
Toxicity – loss of patellar reflexes (early), resp depression, hypotension

Question 20

Intra/Postpartum care of pre-eclampsia

Answer 20

Continue anti-hypertensives and monitoring until no longer high BP.

Encourage breast feeding

Arrange follow-up with GP 2w and 6-8w

Question 21

Management of MILD gestational HTN

Answer 21

Measure ONCE a week
BP, Proteinuria

Foetal monitoring

Deliver > 37 weeks

Question 22

Management of MODERATE gestational HTN

Answer 22

Labetalol

Measure TWICE a week
BP, Proteinuria

Foetal monitoring

Deliver > 37 weeks

Question 23

Management of SEVERE gestational HTN

Answer 23

ADMIT (discharge when BP <160)

Labetalol

Measure BP 4x a day
Measure Proteinuria once a week

Monitor other risks weekly

Foetal monitoring

Deliver > 37 weeks if responsive to treatment. If refractive, deliver ASAP

Question 24

Intra/Postpartum care of gestational HTN

Answer 24

same as pre-eclampsia

Question 25

Prevention of pre-eclampsia in high risk pregnancy - briefly explain how to manage?

Answer 25

At 28-30w and 32-34w:
o USS foetal growth + amniotic fluid vol
o Umbilical artery Doppler
o CTG (if USS abnormal)

If ≥2 mod RFs + ≥1 high RF
o	Aspirin (75mg/d, from 12w)
o	CTG (if foetal abnormality abnormal)