Hypertensive Disorders in Pregnancy

Question 1

When is HTN recognized to be considered gestational HTN?

Answer 1

After 20 wks gestation

Question 2

Evaluation of chronic HTN in pregnancy

Answer 2

Monitor for maternal end-organ damage — CBC, glucose, CMP, 24 hr urine collection for total protein, EKG

Assess for fetal well being with initial US for accurate dating, screening US’s, growth US’s monthly after 28 wks; antepartum fetal testing to begin between 32-34 wks

Question 3

Management of mild chronic HTN in pregnancy

Answer 3

Initiate antihypertensive if reach threshold value

Prenatal visits every 2-4 wks until 34-36 wks, then weekly

Antepartum fetal monitoring

Delivery between 39-40 weeks

Question 4

Management of severe chronic HTN in pregnancy

Answer 4

Antihypertensive therapy — may include methyldopa, labetolol, nifedipine

Close prenatal monitoring for medication dosage change

With associated renal disease — 24 hr urine collection every trimester

Observe for signs of developing superimposed preeclampsia

Antepartum fetal surveillance w/ growth US every 3-4 wks, nonstress tests and/or biophysical profiles

Delivery after 38 wks gestation

Question 5

What common class of antihypertensives must be avoided in pregnancy to avoid damage to fetal kidneys?

Answer 5

ACE inhibitors

Question 6

Gestational HTN = hypertension without any features of _______; occurs after 20weeks gestation or within 48-72 hrs of delivery and resolves by 12 wks postpartum

Answer 6

Preeclampsia

Question 7

Signs/symptoms of preeclampsia

Answer 7

Signs: HTN, proteinuria, edema

Sxs: scotoma, blurred vision, epigastric and/or RUQ pain, HA

Question 8

Risk factors for preeclampsia

Answer 8

Age <20 and >35
Primigravid
Multiple gestation
Hydatiform mole
Diabetes
Thyroid disease
Chronic HTN
Renal disease
Collagen vascular disease
Antiphospholipid syndrome
Prior hx of preeclampsia

Question 9

How might preeclampsia affect the brain, heart, and lungs?

Answer 9

Brain: cerebral edema; possibly fibrinoid necrosis, thrombosis, microinfarcts, and petechial hemorrhages

Heart: absence of normal intravascular volume expansion (third spacing), reduction in circulating blood volume

Lungs: noncardiogenic pulmonary edema

Question 10

How might preeclampsia affect the liver, kidneys, and eyes?

Answer 10

Liver — swelling (stretching of glisson’s capsule results in RUQ pain)

Kidneys — swelling of glomerular capillary endothelial cells, narrowing of capillary lumen

Eyes — retinal vasospasm, retinal edema

Question 11

Preeclampsia may be classified as either mild (preeclampsia without severe features), or severe (preeclampsia with severe features).

What are the criteria for mild preeclampsia?

Answer 11

BP >140/90 but less than 160/110

Proteinuria >300 mg/24hr urine, but less than 5g/24hr urine, or a single specimen urine protein:creatinine ratio of 0.3 mg/dL

Asymptomatic

Question 12

Preeclampsia may be classified as either mild (preeclampsia without severe features), or severe (preeclampsia with severe features).

What are the criteria for severe preeclampsia?

Answer 12

BP systolic >160 or diastolic >110 (2 occasions, 4 hrs apart)

Proteinuria of at least 5g/24hr or 3+ protein on 2 random urine dips at least 4 hrs apart

Oliguria

Symptomatic — cerebral or visual disturbance, pulmonary edema, epigastric or RUQ pain, elevated liver enzymes, thrombocytopenia

Question 13

Exam findings in pt with preeclampsia

Answer 13

Brisk reflexes

Clonus

Edema

Question 14

Lab findings in pt with preeclampsia

Answer 14

Increased H/H, lactate dehydrogenase, transaminases, and uric acid

Thrombocytopenia (low platelets)

Question 15

Management of mild preeclampsia (preeclampsia without severe features) in pt less than 37 weeks gestation

Answer 15

Modified bed rest

Once (BPP) or twice (NST) weekly antepartum testing

Fetal growth US every 3-4 wks

Office visits and lab eval

Possibly hospitalization

Question 16

Management of mild preeclampsia (preeclampsia without severe features) between 37-40 wks gestation

Answer 16

If favorable cervix — induction

If unfavorable cervix — use a cervical ripening agent to begin induction

Question 17

Management of severe preeclampsia (preeclampsia with severe features)

Answer 17

Immediate hospitalization

Delivery if greater than 34 wks

Management of BP with anti-hypertensives: hydralazine, labetolol, nifedipine

If less than 37 weeks, administer corticosteroids and work towards delivery as long as pt and fetus are stable

Question 18

Preferred method of delivery for pts with preeclampsia

Answer 18

Vaginal delivery

[use cervical ripening agents and pitocin as necessary]

Question 19

Intrapartum management of preeclampsia may include _________ administration for seizure prophylaxis. Pain management is similar to a normal vaginal delivery, unless pt is ______ in which case they may not be able to receive an epidural

Answer 19

Magnesium sulfate; thrombocytopenic

Question 20

Management for eclampsia

Answer 20

Protect the airway

Magnesium sulfate is first line tx

May need lorazepam if persistent seizures

Not an indication for cesarean delivery but fetus may need some in-utero resuscitation time

Question 21

What is HELLP syndrome and what is it an indication for?

Answer 21

Hemolysis, Elevated Liver enzymes, and Low Platelets

Indication for immediate delivery!

Question 22

What drug may be utilized during pregnancy to prevent preeclampsia if they have certain risk factors (hx of preeclampsia, multifetal gestation, chronic HTN, etc.)?

Answer 22

Aspirin