Hypertensive Disorders in Pregnancy

Question 1

What is gestational HTN?

When does it occur? (2)
When does it resolve?

True diagnosis is made…

Answer 1

HTN without any of preeclampsia

After 20 weeks gestation OR within 48-72 hrs. after delivery
Resolves by 12 weeks postpartum

True diagnosis is made in retrospect

Question 2

What is superimposed preeclampsia/eclampsia?

Answer 2

Preeclampsia/eclampsia transposed onto chronic HTN

Question 3

Which 2 measures should be taken when taking BP?

Answer 3

Have patient rest for at least 10 min and sit with legs uncrossed and back supported.

Use a cuff that is 1.5x the upper arm circumference.

Question 4

What 4 things should be done in a pregnant woman with chronic HTN?

Answer 4

Initial US for accurate dating

Screening US

Growth US monthly after 28 weeks gestation

Antepartum fetal testing between 32-34 weeks gestation

Question 5

What therapy is used for mild HTN (<160/110)?

When is delivery?

Answer 5

Aspirin therapy at 81 md/daily at 12 weeks until delivery

Delivery between 39-40 weeks gestation

Question 6

What are some anti-hypertensive drugs used in severe HTN in pregnancy (>160/110)?

Answer 6

Methyldopa

Labetalol*

Nifedipine*

Question 7

What drugs are contraindicated in pregnancy?

What do they cause?

Answer 7

ACE-inhibitors and ARBs

Increased risk of malformations (renal dysgenesis, calvarial hypoplasia and FGR)

Question 8

In a patient with severe HTN and associated renal disease, what is done to monitor it?

Answer 8

24-hr. urine collection every trimester

Question 9

What kind of antepartum fetal surveillance is done in a pregnant woman with severe HTN? (2)

When is delivery?

Answer 9

Growth US every 3-4 weeks
Non-stress tests and/or biophysical profiles

Delivery after 38 weeks gestation

Question 10

What is needed for a diagnosis of preeclampsia?

What are some symptoms? (4)

Answer 10

HTN, proteinuria, possible edema

Scotoma, blurred vision, epigastric or RUQ pain, HA

Question 11

What happens in the brain in preeclampsia mainly? What is the main symptom?

What else is possible?

Answer 11

Cerebral edema; HA

Possible fibrinoid necrosis, thrombosis, micro-infarcts and petechial hemorrhages

Question 12

What happens in the heart in preeclampsia?

What is the main symptom?

Answer 12

Third spacing and reduction in circulating blood volume; edema

Question 13

What happens in the lungs in preeclampsia?

What is the main symptom?

Answer 13

Non-cardiogenic pulmonary edema; pulmonary edema

Question 14

What happens in the liver in preeclampsia?

What is the main symptom?

Answer 14

Sinusoidal fibrin deposition in periportal areas with surrounding hemorrhage and portal thrombi; RUQ pain

Question 15

What happens in the kidneys in preeclampsia?

What is the main symptom?

Answer 15

Swelling and enlargement of the glomerular endothelial cells and narrowing of the lumen; proteinuria/edema

Question 16

What happens in the eyes in preeclampsia?

What is the main symptom?

Answer 16

Retinal changes and retinal edema; vision changes

Question 17

What is the BP in mild preeclampsia?
What is the proteinuria?

What is the symptomatology?

Answer 17

BP = 160/110>X>140/90
Proteinuria > 300 mg/24 hrs, but < 5 g/24 hrs., or single specimen urine protein:creatinine of 0.3

Asymptomatic

Question 18

What are features of severe preeclampsia?

Answer 18

BP > 160 systolly, or > 110 diastolly
Proteinuria > 5 g/24 hrs. or 3+ protein on 2 random urine dips at least 4 hrs. apart

Cerebral or visual changes
Pulmonary edema
Epigastric/RUQ pain
Elevated LFTs
Thrombocytopenia

Question 19

What are 2 findings on exam in a patient with preeclampsia?

Answer 19

Brisk reflexes/clonus

Possible edema

Question 20

What lab findings are noticed in preeclampsia? (5)

Answer 20

Increased: Hct, LDH, AST/ALT, uric acid

Thrombocytopenia

Question 21

Management of mild preeclampsia if < 37 weeks gestation may include: (4)

Answer 21

Once (PPP) or twice (NST) weekly antepartum testing
Fetal growth US every 3-4 weeks
Office visits and lab eval.
Possible hospitalization

Question 22

What should be done to the cervix in mild HTN from weeks 37-40 gestation?

Answer 22

If favorable, induce cervix.

If unfavorable cervix, use a ripening agents to begin induction.

Question 23

At what point should delivery be considered if the mom become preeclamptic with severe features?

What else should be done? (2)

Answer 23

If > 34 weeks

Immediate hospitalization and management of BP medically

Question 24

Magnesium sulfate is indicated for…

What is the loading dose for preeclampsia?
What is the maintenance dose for preeclampsia?
What is the therapeutic value?

What happens if too much is given?

How long is it continued for?

Answer 24

Preeclampsia with severe features for seizure prophylaxis

Loading dose: 4 g bolus
Maintenance: 2 g bolus
Therapeutic value: 5-9 g/dl
->9 loss of patellar reflexes
->12 respiratory paralysis
->30 cardiac arrest

If overloaded, respiratory and cardiac arrest (calcium gluconate is given to reverse course)

Continue for 24 hrs. post delivery

Question 25

What should be done first in eclampsia?

What is the 1st line treatment?

Answer 25

Protect airway

Magnesium sulfate (may need lorazepam if persistent)

Question 26

HELLP syndrome includes:

Symptoms (3)

What must be done if this presents?

Answer 26

Hemolysis, elevated liver enzymes and low platelet count (variant of preeclampsia)

RUQ pain, epigastric pain, N/V

Immediate delivery