Hypertensive disorders in pregnancy

Question 1

Does blood pressure normally change during pregnancy?

Answer 1

Yes, falls in the second trimester by about 30/15. By term, blood pressure should be back to pre-pregnant levels.

Question 2

How does pre-eclampsia cause HTN?

Answer 2

Largely due to increase in systemic vascular resistance. Protein excretion in normal pregnancy is increased, but not by much.

Question 3

How can HTN in pregnancy be classified?

Answer 3

Pregnancy-induced HTN and pre-existing or chronic HTN.

Question 4

What is pregnancy-induced HTN?

Answer 4

BP raises above 140/90 after 20 weeks, either transiently or due to PE.

Question 5

What is preeclampsia (PE)?

Answer 5

HTN and proteinuria >0.3g/24h after 20w gestation, often with oedema

Question 6

What is eclampsia?

Answer 6

The occurrence of epileptiform seizures, the most dramatic complication

Question 7

Are patients with chronic HTN at increased risk of PE?

Answer 7

Yes, six fold more risk

Question 8

What is the pathology of PE?

Answer 8

Systemic blood vessel endothelial cell damage, in association with an exaggerated maternal inflammatory response, leading to vasospasm and increased capillary permeability and clotting dysfunction.

Question 9

What is the course of PE?

Answer 9

The disease is progressive, but variable and unpredictable. HTN usually precedes proteinuria.

Question 10

Is PE more common in nulliparous or multiparous women?

Answer 10

It is less common in multiparous women unless additional risk factors at present

Question 11

Is PE likely to recur?

Answer 11

There is a 15% recurrence rate; this is up to 50% if there has been severe pre-eclampsia before 28 weeks

Question 12

What is mild PE?

Answer 12

Proteinuria and mild/moderate HTN

Question 13

What is moderate PE?

Answer 13

Proteinuria and severe HTN (160/110)with no maternal complications

Question 14

What is severe PE?

Answer 14

Proteinuria and any hypertensions <34 weeks or with maternal complications

Question 15

What are the high risk factors for PE?

Answer 15

1. hypertensive disease in a previous pregnancy
2. chronic kidney disease
3. autoimmune disease, such as systemic lupus erythematosus or antiphospholipid syndrome
4. type 1 or type 2 diabetes
5. chronic hypertension

Question 16

What is HELLP syndrome?

Answer 16

A life-threatening pregnancy complication usually considered to be a variant or complication of pre-eclampsia

Question 17

What are the symptoms of HELLP syndrome?

Answer 17

H (haemolysis): dark urine, raised LDH, anaemia
EL (elevated liver enzymes): epigastric pain, liver failure, abnormal clotting
LP (low platelets): normally self-limiting

Question 18

What are the clinical features of PE?

Answer 18

Usually asymptomatic, but headache, drowsiness, visual disturbances, nausea/vomiting or epigastric pain may occur

Question 19

What are the maternal complications of PE?

Answer 19

Eclampsia; cerebrovascular haemorrhage; liver and coagulation problems (HELLP); renal failure; pulmonary oedema

Question 20

What is the pathology of eclampsia?

Answer 20

Generalised tonic clonic seizures, probably resulting from cerebrovascular vasospasm.

Question 21

How does eclampsia cause mortality?

Answer 21

It can result from hypoxia and concomitant complications of severe disease

Question 22

How do you treat eclampsia?

Answer 22

Magnesium sulphate, and intensive surveillance for other complications

Question 23

How does eclampsia cause cerebrovascular haemorrhage?

Answer 23

Failure of cerebral blood flow autoregulation an mean arterial pressures above 140mmHg. Treatment of HTN should prevent this

Question 24

How do you treat HELLP syndrome?

Answer 24

Supportive treatment and magnesium sulphate eclampsia prophylaxis. Intensive care treatment is required in severe cases

Question 25

What are the fetal complications of PE?

Answer 25

IUGR; preterm birth; placental abruption and hypoxia

Question 26

How do you investigate PE?

Answer 26

Exclude urine infection; urine protein:creatinine ratio is used to determine protein levels. Screen for maternal and fetal complications

Question 27

What antihypertensive is recommended in pregnancy for PE?

Answer 27

Labetalol

Question 28

How quickly do symptoms occur after proteinuria?

Answer 28

As a general rule, one or more fetal or maternal complication is likely to occur within 2 weeks

Question 29

Does PE alter how the baby is delivered?

Answer 29

It can be either C section or vaginal if there is no urgency (complications). CTG is used to closely monitor the fetal heartbeat and blood pressure should be monitored during labour

Question 30

What are the pitfalls in treating PE?

Answer 30

It is unpredictable
HTN may be absent; watch for proteinuria
LFTs must be performed with epigastric pain
Severe HTN must be treated
HTN treatment may disguise the PE
Excessive fluids causes pulmonary oedema

Question 31

Does PE stop as soon as the baby is delivered?

Answer 31

No, it can often take at least 24 hours and may worsen in this time so maternal monitoring needs to continue

Question 32

What are the risk factors for pre-existing HTN?

Answer 32

Common in older and obese women with a positive family history or who developed HTN on combined oral contraceptive

Question 33

Does pregnancy often alter pre-existing HTN?

Answer 33

HTN usually increases in late pregnancy

Question 34

Are any HTN treatments teratogenic?

Answer 34

Yes, ACE inhibitors, use labetalol

Question 35

List 6 moderate risk factors for PE.

Answer 35

1. first pregnancy
2. age 40 years or older
3. pregnancy interval of more than 10 years
4. body mass index (BMI) of 35 kg/m² or more at first visit
5. family history of pre-eclampsia
6. multiple pregnancy