Hypertensive Disorders of Pregnancy

Question 1

Risk (%) of Pre-eclampsia /w chronic hypertension

and if BP increases <34 weeks

Answer 1

10-20%
and
35%

Question 2

Definition of gestation hypertension

Answer 2

onset >20 weeks

Question 3

Definition of pre-existing hypertension

Answer 3

onset pre preg or <20 weeks

can be essential or secondary

Question 4

hypertension is defined as:
and
severe hypertension is defined as:

Answer 4

> 90 diastolic on 2 measurements avg (systolic unreliable, false +ves)

and

> = 160 / 110 (either)

Question 5

Pre-eclampsia definition

Answer 5

new hypertension with 1 or more:

• new proteinuria
• an adverse condition or severe complication

OR pre-existing hypertension with

• new or worse proteinuria
• adverse / severe complication
• or resistant hypertension (3+ drugs)

OR gestational hypertension plus:

• new or worse proteinuria
• a severe complication

Question 6

severe pre-eclampsia definition

Answer 6

/w 1 or more severe complication

Question 7

eclampsia definition

Answer 7

seizures without another cause in pre-eclampsia

Question 8

adverse clinical conditions of pre-eclampsia

Answer 8

headache (ischemia/edema), vision change (occ cortical ischemia), abdo pain (liver), chest pain, dyspnea (edema), N/V, abruption, abnormal labs

fetal: oligo, IUGR, FD, absent or reversed UA doppler, redistribution of MCA, DV abnormalities

Question 9

severe complications

Answer 9

eclampsia, PRLE sydrome, cortical blindness, retina detach, GCS <13, stroke/tia, severe uncontrolled HTN, O2 desat, pulm edema, MI, platelets <50, transfusion, AKI, dialysis, hepatic rupture/haematoma, INR >2 (no DIC or warfarin)

fetal: abruption + compromise, stillbirth, reversed DV wave

Question 10

How to dx proteinuria

Answer 10

suspect: dipstick 1+

300mg/day (24hr) or 30mg/mmol creatinine in 1 test

ACR accuracy unknown in preg, normal prot:creatinine= 17-57 mmol/L

severe proteinuria = 3-5g/day

Question 11

pre-eclampsia comorbidities

Answer 11

any HTN
DM (not GDM)
cerebrovasc disease
renal parenchymal or vasc disease

Question 12

What BP are you at risk for stroke?

Answer 12

> =160mmg systolic

Question 13

leading causes of death in pre-eclampsia

Answer 13

stroke, pulmonary edema

Question 14

investigations for pre-eclampsia: maternal

Answer 14

Hg (hemoconc or hemolysis), WBC + diff (neutrophil), platelets, blood film (microangiopathy/frags), INR + PTT (for DIC), fibrinogen, creatinine, uric acid (higher), glucose (low in fat liver), AST, ALT, LDH, albumin, bilirubin (hemolysis=unconj, or liver dysfunction=conj), urinalysis, proteinuria (dipstick, spot, 24hr)

Question 15

investigations for pre-eclampsia: fetal

Answer 15

FM counts, NST, BPP, deepest fluid pocket, US for growth, UA doppler (increase resistance, absent or reversed end diastolic)

Question 16

RFs for pre-eclampsia

Answer 16

multiples
Prev hx or fam hx

APA syndrome
thrombophilia

HTN or renal disease
DM
obesity
BP already >130/80
Fam Hx early CVD

age >40
>10 years since last preg, or <2 years
IVF
ethnicity: nordic, black, SouthA, PI
low SES

infection in preg
gest trophoblastic disease

non-smoker
cocaine or meth

in 3rd trimester: HTN, abnormal MSS or UA doppler, CO>7.4L/min, uric acid high

Question 17

Hints that HTN is chronic

Answer 17

retinal change on fundoscopy
cardiac enlargement (CXR or ECG)
renal disease
metabolic syndrome
prev hx of PIH
persists beyond 6wks PP

Question 18

etiology of pre-eclampsia

Answer 18

trophoblast invasion
uteroplacental mismatch
vasc endothelial damage
endothelial cell activation
cardiovasc maladaptation
coag abnormalities
immune
genetic 
dietary def or excesses

Question 19

prevention in low-risk women

Answer 19

Ca supplement if low dietary intake

normal stuff: no EtOH, exercise, folate, smoking cessation

non-specific but help other complications:

• prostaglandin precursors (fish oil)
• Mg or Zn

NOT recommended:

• salt restriction
• caloric restriction
• ASA
• Vit C, E, thiazide diuretics

Question 20

prevention in high risk women

Answer 20

Ca
ASA 75-100mg, pre-preg or at conception, must start <16wks, stop at 35-36wks (or delivery soon)

may help: avoid inter-preg weight gain, rest in 3rd trim, reduce stress

NOT recommended: caloric restriction, weight maintenance in obese, antihypertensives to prevent, vit C or E

antihypertensives: don’t prevent pre-eclampsia, but decrease incidence of severe HTN in those /w mild

Question 21

Who to hospitalize

Answer 21

severe HTN (160/110) or severe pre-eclampsia = inpatient

non severe: consider day unit or home care

bedrest NOT helpful (rest may be)

Question 22

Treatment of HTN

Answer 22

severe: target under 160/110

meds:
labetalol:
20mg IV
then 20-80mg q30min
OR 1-2mg/min
(max 300mg, then go PO).
Avoid if asthma or CHF. Caution neonatal brady.

nifedipine:
5-10mg caps PO q30min
10mg PA tab q45min (max 80mg/d)

hyrdalazine: 
5mg IV, 
then 5-10mg IV q30min OR
0.5-10mg/hr,
max = 20mg IV (or 30IM)

FHR monitor until stable

can combine nifedipine /w MgSO4

Question 23

Non-severe hypertension treatment

Answer 23

140/90-160/110

target <155/105
if comorbidities <140/90

meds:
methyldopa
250-550mg po BID-QID, max = 2g/day

labetalol
100-400mg po bid-tid
max = 1200mg/day

nifedipine
PA 10-20mg bid-tid, max=180mg/d
XL 20-60mg po OD, max=120mg/d

Question 24

When to use steroids

Answer 24

pre-eclampsia <34 weeks

gestational HTN <34 weeks if delivery may be <7 days away

Note steroids –> low HR variability for 4 days

Question 25

Labour and Delivery notes

who can get epidural?

Answer 25

early epidural
can do spinal or epi if pts >75 (even /w ASA), if on LMWH 12 hrs after prophylactic or 24hrs if therapeutic dose

NO IV fluid bolus before anaesthesia/analgesia

minimize fluids, even if oliguria

no dopamine or furosemide

Question 26

What other thing need tx in pre-eclampsia?

Answer 26

N/V, abdo pain, seizure prophylaxis, MgSO overdose, fetal monitoring, BP

Question 27

tx of RUQ/epigastric pain

Answer 27

morphine 2-4mg IV

antacid

Question 28

seizure prophylaxis

Answer 28

MgSO4 if

• eclampsia
• severe pre-eclampsia
• consider in non-severe

dose: 4g IV, then 1-2g/hr IV

continue until 24hrs post-partum

Question 29

MgSO4 overdose

Answer 29

observe for toxicity:

• weakness, resp paralysis, somnolence, heart block
• high risk: renal failure, oliguria, CCBs

tx:

• stop infusion
• 10% Calcium gluconate 10ml IV over 3 mins

Question 30

treatment of eclampsia

Answer 30

• don’t shorten initial convulsion
• prevent injury/aspiration
• maintain O2
• avoid polypharmacy

Question 31

HELLP syndrome tx

Answer 31

• corticosteroids if pts <50
• consider transfusion if pts <50, falling rapidly, or coagulopathy/excessive bleeding
• strongly consider if VD and <20
• recommended if CS and <20

Question 32

who to transfer if resources limited

Answer 32

• stable (BP, fetal status reassuring)
• discuss /w patient + receiver
• give anti-HTN + MgSO if indicated

Question 33

Cure of HTN in preg

Answer 33

delivery

• stabilize mom 1st
• delay only for fetal maturity or transfer if condition allows
• progressive dx, don;t wait if severe of fetal compromise

Question 34

who can get expectant management in pre-eclampsia

Answer 34

<34wks, may do expectant management, if stable. Consider transfer to centre that can care for premie
34-36wks - no evidence
37wks - deliver

Question 35

postpartum management

Answer 35

follow BP
restart anti-HTNs
severe: target <160/110

treat if non-severe esp /w comorbidities

safe in BFing: nifedipine XL, labetalol, methyldopa, captopril, enalapril

ensure end-organ issue resolved

Question 36

pre-conception in patients /w HTN

Answer 36

optimize health
switch to anti-hypertensives safe in preg
methyldopa, labetalol, CCBs ok in 1st trimester

may not need to replace anti-HTNs