Hypertensive pregnancy disorders

Question 1

What are the 4 types of hypertensive pregnancy disorders and definitions?

Answer 1

Gestational hypertension: pregnancy-induced hypertension with onset after 20 weeks gestation. blood pressure ≥ 140 mmHg or diastolic blood pressure ≥ 90 mmHg on 2 separate measurements
Chronic hypertension: hypertension diagnosed < 20 weeks gestation or before pregnancy
Preeclampsia: gestational hypertension with proteinuria, renal insufficiency, thrombocytopenia, evidence of liver damage (e.g., elevated liver enzymes, epigastric pain), pulmonary edema, and/or cerebral edema (headache, visual blurring, vomiting, an altered mental status)
Eclampsia: severe form of preeclampsia with convulsive seizures and/or coma

Question 2

What are the types of pre-eclampsia?

Answer 2

Superimposed preeclampsia: preeclampsia that occurs in a patient with chronic hypertension
HELLP syndrome: a life-threatening form of preeclampsia (HELLP is an acronym: H = hemolysis; EL = elevated liver enzymes; LP = low platelets)

Question 3

What are the risk factors of hypertensive pregnancy disorders?

Answer 3

(General) 
Thrombophilia (e.g., antiphospholipid syndrome)
Obesity (BMI ≥ 30)
Age < 20 or > 40 years
African-American race
Diabetes mellitus or gestational diabetes
(Pregnancy related) 
Nulliparity
Multiple gestation (twins)

Question 4

What is the pathophysiology in hypertensive pregnancy disorders?

Answer 4

Risk factors leading to placental hypoperfusion → release of vasoactive substances → ↑ maternal blood pressure to increase blood supply of the fetus
Hypoperfusion of fetus also ↑ placental release of factors (i.e. VEGF) → endothelial lesions that lead to microthrombosis

Question 5

What are the clinical features of gestational hypertension?

Answer 5

Asymptomatic hypertension
Nonspecific symptoms (e.g., morning headaches, fatigue, dizziness)

Question 6

What are the clinical features of preeclampsia

Answer 6

(Non-severe features) 
Usually asymptomatic
Nonspecific symptoms may include:
Headaches
Visual disturbances
RUQ or epigastric pain
Rapid development of edema
Hypertension
Proteinuria
(Severe features) 
Severe hypertension (systolic ≥ 160 mmHg or diastolic BP ≥ 110 mmHg)
Visual disturbance
pulmonary oedema

Question 7

What are the clinical features of HELLP?

Answer 7

Preeclampsia usually present (∼ 85%)
Nonspecific symptoms: nausea, vomiting, diarrhea
RUQ pain (liver capsule pain; liver hematoma)
Rapid clinical deterioration (DIC, pulmonary edema, acute renal failure, stroke, abruptio placentae)

Question 8

What are the clinical features of eclampsia?

Answer 8

Preeclamsia symptoms + generalized tonic-clonic seizures

Question 9

How is HPD diagnosed?

Answer 9

(Blood pressure) BP ≥ 160 mmHg or diastolic BP ≥ 110 mmHg
(Urine dipstick) 1–2 + protein
(Laboratory analysis, if HELLP suspected)
CBC (RBC, platelets)
Liver function tests (transaminases)
Kidney function tests (creatinine)
Peripheral smear (assess for hemolysis) and coagulation studies
(Fetal assessment) US, Cardiotocography

Question 10

What is the treatment for gestational hypertension or non-severe preeclampsia?

Answer 10

Antepartum evaluation (CBC, platelet count, serum creatinine, liver enzyme levels, Urine protein test, symptoms of severe preeclampsia, fetal ultrasound) 
 Antihypertensive drug therapy for severe hypertension (systolic BP ≥ 160 mmHg or diastolic BP ≥ 110 mmHg) (i.e.Labetalol, Hydralazine, Nifedipine)

Question 11

What is the treatment for pre-eclampsia with severe features?

Answer 11

Delivery (only curative option)
(If pregnancy < 34 0/7 weeks gestation)
IV magnesium sulfate prophylaxis, antihypertensive drugs, corticosteroids (if needed) + immediate delivery

Question 12

What is the treatment for eclampsia?

Answer 12

Magnesium sulfate IV

Delivery

Question 13

What is the treatment for HELLP syndrome?

Answer 13

Stabilization
IV fluids
Blood transfusions
Antihypertensive agents (labetalol, hydralazine)
Magnesium sulfate
Deliver