PIH

Question 1

What percentage of pregnancies does HTN affect?

Answer 1

6 to 10%

Question 2

What are the 4 (5 if you include the subcategory) classes of hypertensive disorders in pregnancy according to the 2013 ACOG Taskforce on HTN in pregnancy?

Answer 2

• Chronic hypertension
• Chronic hypertension with superimposed preeclampsia
• Gestational hypertension
• Preeclampsia
  
  • Without severe features
  • Severe

Question 3

Gestational Hypertension

• Definition:
• Most cases develop after a gestational age of:
• What % go on to develop preeclampsia?
• A definitive diagnosis can only be made ______.

Answer 3

Gestational Hypertension

• Definition:
  
  • HTN after 20 weeks’ gestation in the absence of chronic HTN
  • Without proteinuria
• Most cases develop after a gestational age of 37 weeks
• What % go on to develop preeclampsia? 1/4
• A definitive diagnosis can only be made retrospectively once chronic htn is excluded based on a return to normotension

Question 4

Preeclampsia

• Definition:

Eclampsia

• Definition:

Answer 4

Preeclampsia

• Definition:​
• New onset HTN (>140/90)
• And proteinuria (>300mg/24h, 1+ on dipstick or protein-crt ratio >0.3)
• After 20 weeks’ gestation
• But, consider the dx if no proteinuria but persistent signs or symptoms of end-organ involvement present:
  
  • ​RUQ or epigastric pain
  • Cerebral symptoms
  • IUGR
  • Thrombocytopenia
  • Elevated liver enzymes

Eclampsia

• Definition:
  
  • When CNS involvement in preeclampsia results in new onset seizures
  • The outward manifestation of disease progression in the brain

Question 5

What is the definition of HELLP Syndrome?

Answer 5

• May be a variant of severe preeclampsia but controversial as may be its own entity
• Hemolysis, elevated liver enzymes, low plts

Question 6

Distinguish the diagnostic criteria of preeclampsia without severe features from severe preeclampsia.

Answer 6

Question 7

How do you diagnose preeclampsia in a patient with chronic, preexisting HTN?

Answer 7

New proteinuria, or a sudden increase in proteinuria or hypertension, or the appearance of other manifestations of severe preeclampsia occur

Question 8

Can preeclampsia occur in the absence of a fetus? Example?

Answer 8

Can preeclampsia occur in the absence of a fetus? Yes

Example? A molar pregnancy

Question 9

1 - sentance summary of preeclampsia:

Answer 9

1 - sentance summary of preeclampsia:

• A multisystem disease characterized by generalized endothelial damage & dysfunction
• Disturbed endothelial control of vascular tone causes hypertension and increased vascular permeability resulting in edema, proteinuria and abnormal endothelial expression of procoagulants leading to coagulopathy
• These changes ultimately can cause ischemia of end organs, including the brain, liver, kidney, and placenta

Pathophysiology: “superficial placentation related to abnormal angiogenesis leading to placental hypoxia and the release of soluble substances toxic to vascular endothelium.”

Disease pathophysiology involves superficial placentation related to abnormal angiogenesis leading to placental hypoxia and the release of soluble substances toxic to vascular endothelium.

•

Disease pathophysiology involves superficial placentation related to abnormal angiogenesis leading to placental hypoxia and the release of soluble substances toxic to vascular endothelium.

•

Disease pathophysiology involves superficial placentation related to abnormal angiogenesis leading to placental hypoxia and the release of soluble substances toxic to vascular endothelium.

Question 10

1. In preeclampsia, the disease typically regresses rapidly after _______, with resolution of symptoms within _____.
2. Postpartum can you get eclampsia?
3. Postpartum preeclampsia usually presents within ______ of delivery.

Answer 10

1. In preeclampsia, the disease typically regresses rapidly after delivery, with resolution of symptoms within 48 hours
2. Postpartum can you get eclampsia? Yes
3. Postpartum preeclampsia usually presents within 7 days of delivery.

Question 11

Are patients with preeclampsia hyper or hypo- coagulable?

Answer 11

If the patient has preeclampsia without severe features, she is likely to be hyper coagulable.

If she has severe preeclampsia, she is likely hypo coagulable.

Question 12

What happens to the GFR in preeclamptic pts?

Therefore, what may the BUN and creatinine levels be like?

What about uric acid?

Answer 12

What happens to the GFR in preeclamptic pts?

In normal pregnancy, GFR increases 40 - 60%. In preeclampsia, this response is blunted, so the GFR doesn’t increase as much.

Therefore, what may the BUN and creatinine levels be like?

BUN and creatinine may technically be in the “normal” range, but for a pregnant patient, this means they are too high.

What about uric acid?

It is actually elevated in preeclampsia, and elevated early.

Question 13

In the obstetric management of preeclampsia without severe features, how will care differ from that of routine mgmt of healthy pregnant women? (2 things)

Answer 13

In the obstetric management of preeclampsia without severe features, how will care differ from that of routine mgmt of healthy pregnant women? (2 things)

1. Careful monitoring to detect pregression to severe preeclampsia
2. Induction after 37 weeks’ gestation (also recommended for this similar condition: _____)

Ans: gestational hypertension

Question 14

Corticosteroids should be given to women with severe preeclampsia between which gestational ages?

Why are they given?

Which steroid is given?

Which conditions is this designed to prevent?

Answer 14

Corticosteroids should be given to women with severe preeclampsia between which gestational ages?

• 24 wks to <35 wks gestation

Why are they given?

• To accelerate fetal lung maturity

​Which steroid is given?

• Betamethasone

Which conditions is this designed to prevent?

• Respiratory distress syndrome
• Intraventricular hemorrhage
• Infection
• Death

Question 15

Obstetrical managment of patients with severe preeclampsia:

In women with severe preeclampsia, at what gestational age is induction of labour recommended?

If the fetus is below this gestational age, what is your management?

• What conditions would prompt expedited delivery before 34 weeks regardless of whether steroids have been given?

What conditions would prompt steroid administration and then delivery after 48 hours?

Answer 15

Obstetrical managment of patients with severe preeclampsia:

In women with severe preeclampsia, at what gestational age is induction of labour recommended?

• 34 weeks

​If the fetus is below this gestational age, what is your management?

• Expectant management unless there are contraindications¹
• Transfer to a facility with maternal and neonatal ICU resources
• Observe in L&D for the first 24 to 48 hrs
• Administer MgSO₄^- prophylaxis and antihypertensive medication to the mother
• Administer corticosteroids for fetal lung maturity
• Nonstress test or biophysical profile, fetal U/S, frequent reassessment of mother’s symptoms and lab tests
• After 24-48 hrs, admit, stop MgSO₄^-, daily FHR, change to antihypertensive drugs to PO, daily labs

¹What conditions would prompt steroid administration, transfer to a facility with ICU/NICU and then delivery after 48 hours?

• HELLP or partial HELLP syndrome
• IUGR < 5^th percentile
• Severe oligohydramnios
• Reversed end-diastolic flow on umbilical artery doppler study
• Labour
• Premature ROM
• Significant renal dysfunction

¹What conditions would prompt expedited delivery before 34 weeks regardless of whether steroids have been given?

• Uncontrollable severe HTN, refractory despite maximal antihypertensive Rx
• Persistent cerebral symptoms while receiving MgSO₄^- (within 24 to 48hrs)
• Eclampsia
• Pulmonary edema
• DIC
• Placental abruption
• Abnormal FHR
• < 24 weeks gestation (nonviable)
• Fetal demise

Question 16

What are initial lab investigations to order for a pregnant woman who develops HTN after 20 weeks gestation?

What is one lab test to get if delivery is indicated?

Answer 16

What are initial lab investigations to order for a pregnant woman who develops HTN after 20 weeks gestation?

• Urine protein-creatinine ratio or 24hr urine protein excretion:
  
  • Rationale: Presence of proteinuria distinguishes preeclampsia from gestational hypertension
• Plt count, and if <100,000, PT, PTT, fibrinogen:
  
  • Rationale: Thrombocytopenia suggests severe preeclampsia. If plt >100,00, coagulopathy is rarely present so other coagulation testing is not required
• Liver function tests:
  
  • Rationale: Abnormal levels indicate more severe disease, may prompt delivery
• Hemoglobin and hematocrit:
  
  • Rationale: Hemoconcentration supports diagnosis of preeclampsia and is an indicator of severity. Values are decreased if hemolysis is present.
• Serum creatinine level:
  
  • Rationale: Abnormal or rising levels suggests severe preeclampsia

What is one lab test to get if delivery is indicated?

• Type and screen
• Consider crossmatching at least 2 units PRBC (these pts are at risk for PPH)

Question 17

If trying to decide whether to perform an epidural on a labouring woman with preeclampsia, what things should you get?

Answer 17

If trying to decide whether to perform an epidural on a labouring woman with preeclampsia, what things should you get?

• Plt count; if <100,000, do serial counts q6h to detect declining numbers

Question 18

Hypertensive treatment in preeclampsia

1. At what BP do we start treating with antihypertensives?
2. What complications are we trying to prevent?
3. While we want to get the BP down, we want to avoid _________
4. The aim of therapy is to decrease the MAP by:
5. The target SBP is:
6. The target DBP is:

Answer 18

Hypertensive treatment in preeclampsia

1. At what BP do we start treating with antihypertensives?
   
   • SBP > 160 or DBP >110
2. What complications are we trying to prevent?
   
   • ​Hypertensive encephalopathy, cerebrovascular hemorrhage, myocardial ischemia, CHF
3. While we want to get the BP down, we want to avoid abrupt changes
4. The aim of therapy is to decrease the MAP by:
   
   • no more than 15% to 25%
5. The target SBP is: 120 to 160 mmHg
6. The target DBP is: 80 to 105 mmHg

Question 19

Hypertensive treatment in preeclampsia

What are 3 commonly used antihypertensive drugs for preeclamptic patients? Doses?

What is one second-line drug? Dose?

• What is a potential fetal complication of this?

What is the safety profile of each of these for the fetus?

Answer 19

Hypertensive treatment in preeclampsia

What are 3 commonly used antihypertensive drugs for preeclamptic patients?

• Labetalol 20mg IV, then 40-80mg q10mins, max 220mg IV
• Hydralazine 5mg IV q20mins, max 20mg IV
• Nifedipine 10mg PO q20min, max 50mg

What is one second-line drug?

• Sodium nitroprusside 0.25 - 5.0 mcg/kg/min IV infusion
• What is a potential fetal complication of this?
  
  • Fetal cyanide poisoning with treatment > 4 hours

What is the safety profile of each of these for the fetus?

• In usual clinical doses, all safe for the fetus

Question 20

More on antihypertensives in preeclampsia

• Labetalol: avoid in patients with ______ and _______
• Hydralazine:
  
  • 4 side effects include:
  • Before administering, consider giving:
• Nifedipine:
  
  • Should really be used as a PO medication once…
  • Immediate-release capsule should never be administered to women with:
• Sodium nitroprusside:
  
  • Caveat: Should only be used in _______
  • Fetal harm unlikely if doses are kept <
  • If you’re gonna use it, _____ is mandatory
• Esmolol:
  
  • Can be used cautiously, but what is the concern?

Answer 20

More on antihypertensives in preeclampsia

• Labetalol: avoid in patients with severe asthma or CHF
• Hydralazine:
  
  • 4 side effects include:
    
    • Neonatal thrombocytopenia
    • Headache
    • Tachycardia
    • Palpitations
  • ​Before administering, consider giving:
    
    • IV fluid, to decrease the risk for maternal hypotension
• Nifedipine:
  
  • Should really be used as a PO medication once the severe hypertension has stabilized; it’s long-acting.
  • Immediate-release capsules should never be administered to women with:
    
    • CAD
    • Long-standing DM
    • Aortic stenosis
    • Age >45
  • ​(because of an increased risk of sudden cardiac death)
• Sodium nitroprusside:
  
  • Caveat: Should only be used in emergency situations
  • Fetal harm unlikely if doses are kept <2mcg/kg/min
  • If you’re gonna use it, intra-arterial BP monitoring is mandatory
• Esmolol:
  
  • Can be used cautiously, but what is the concern?
    
    • Fetal bradycardia. Placental transfer is rapid. Expect to see the effects of B-blockade in the fetus.

Question 21

• What is magnesium used to prevent exactly?
• Is it used for women with preeclampsia, severe preeclampsia, HELLP or eclampsia?

Answer 21

• What is magnesium used to prevent exactly? Seizures
• Is it used for women with preeclampsia, severe preeclampsia, HELLP or eclampsia?
• Severe preeclampsia, HELLP and eclampsia (to prevent recurrent seizures)

Question 22

Although there is no consensus, this is what most OBs give for Mg therapy:

• Loading dose:
• Maintenance infusion:
• Initiated when:
• Duration of infusion:
• If undergoing C-section, Mg should be started at least ______ in advance of the surgery and continued for _____\_

Answer 22

Although there is no consensus, this is what most OBs give for Mg therapy:

• Loading dose: 4 to 6g over 20 to 30 mins
• Maintenance infusion: 1 to 2g/hr
• Initiated when: decision to deliver is made
• Duration of infusion: For 24h post-partum
• If undergoing C-section, Mg should be started at least 2 hours in advance of the surgery and continued for 12 hours post-partum

Question 23

• How is magnesium sulfate eliminated?
• Side effects of magnesium toxicity include:
• In untreated patients, the normal Mg range is:
• The therapeutic range we aim for is:
• We do reflex testing because:
• Patellar reflexes are lost at magnesium levels of:
• Treatment for magnesium toxicity is:

Answer 23

• How is magnesium sulfate eliminated? Renally
• Side effects of magnesium toxicity include: Chest pain, palpitations, sedation, transient hypotension
• In untreated patients, the normal Mg range is: 1.7 to 2.4 mg/dL
• The therapeutic range we aim for is: 5 to 9 mg/dL
• We do reflex testing because: It’s a screen. If not present, the more serious side effects usually do not occur
• Patellar reflexes are lost at magnesium levels of: 12 mg/dL
• Treatment for magnesium toxicity is: Calcium gluconate 1g over 10 mins

Question 24

• Assuming no other indications for surgical delivery, which route of delivery is recommended for women with:
  
  • Preeclampsia without severe features?
  • Preeclampsia with severe features?
  • For each, why?

Answer 24

• Assuming no other indications for surgical delivery, which route of delivery is recommended for women with:
  
  • Preeclampsia without severe features? Vaginal
  • Preeclampsia with severe features? Vaginal
  • For each, why?

Because it avoids addition of the stress of surgery to the multiple physiologic aberrations. Labor induction should be carried out aggressively once the decision for delivery has been made. In gestation remote from term in which delivery is indicated, and with fetal and maternal conditions stable enough to permit pregnancy to be prolonged 48 hours, glucocorticoids should be given.

Question 25

• When is C/S indicated for a pt with preeclampsia?

Answer 25

When the maternal or fetal condition mandates immediate delivery or when other indications for cesarean delivery exist.

Question 26

• MOst strokes in preeclampsia depend on this aspect of the blood pressure:

Answer 26

SBP >160, much less so on MAP or DBP

Question 27

• Is HELLP syndrome a variant of severe preeclampsia?

Answer 27

• Controversial. A substantial fraction of these patients do not have htn or proteinuria.

Question 28

• In women with preeclampsia or HELLP, if the platelet count is less than ____, neuraxial anesthesia should not be given and if a C/S is necessary the method of anesthesia should be:
• You can try giving this medication to increase platelet count:
• If it does increase the platelet count, which type of anesthetic should be chosen for a c-section?

Answer 28

• In women with preeclampsia or HELLP, if the platelet count is less than 50,000, neuraxial anesthesia should not be given and if a C/S is necessary the method of anesthesia should be GA.
• Dexamethasone
• If it does increase the platelet count, which type of anesthetic should be chosen for a c-section?
  
  • Must weigh the risk of recurrent thrombocytopenia with risk of difficult airway and htn during GA

Question 29

• Plt transfusions are indicated for these 3 cases:
  *

Answer 29

• Plt count is <20,000 in all pts
• Plt count <40,000 in pts undergoing C/S
• Significant bleeding

Question 30

• Pre-op optimization for pts with HELLP includes because of the increased risk for this complication:

Answer 30

• Large bore IV access
• T & S and crossmatch at least 2 units PRBC
• PPH

Question 31

• Abdominal pain or epigastric pain +/- N/V, with hypotension and shock could be this life-threatening complication of preeclampsia or HELLP:
• Treatment is:
• Anesthetic mgmt broadly speaking is:
• If there isn’t any shock, treatment typically is:

Answer 31

• Rupture of a subcapsular hematoma of the liver
• Surgical emergency!
• Fluid & blood resuscitation
• No shock: Conservative mgmt but avoid all trauma to the liver to avoid capsular rupture! Including avoiding seizures, vomiting or palpating the abdomen.

Question 32

• Anesthetic mgmt of the patient with preeclampsia without severe features ________
• Must do this though:

Answer 32

• Anesthetic mgmt of the patient with preeclampsia without severe features differs little from the mgmt of a healthy pregnant woman.
• Must do this though: Monitor and reassess frequently as rapid progression to the severe form can occur. Always be prepared for a stat C-section.

Question 33

• Are there any complications which increase in likelihood postpartum?

Answer 33

• The risks for pulmonary edema, cerebrovascular accident, and VTE are increased in the postpartum period.