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A. MLA Map Obstetrics and Gynaecology > Pre-eclampsia, Hypertension and Hypertensive Disorders in Pregnancy > Flashcards

Pre-eclampsia, Hypertension and Hypertensive Disorders in Pregnancy Flashcards

1
Q

Pre-eclampsia is defined as high blood pressure (systolic >140 and/or diastolic >90) >20 weeks, but also needs how many of the following new onset features:

  • significant proteinuria
  • maternal organ dysfunction (renal insufficiency, liver involvement)
  • neurological complications
  • haematological complications

1 - all of the above
2 - >2
3 - >3
4 >1

A

4 >1
- patients need one or more of these with the high BP after 20 weeks

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2
Q

Which of the following is NOT a HIGH risk factor for pre-eclampsia?

1 - Previous pre-eclampsia
2 - Nulliparity
3 - Chronic hypertension
4 - Autoimmune disease
5 - Diabetes mellitus
6 - Chronic kidney disease

A

2 - Nulliparity
- this is a moderate risk factor

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3
Q

Which of the following is NOT a MODERATE risk factor for pre-eclampsia?

1 - Nulliparity
2 - Age >40
3 - CKD
4 - Pregnancy interval >10yr
5 - BMI >35
6 - Family hx pre-eclampsia
7 - Multiple pregnancy

A

3 - CKD
- this is a high risk factor

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4
Q

Patients who are high risk for pre-eclampsia should be started on aspirin 75-150mg if they are high risk. How many moderate risk factors from below do they need before they should be started on aspirin from 12 weeks?

  • Nulliparity
  • Age >40
  • Pregnancy interval >10yr
  • BMI >35
  • Family hx pre-eclampsia
  • Multiple pregnancy

1 - all of these moderate risk factors
2 - 2 or more
3 - 3 or more
4 - 4 or more

A

2 - 2 or more

  • must be started before 16 weeks
  • some stop at 37 weeks to reduce risk of bleeding and risk of post-partum haemorrhage
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5
Q

Patients who are high risk for pre-eclampsia should be started on aspirin 75-150mg if they are high risk. How many high risk factors from below do they need before they should be started on aspirin from 12 weeks?

  • Previous pre-eclampsia
  • Chronic hypertension
  • Autoimmune disease
  • Diabetes mellitus
  • Chronic kidney disease

1 - all of these moderate risk factors
2 - 4 or more
3 - 3 or more
4 - 1 or more

A

4 - 1 or more

  • must be started before 16 weeks
  • some stop at 37 weeks to reduce risk of bleeding and risk of post-partum haemorrhage
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6
Q

Does the research surrounding aspirin use in pre-eclampsia indicate that aspirin is able to stop all pre-eclampsia?

A
  • no
  • effective at preventing pre-term pre-eclampsia
  • preterm = 28 to <37 weeks
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7
Q

Which blood vessels have been postulated to be a key cause of pre-eclampsia?

1 - uterine arteries
2 - ovarian arteries
3 - spiral arteries
4 - arcuate arteries

A

3 - spiral arteries
- spiral arteries become narrow and fibrosed
- placenta becomes hypoperfused and releases cytokines

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8
Q

Pre-eclampsia is linked with spiral artery fibrosis and placental hypoperfusion. This leads to inflammatory cytokine release that leads to all of the following, EXCEPT which one?

1 - endothelial damage and hypertension
2 - AKI and proteinuria
3 - HELLP syndrome
4 - pancreatitis
5 - neurological impairments
6 - increased vascular permeability (oedema)

A

4 - pancreatitis

HELLP syndrome =
H - Haemolysis (RBC destruction)
EL - Elevated Liver Enzymes
LP - Low platelets

Proteinuria =
- occurs to endothelial lining of kidneys is disrupted, leading to protein loss

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9
Q

Which of the following is NOT a maternal affect if mother has pre-eclampsia?

1 - Cerebral oedema: eclampsia
2 - Vasospasm: hypertension, renal failure
3 - Endothelial injury: low platelets, disseminated intravascular coagulopathy (DIC)
4 - Albumin leakage: proteinuria, pulmonary oedema
5 - Chronic liver failure and cirrhosis

A

5 - Chronic liver failure and cirrhosis

  • eclampsia - can lead to hyperreflexia and seizures
  • hypertension then leads to renal failure, AKI
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10
Q

Which of the following is NOT a foetal affect if mother has pre-eclampsia?

1 - Growth restriction
2 - Prematurity (iatrogenic due to delivering baby early to protect mum and baby)
3 - Placental abruption
4 - Fetal death
5 - Macrosomia

A

5 - Macrosomia

  • Placental abruption = placenta comes away from the uterus before baby is born
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11
Q

Screening using NICE guidelines is able to detect aprox 40% of patients at high risk of pre-eclampsia. Which of the following has the best detection rate for identifying patients at high risk of pre-eclampsia?

1 - Maternal factors (MF) alone
2 - MF + Mean arterial pressure (MAP)
3 - MF + MAP + PAPP-A
4 - MF + MAP + PAPP-A + UtA-PI
5 - MF + MAP + PlGF + UtA-PI

  • PAPP-A = Pregnancy Associated Plasma Protein-A
  • PIGF = Placental growth factor
  • UtA-Pl = uterine artery pulsatility index
A

5 - MF + MAP + PlGF + UtA-PI
- able to detect aprox 82% of patients at high risk of pre-eclampsia

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12
Q

Placental like growth factor (PlGF) is part of the VEGF family. What is the primary role of PlGF?

1 - provide nutrients to the foetus
2 - ensure adequate blood supply to foetus
3 - transport immune cells to foetus
4 - all of the above

A

2 - ensure adequate blood supply to foetus
- involved in proliferation, growth and survival of vascular cells, angiogenic in nature

PIGF and VEGF bind with Flt-1, tyrosine kinase receptor that promotes endothelial health and survival

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13
Q

Placental like growth factor (PlGF) is part of the VEGF family that binds with the endothelial bound receptor Flt-1, tyrosine kinase receptor that promotes endothelial health and survival. There is also soluble-Flt-1 (sFlt-1). In pre-eclampsia is this high or low?

A
  • high
  • released by a placenta under hypoxic stress
  • as soluble binds with PlGF, meaning the endothelial cells don’t get the signalling they should causing endothelial dysfunction
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14
Q

In patients with pre-eclampsia, is the sFlt-1:PlGF ratio high or low?

A
  • High
  • PlGF appears low as all bound to sFlt-1
    receptor
  • indicates a dysfunctional placenta
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15
Q

What is the cut off ratio to rule out a patient as having pre-eclampsia based on the sFlt-1:PlGF ratio?

1 - <33
2 - <66
3 - <110
4 - >150

A

1 - <33

  • > 85 for 20+0 – 33+6 = pre-eclampsia
  • > 110 for 34+0 – Delivery = pre-eclampsia
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16
Q

Which of the following matches the definition of pre-existing hypertension?

1 - proteinuria and high BP <20 weeks
2 - high BP <20 weeks
3 - proteinuria with high BP >20 weeks
4 - high BP alone >20 weeks

A

2 - high BP <20 weeks

  • patients can have significant proteinuria before 20 weeks which may be causing their high BP, but this is not pre-eclampsia
  • the reason for proteinuria does need to be investigated though
17
Q

Which of the following matches the definition of gestational hypertension?

1 - proteinuria and high BP <20 weeks
2 - high BP <20 weeks
3 - proteinuria with high BP >20 weeks
4 - high BP alone >20 weeks

A

4 - high BP alone >20 weeks
- no pre-existing BP problems

18
Q

What is the proteinuria cut off in pre-eclampsia?

1 - >100mg/24h
2 - >200mg/24h
3 - >300mg/24h
4 - >400mg/24h

A

3 - >300mg/24h
Can also use:
- Protein:Creatinine ratio (PCR) >30 mg/mmol
- +2 urine dipstick

PATIENTS DO NO HAVE TO HAVE PROTEINURIA TO BE DIAGNOSED WITH PRE-ECLAMPSIA THOUGH

19
Q

Renal impairment can be caused by pre-eclampsia, what is the cut off for creatinine?

1 - >0.9 μmol/litre
2 - >9 μmol/litre
3 - >90 μmol/litre
4 - >900 μmol/litre

A

3 - >90 μmol/litre

20
Q

Pre-eclampsia can cause haematological complications. What is the platelet cut off that can be used as part of the diagnostic criteria?

1 - <150,000 x 109/L
2 - <200,000 x 109/L
3 - <300,000 x 109/L
4 - <500,000 x 109/L

A

1 - <150,000 x 109/L

  • can also see Disseminated intravascular coagulation, clotting factors become overactive
  • can also see haemolysis due to endothelial damage, which in-turn damages RBCs
21
Q

Which of the following is NOT a sign of someone who is high risk for pre-eclampsia?

1 - Always have symptoms
2 - Headaches (frontal, not relived by analgesia)
3 - Flashing lights
4 - Epigastric pain
5 - Nausea / vomiting
6 - Confusion

A

1 - Always have symptoms
- patients may be asymptomatic, but still have high BP and abnormal blood/urine results

22
Q

Which of the following is NOT a symptom of someone who is high risk for pre-eclampsia?

1 - Hypertension (SBP>140 and/or DBP >90)
2 - Proteinuria
3 - Hyper-reflexia
4 - Clonus
5 - UTI

A

5 - UTI

23
Q

Which of the following is the 1st line medication of a patient with pre-eclampsia to attain a target BP of SBP 130-140 and DBP 80-90mmHg?

1 - Labetalol 2g/day
2 - Nifedipine 80mg/day (20-30mg TDS)
3 - MethylDopa 3g/day (1000mg TDS)
4 - Ramipril 1g/day

A

1 - Labetalol 2g/day
- contraindication in asthma and IHD

  • Nifedipine = 2nd line or in combination with Labetalol
    contraindication in aortic stenosis
  • MethylDopa = 3rd line
    contraindication in depression, AND CAN LEAD TO POST-NATAL DEPRESSION
24
Q

The first and second line medication for high BP in pre-eclampsia is Labetalol and Nifedipine, respectively. But which drug would be more effective if the patient presented with the following:

  • pulse <90bpm suggesting low Q but high resistance
  • pulse >90bpm suggesting high Q but low resistance
A
  • pulse <90bpm suggesting low Q but high resistance = Nifedipine = better vasodilator
  • pulse >90bpm suggesting high Q but low resistance = Labetalol = better rate controller beta blocker (a and b though, this is why contraindicated in asthmatics)
25
Q

Which of the following is the correct diagnosis for severe pre-eclampsia?

1 - >140/90
2 - >160/110
3 - >200/115
4 - >250/120

A

2 - >160/110

26
Q

In addition to a high BP >160/110mmHg, which of the following is NOT included when trying to diagnose a patient with severe pre-eclampsia?

1 - >proteinuria +++
2 - signs or symptoms of imminent eclampsia
3 - severe RUQ pain

A

3 - severe RUQ pain

Signs or symptoms of imminent eclampsia
- Hyper-reflexia (neuronal irritability)
- Frontal headache
- Blurred vision (cerebral vasospasm)
- Epigastric tenderness (tension on liver capsule)

27
Q

What medication is given to patients with severe pre-eclampsia?

1 - calcium carbonate
2 - vitamin B12
3 - calcium citrate
4 - magnesium sulphate

A

4 - magnesium sulphate

  • given immediately if a patient has a eclamptic seizure as medical emergency
28
Q

What is the safest position for a pregnant women to be in if she has a seizure?

1 - on her back
2 - foetal position
3 - left lateral position
4 - right lateral position

A

3 - left lateral position
- reduces risk of vena cava compression

29
Q

In a pregnant women who has pre-clampsia, but is stable at what week should they not go beyond for delivery?

1 - <30 weeks
2 - <33 weeks
3 - <37 weeks
4 - <41 weeks

A

3 - <37 weeks
- in mild pre-eclampsia or gestational HTN

  • mild/moderate pre-eclampsia 34-37 weeks, BUT increased risk of baby needed NICU
30
Q
A

A. MLA Map Obstetrics and Gynaecology (29 decks)

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