Preconception + HTN counselling

Question 1

A 36 yearly female is planning for pregnancy. Her BP in your office is repeatedly high and is 152/94 mmHg. Her BMI is 27.5. The patient does not want to take medications as she does not feel unwell. How would you manage her?

Answer 1

Key issues

• Hypertension
• Pre-conception

Consider whether patient has essential HTN, or a secondary cause including;
- renal artery stenosis
- Thyroid disease
- renal parenchyma disease
- Pheo
- Endocrine: hyperthyroid
- Drugs
Other: white coat hypertension

Goals

• undertake thorough Hx/Ex/Ix to consider differential diagnosis for HTN
• discuss non-pharm and pharm management options for HTN, in context of pregnancy planning.

Question 2

Pre-conception + HTN counselling – History

Answer 2

History

• sx: headaches, visual changes, focal neurology, changes to urination,
• PMHx: diabetes, renal disease
• Medications
• O&G hx: GTPAL, past obstetric complications. Ask about if currently trying or planning, any discussions with GP about this, contraception, fertility treatment, etc
• Vaccinations, supplements
• SNAP

Question 3

Pre-conception + HTN counselling – Examination

Answer 3

Examination

• General obs + vitals
• Anthropometric measurements
• Neurological exam: focal neurology, consider fundoscopy if any visual changes
• systems review for preconception

Question 4

Pre-conception + HTN counselling – Investigations

Answer 4

Investigations
Lots. of HTN complications and
- Bedsides: Ambulatory BP, ECG, urinalysis (end-organ damage), uACR, TFTs
- Bloods: FBC, UEC, LFT, CRP, fasting lipids.

Pheo: urine catecholamines + renal metanephrines
Cushings: Low then High-dose dexamethasone suppression/late night salivary cortisol/serum ACTH

Consider renal artery dopplers, etc.

Could consider complete antenatal work-up here, but would likely wait.

Question 5

Pre-conception + HTN counselling – Management

Answer 5

Non-pharmacological
- lifestyle changes (diet, exercise)
- smoking cessation
- alcohol reduction
- weight loss
Pre-conception counselling:
- HTN can increases risks during pregnancy (pre-term, antenatal complications, etc
- important to reduce BP and optimise health prior to pregnancy
- consider folic acid and B12 supplementation in preparation, iodine supplementation, Iron supplements

Pharmacological

• 1st line is non-pharm, then escalate to BP management
• treat any secondary causes that are identified
• Meds: if planning pregnancy, would use those that are safe in pregnancy: nifedipine, hydralazine, labetalol, methyldopa