Hypertensive disorders

Question 1

Definition

Answer 1

BP 140/90 on 2 separate readings 4 h
hours apart or +systolic >30mmHg, diastolic
>15mmHg from booking visit

Question 2

Deadly triad

Answer 2

1. Hypertension
2. Hemorrhage
3. Infection
   ?VTE

Question 3

Classification of hypertension in pregnancy

Answer 3

1. Gestational hypertension
2. Chronic hypertension
3. Chronic hypertension superimposed w/ pre-eclampsia

Question 4

Define pre-eclampsia

Answer 4

1. Pregnancy specific
2. Reduced organ perfusion
3. Secondary to vasospasm and endothelial activation
4. > 140/90 on 2 occasions w/ proteinuria or systemic involvement: renal insufficiency (Cr >80) or liver dysfunction: AST/ALT +, RUQ/epigastric pain due to liver necrosis, ischemia and edema

Question 5

Etiology

Answer 5

1. Failed invasion of trophoblast cells->maladaption of maternal spiral arterioles
   2, Immune intolerance
2. Maternal maladaption to CV/inflammatory changes of pregnancy
3. Dietary deficiencies
4. Genetic influences

Question 6

Pathogenesis

Answer 6

1. Abnormal invasion–> abnormal prostacyclin:thromboxane
   ratio–> +thromboxane= vasoconstriction,
   PLT aggregation
2. maladapt arterioles % vasospasm (immune and genetic)–>abnormal villous development=placental insufficiency
3. fetal growth restriction,
4. ++vascular resistance + HTN
5. endothelial cell activation after damage
   ++coagulation
6. Inflammatory activation–> +vascular permeability= HTN
   and proteinuria
7. PLTS, fibrinogen deposit subendotheliallum, edema–>
   manifest eclampsia (cerebral edema) and HELLP (liver vascular dysreg + edema causing abdominal
   pain) pulmonary edema (cap leak)

Question 7

Hematological changes in pre-eclampsia

Answer 7

Thrombocytopenia
Hemolysis
DIC

Question 8

Neurological changes in pre-eclampsia

Answer 8

Severe headache
Visual disturbances
Hyperreflexia w/ sustained clonus
Convulsions
Stroke

Question 9

Risk factors for preeclampsia

Answer 9

•Previous history of preeclampsia
• Family history of preeclampsia
• Inter-pregnancy interval > 10 years
• Nulliparity
•Pre-existing medical conditions
o APLS
o Pre-existing diabetes
o Renal disease
o Chronic hypertension
o Chronic autoimmune disease
•Age > 40 years
•BMI > 35 kg/m2
• Multiple pregnancy
•Elevated BP at booking
• Gestational trophoblastic disease
• Fetal triploidy

Question 10

Evaluation for hypertension at >20 weeks

Answer 10

1. History
Abdominal pain
Blurred vision
Edema, rapid weight gain
Fetal movements
Urine output
2. Examination
BP
Visual field
Hyper-reflexia, clonus
Abdominal examination->fetal presentation etc
Fetal assessment->CTG, USS
3. Investigations
Urine dipstick
Spot urine PCR
FBC
UEC
LFTs, LDH
Urate
4. Consider initiation of hypertensives
Commence= >160 or d>110
Consider= >140/90
5. Consider admission

Question 11

Options for antihypertensives

Answer 11

1. Methyldopa
2. Labetolol
3. Nifedipine
4. Hydralazine
5. Clonidine

Question 12

Outpatient vs inpatient care

Answer 12

1. Outpatient if:
Mild HTN w/o pre-eclampsia
2. Consider admission
Concern for fetal wellbeing
SBP >140 or dBP >90
Symptoms of preeclampsia, proteinuria or abnormal bloods

Question 13

Inpatient monitoring

Answer 13

1. BP 4 hourly if stable
2. CTG daily
3. Daily ward urinalysis
4. Maintain fluid balance
5. Daily review
6. Normal diet
7. Bed rest not usually required
8. VTE prophylaxis

Question 14

Indications for birth

Answer 14

• Non-reassuring fetal status
• Severe fetal growth restriction
• ≥ 37 weeks
• Eclampsia
• Placental abruption
• Acute pulmonary oedema
• Uncontrollable hypertension
• Deteriorating platelet count
• Deteriorating liver and/or renal
function
• Persistent neurological symptoms
• Persistent epigastric pain, nausea
or vomiting

Question 15

Stabilising prior to birth and postpartum management

Answer 15

1. Prior to birth
Control HTN
Correct coagulopathy
Consider eclampsia prophylaxis->Mg Sulphate
Attention to fluid status
2. Postpartum
Close clinical surveillance
VTE prophylaxis
Timing of discharge
Arrange F/U in 6 weeks to determine if underlying hypertension
Maternal screening

Question 16

Maternal risks of pre-eclampsia

Answer 16

1. CVA
2. Renal failure
3. Liver failure
4. Coagulation failure
5. Adrenal failure
6. Eclampsia

Question 17

Fetal risks

Answer 17

1. Asymmetrical IUGR
2. Placental abruption
3. Iatrogenic preterm delivery

Question 18

Management of eclampsia

Answer 18

1. DRSABCD
2. Control seizures
   Loading magnesium sulphate
   If ongoing diazepam
   Maintenance Mg sulphate
3. Monitoring
   BP and pulse/5 minutes
   RR, patellar reflexes
   T 2nd hourly
   Continuous CTG
   Urine output via IDC
   Fluid balance monitoring
   Check serum Mg levels
4. Control hypertension
   Aim for 130-150 and 80-100
   Avoid hypotension
   Nifedipine
   Hydralazine
   Labetolol
   Diazoxide
5. If antepartum, plan birth
   Continue fetal monitoring
   Stabilise mother
   Ergometrine not used
   VTE prophylaxis
   Consider use of steroids for lung maturation if preterm
6. Investigations
   FBC, PLTs
   UEC
   LFTs/LDH
   Coagulation
   Group and hold

Question 19

What is HELLP syndrome

Answer 19

1. Variant of severe preeclampsia

2. Hemolysis, +LFTs, -ve PLT

Question 20

Management of HELLP

Answer 20

1. Liase with obstetrician/hematologist/anesthetist
2. > 34 weeks, plan for birth
3. Consider Mg sulphate infusion
4. Consider PLT infusion

Question 21

Prevention of pre-eclampsia in subsequent pregnancies

Answer 21

1. Aspirin

Question 22

Outpatient care for mild pre-eclampsia

Answer 22

1. Attendance to day unit->rest and recheck blood, CTG, do investigations
2. Three times weekly visits for BP, blood results, proteinuria, fetal moevements and CTG
3. USS for growth, AFI, umbilical cord flow->monitoring for IUGR
4. Expectant management if doesn’t worsen util 37-38 weeks and induction of labour advised.