Hypertensive Disorders in Pregnancy

Question 1

Define hypertension and severe hypertension in pregnancy.

Answer 1

• Hypertension = 140/90 to 159/109mmHg
• Severe = >160/110mmHg

Question 2

Define pre-eclampsia.

Answer 2

Hypertension present after 20 weeks (>140/90mmHg) and ≥1 of:

• Proteinuria (>0.3g in 24 hours); AND/OR
• Any maternal organ dysfunction:
  
  • Renal - rising creatinine
  • Liver - rising AST/ALT ± epigastric/RUQ pain
  • Neuro - eclampsia, blind/burred vision, stroke, clonus, severe headache
  • Haematological - thrombocytopaenia, DIC, haemolysis
  • Uteroplacental - IUGR, abnormal dopplers, stillbirth

Question 3

Define HELLP.

Answer 3

Haemolysis, Elevated Liver enzymes, and Low Platelets

• Severe form of pre-eclampsia

Question 4

Define Eclampsia.

Answer 4

≥1 seizure in a patient with pre-eclampsia

Question 5

What are the risk factors for pre-eclampsia?

Answer 5

• High Risk Factors - ≥1 = Aspirin
• Pre-eclampsia in previous pregnancy
  
  • Chronic kidney diseaseAutoimmune disease (SLE, antiphospholipid syndrome)
  • T1DM, T2DM
  • Chronic hypertension
• Moderate Risk Factors - ≥2 = Aspirin
  
  • Primigravid
  • Age ≥40 years
  • Pregnancy interval of >10 years
  • BMI ≥35
  • FHx of pre-eclampsia
  • Multiple pregnancy

Question 6

What are the signs and symptoms of pre-eclampsia?

Answer 6

• Asymptomatic
• Severe headache
• Visual disturbances (i.e. flashing lights)
• Epigastric/RUQ pain
• Vomiting
• Breathlessness
• Sudden swelling face, feet, hands

Question 7

What are the investigations for suspected pre-eclampsia?

Answer 7

• Urine dipstick → proteinuria, if ≥1+ or more → PCR quantification = >30mg/mmol is significant
• Do NOT use 24hr urine collection

Question 8

What is the management of a patient who is at high risk of pre-eclampsia?

Answer 8

• High risk pre-eclampsia
  
  • Aspirin (75mg OD, from 12w until birth)
• Give healthy lifestyle advice
• Dip urine at every appointment

Question 9

What is the management of pre-eclampsia?

Answer 9

• 1st line: Labetalol (100mg, BD) → contraindicated in asthma
• 2nd line: Nifedipine → causes tocolysis (use methyldopa at term)
• 3rd line: Methyldopa (250mg, BD or TDS)

Question 10

What is the management of eclampsia?

Answer 10

• IV magnesium sulphate (potent cerebral vasodilator)
• Deliver baby as soon as possible

Question 11

What monitoring should be carried out in pre-eclamptic patients?

Answer 11

Question 12

What is the management of pre-eclampsia antepartum?

Answer 12

Question 13

How should birth be timed in pre-eclampsia?

Answer 13

• Epidural will help to reduce the BP

Question 14

What is the critical setting management of severe pre-eclampsia/eclampsia?

Answer 14

Question 15

What is the post-natal monitoring of a patient with pre-eclampsia

Answer 15

• Inpatient for 5 days → highest risk period (deemed at risk for up to 6 weeks)
• Discharge criteria:
  
  • No symptoms of pre-eclampsia
  • Blood pressure <150/100mmHg (with or without treatment)
  • Blood test results are stable or improving
• BP monitoring:
  
  • Targets achieved (i.e. BP <150/120mmHg) → wean down anti-HTN
  • BP <130/80mmHg → stop anti-HTN

Question 16

What is the advice on breastfeeding for patients with pre-eclampsia/eclampsia?

Answer 16

• Avoid diuretic treatment
• NOT recommended when breastfeeding:
  
  • ARBs
  • ACE inhibitors (except enalapril and captopril)
  • Amlodipine
• Drugs that are safe: labetalol, nifedipine, enalapril, captopril, atenolol, metoprolol

Question 17

What counselling should be given to a patient with pre-eclampsia?

Answer 17

• Adapt the counselling based on severity
• Explain that admission may be needed - at least until blood pressure is controlled
• Explain pre-eclampsia and the risks (early delivery, reduced placental function, IUGR, risks to mother)
• Risk of recurrence → 15%
• Explain treatment - labetalol
• Explain that blood pressure will be monitored closely with regular bloods
• Explain that early delivery may be recommended

Question 18

What is the aetiology of pre-eclampsia?

Answer 18

Impaired trophoblastic invasion of spiral arteries

• (1) Impaired invasion → high resistance flow
• (2) Low flow → poor perfusion of placenta
• (3) Placenta releases factors into circulation
• (4) Factors promote further systemic effects seen:
  
  • Peripheral vasoconstriction
  • Increased permeability → oedema
  • Glomeruloendotheliosis → proteinuria
  • Endothelial damage → platelet consumption
  • Elevated liver enzymes (HELLP syndrome)
  • Vasospasm, cerebral oedema → eclampsia