Hypertensive disease in pregnancy

Question 1

What is pre-eclampsia?

Answer 1

Proteinuric HTN in pregnancy, developing after 20/40.

Question 2

What is the aetiology of pre-eclampsia?

Answer 2

Nulliparity, high maternal age, FHx, PMHx, HTN, new partner, pre existing renal disease, DM, pCOS, multiple pregnancy, obesity, SLE and kidney disease.

Question 3

What is the epidemiology of pre-eclampsia?

Answer 3

5 in 10,000 pregnancies

Pre eclampsia and eclampsia are second leading cause of maternal death in UK.

Question 4

What is the history/ exam of pre-eclampsia?

Answer 4

Headache, odema, visual disturbance, RUQ pain due to liver capsule swelling. May be asymptomatic.

General: high BP, odema (facial most) hyperreflexia, clonus, papillodema if huge.

Abdomen: RUQ tenderness, reduced fundal height.

Question 5

What is the pathology of pre-eclampsia?

Answer 5

Impaired trophoblastic invasion into the spiral arteries during placentation. Increased resistance in the uteroplacental circulaiton leads to hypoperfusion or ischaemia releasing inflammatory mediators which cause widespread endothelial damage, end organ dysfunction and oedema.

Question 6

What investigations do you do for pre-eclampsia?

Answer 6

Bloods: FBC (low Pl, concentration), UE and urate (renal impairment), LFT (high transaminases), clotting.

Urine: urinalysis for protein, blood, MSU, 24h collection (>0.3g proteinuria for 24h, significant)

USS for fetal growth, liquor volume, umbilical doppler. CTG for fetal wellbeing.

Question 7

What is the management of pre-eclampsia?

Answer 7

Depends on gestaitonal age and severity at presentation. Resolves at delivery.

· Mild to moderate: regular BP monitoring, urinalysis, regular FBC and USS, fetal growth, CTG, antiHTN treatment (In this order: labetalol, nifedipine, methyldopa). Aim to deliver at 37wk.

· Severe: immediate delivery. Anti HTN: labetalol, nifedipine, hydralazine. Seizure prophylaxis with IV MgSO4. Fluid restrict and strict fluid balance with catheter, consider CVP monitor. Steroids for lung maturity in child if preterm.

Question 8

What are the complications/ prognosis of pre-eclampsia?

Answer 8

Maternal: eclampsia, PABR, CVA, P.odema, C.odema, RF, liver F, DIC, HELLP (haemolysis, liver enzymes, low platelets). Fetal IUGR, death. 10% recurrence in next pregnancy.

Question 9

What is eclampsia?

Answer 9

Grand mal seizures on background of pre eclampsia.

Question 10

What is the aetiology of eclampsia?

Answer 10

Unclear

PRE existing pre-eclampsia

Question 11

What is the epidemiology of eclampsia?

Answer 11

5/100k

Question 12

What is the history/ exam of eclampsia?

Answer 12

Symptoms impending eclampsia: headache, epigastric pain, visual, odema, previous examination finding of hyperreflexia and clonus.

Grand mal seizure

Question 13

What is the pathology of eclampsia?

Answer 13

Related to cerebral vasospasm, hypertensive encephalopathy, tisue oedema, or haemorrage.

Question 14

What investigations do you do for eclampsia?

Answer 14

loods: FBC, clotting, UE, LFT, G&S, consider ABG.

Urine: proteinuria?

Imaging: CT head, CXR if chest signs

Question 15

What is the management of eclampsia?

Answer 15

· AB: apply O2, maintain airway, ventilat if appropriate.

· Circulaiton: manage on left tilt, ensure IV large bore access. Pulse/BP.

· Drugs: IV MgSulph (4g load, then 1g/hr) -> (monitor urine output, RR, Reflexes).

· Recurent: Consider further MgSulph bolus. If not, consider thiopentone, diazepam, IPPV and muscle relaxants.

· Post seizure: assess chest, BP control, strict fluid management, CVP monitoring, deliver baby when more stabilised and consider ITU.

Question 16

What are the complications/ prognosis of eclampsia?

Answer 16

Cardiac arrest, death, permanent CNS damage (cortical blindness), CVA (2%), renal failure, DIC, ARDS.

Maternal mortality 1.8%, permanent morbidity 35%.

Question 17

What is chronic HTN of pregnancy?

Answer 17

HTN that is either present prior to conception or remaining after pregnancy finished.

Question 18

What is the aetiology of chronic HTN of pregnancy?

Answer 18

Essential in 90-95% (unknown cause, like normal HTN). Other are endocrine (Cushings, PHCT, CAH), renal (RAS, CKD) or vascular (CoA).

Risk factors
Increasing age, Afro Caribbean, obesity, diabetes, smoking, FHx, Pre eclampsia.

Question 19

What is the epidemiology of chronic HTN of pregnancy?

Answer 19

1-5% pregnancies.

Question 20

What is the history/ exam of chronic HTN of pregnancy?

Answer 20

Asmyptomatic, only symptoms if malignant.

BP normal in first trimester due to low PVR. Then increases.

II causes: renal bruits or radiofemoral delay in CoA.

Question 21

What is the pathology of chronic HTN of pregnancy?

Answer 21

Chronic systemic inflammation increases susceptibility to pre eclampsia. Placental pathology similar to pre eclampsia (arterial occlusive changes, excess villous syncitial knots, infarction) leads to hypoperfusion of maternal space.

Question 22

What investigations do you do for chronic HTN of pregnancy?

Answer 22

Blood: FBC, UE, LFT, urate.

Urinalysis: proteinuria, urinary catecholamines, renal artery USS.

Fetal: serial USS for growth and IUGR etc .

Question 23

What is the management of chronic HTN of pregnancy?

Answer 23

Medicaiton: convert to non teratogenic medications -> methyldopa, nifedipine, lebatalol.

ACEI ARE TERATOGENIC – NEVER USE!!!

Aspirin reduces risk of pre eclampsia or IUGR.

Monitor fetal growth, renal dopplers, serial USS, Uterine artery doppler 24/40.

Question 24

What are the complications/ prognosis of chronic HTN of pregnancy?

Answer 24

IUGR, superimposed pre-eclampsia, placental abruption, prematurity. Most morbidity relates to superimposed pre eclampsia, not HTN per se.