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OBSTETRICS AND GYNAECOLOGY COPY > HYPERTENSION IN PREGNANCY > Flashcards

HYPERTENSION IN PREGNANCY Flashcards

1
Q

What are the three categories of hypertension in a pregnant woman?

A

Pre-existing or chronic hypertension

Gestational or pregnancy induced hypertension

Pre-eclampsia or proteinuric hypertension

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2
Q

What is the definition of pregnancy induced hypertension?

A

Hypertension presenting after 20 weeks of pregnancy with no previous history of hypertension and in the absence of proteinuria.

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3
Q

What is the definition of pre-eclampsia?

A

New hypertension developing after 20 weeks of pregnancy with significant proteinuria.

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4
Q

What is considered mild hypertension in the context of pregnancy?

A

Less than 149/99 mmHg

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5
Q

What is considered moderate hypertension in the context of pregnancy?

A

Between 150/100 mmHg and 159/109 mmHg

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6
Q

What is considered severe hypertension in the context of pregnancy?

A

Over 160/110 mmHg

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7
Q

What are the risk factors for developing pre-eclampsia?

A

High risk:

Previous history of pre-eclampsia

Chronic kidney disease

Diabetes (I + II)

SLE

Antiphospholipid syndrome

Moderate risk:

Primips

Age over 40

BMI over 35kg

Family Hx of pre-eclampsia (especially sister)

Multiple pregnancy

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8
Q

Hypertension in pregnancy is for the most part asymptomatic, however, what symptoms must you ask about when taking a history from a hypertensive pregnant woman that might indicate pre-eclampsia?

A

Headache

Visual disturbances - typically flashing lights (sign of papilloedema)

Right upper quadrant pain - oedema in liver capsule

Vomiting

Swelling of hands, feet or face.

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9
Q

Why is it important to ask about a previous use of the contraceptive pill when taking the history from a hypertensive pregnant woman?

A

A history of hypertension when taking the oral contraceptive pill indicates a susceptibility to high blood pressure in pregnancy.

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10
Q

On examination of a patient with pregnancy induced hypertension or pre-eclampsia, what might you expect to find?

A

Raised BP

Facial oedema

Papilloedema

Brisk reflexes

Clonus

Liver tenderness

Small uterus for dates

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11
Q

What investigations would you do in a pregnant patient with hypertension?

A

Urine dipstick

MSU urinalysis - protein creatinine ratio

24 hour urine collection

FBC

U&Es

LFTs

Clotting

USS - fetal growth can be affected

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12
Q

What would the urine dipstick of a patient with pre-eclampsia reveal?

A

More than 2+ protein

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13
Q

What would urinalysis of a patient with pre-eclampsia reveal?

A

A protein creatinine ratio of more than 30

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14
Q

What amount of protein in the urine over 24 hours would be considered significant for pre-eclampsia?

A

0.3g

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15
Q

How would the FBC of a woman with pregnancy induced hypertension be different from the FBC of a woman with pre-eclampsia?

A

PIH:
Normal

PET:
Low platelet
High haematocrit

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16
Q

How would the U&Es of a woman with pregnancy induced hypertension be different from the U&Es of a woman with pre-eclampsia?

A

PIH:
Normal (or at least no change from booking screen)

PET:
High creatinine

17
Q

How would the LFTs of a woman with pregnancy induced hypertension be different from the LFTs of a woman with pre-eclampsia?

A

PIH:
Normal

PET:
High ALT and AST

18
Q

How would the clotting screen of a woman with pregnancy induced hypertension be different from the clotting screen of a woman with pre-eclampsia?

A

PIH:
Normal

PET:
Deranged

19
Q

What is HELLP syndrome?

A

Haemolysis Elevated Liver enzymes and Low Platelets

It is a severe form of pre-eclampsia which is named after its features.

20
Q

How do we manage pregnant patients with pre-existing essential hypertension?

A

Aim to keep BP below 150/100 mmHg, unless they have end organ damage (renal or retinal) in which case aim to keep below 140/90 mmHg, using antihypertensives.

If using ACE inhibitors or angiotensin receptor antagonists, these must be stopped and replaced with another. First line is labetalol.

Low dose aspirin (75mg) daily from 12 weeks gestation until delivery has been shown to reduce risk of developing pre-eclampsia.

21
Q

How do we manage pregnant patients with pregnancy induced hypertension?

A

Aim to keep BP below 150/100 mmHg, unless they have end organ damage (renal or retinal) in which case aim to keep below 140/90 mmHg, using antihypertensives. First line is labetalol.

Low dose aspirin (75mg) daily from 12 weeks gestation until delivery has been shown to reduce risk of developing pre-eclampsia.

Early delivery before 37 weeks is not usually indicated but if there are signs of fetal compromise should be considered and where possible in this scenario a course of steroids should be administered to aid fetal lung maturity.

22
Q

How do we manage patients with pre-eclampsia?

A

Aim to keep BP below 150/100 mmHg. Those with severe (above 160/110 mmHg) if not responsive to first-line therapy may require urgent IV anti-hypertensives (eg hydralazine).

Low dose aspirin (75mg) daily from 12 weeks gestation until delivery

Where the mean arterial pressure remains above 125 mmHg and the patient is experiencing symptoms, there is a risk of eclampsia and prophylactic IV magnesium sulphate should be considered.

Limit fluid intake

23
Q

What are the anti-hypertensives that should definitely not be used in pregnancy?

A

ACE inhibitors

Angiotensin II receptor antagonists

24
Q

What is the first line medication for treating hypertension in pregnancy? Include dose.

A

Labetalol - 100 mg BD

25
Q

What class of drug is labetalol?

A

Alpha and beta blocker

26
Q

In which pregnant patients would labetalol be contraindicated to treat hypertension?

A

Asthmatics

27
Q

If labetalol is contraindicated or hypertension in pregnancy is not responding to the medication, what are the other antihypertensives that can be used in pregnancy? Include dose.

A

Methyldopa - 250 mg BD/TDS

Nifedipine (modified-release preparation) - dose dependent on brand

28
Q

What are the side effects of nifedipine?

A

Headaches

Weight gain

29
Q

If prescribing methyldopa for a pregnant woman with hypertension, what must you tell her regarding her prescription?

A

She must stop methyldopa within 2 days of delivery and be swapped to another agent as methyldopa increases risk of post-natal depression.

30
Q

What class of drug is nifedipine?

A

Calcium channel blocker

31
Q

What class of drug is methyldopa?

A

Alpha agonist which prevents vasoconstriction

32
Q

What is eclampsia?

A

Seizures that occur in pregnancy on a background of pre-eclampsia.

33
Q

What is the incidence of eclampsia?

A

1 in 2000

34
Q

What percentage of patients who suffer eclampsia have there seizures postnatally?

A

40% (normally occur within 48 hours of delivery)

35
Q

What is the differential diagnosis of seizures within pregnancy?

A

Epilepsy

Meningitis

Cerebral thrombosis

Intracerebral bleed

Intracerebral tumour

Seizures presenting for the first time in pregnancy should always be assumed to be eclamptic until proven otherwise.

36
Q

How do you manage a patient with eclampsia?

A

ABCDE approach

MgSO4 - 4 gram IV bolus over 5 minutes, a further dose of 2–4 g given over 5 minutes if the woman is having recurrent seizures

MgSO4 - 1 gram/hour for 24 hours after last seizure

Treat hypertension using IV antihypertensives

Consider delivery based on response

37
Q

If using hydralazine IV as an antihypertensive in a pregnant woman, what must you give the patient before administering the drug?

A

Bolus of fluid as can cause rapid hypotension.

38
Q

Do we give prophylactic treatment for pre-eclampsia?

A

Yes. Women with 2 or more moderate risk factors or any high risk factors should be given prophylactic aspirin 75 mg.

Moderate risk factors:

First pregnancy

BMI > 35 kg/m2

Age over 40

Family history of first degree relative with pre-eclampsia (Mother or sister)

Multiple pregnancy (e.g. twins)

Pregnancy interval of more than 10 years

Severe risk factors:

Hypertensive disease during previous pregnancy

Chronic kidney disease

Autoimmune disease such as systemic lupus
erythematosis or antiphospholipid syndrome

Type 1 or type 2 diabetes

OBSTETRICS AND GYNAECOLOGY COPY (34 decks)

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