8. Hypertensive Disorders of Pregnancy

Question 1

Hypertensive disorders of pregnancy are classified how? (2)

Answer 1

• either pre-existing or gestational HTN.
• Pre- eclampsia and eclampsia are included in the spectrum of hypertensive disorders of pregnancy

Question 2

Define: Pre-existing hypertension (2)

Answer 2

• BP ≥140/90 prior to 20 wk GA; BP should be elevated on ≥2 occasions at least 15 minutes apart
• essential HTN is associated with an increased risk of gestational HTN, abruptio placentae, intrauterine growth restriction (IUGR), and intrauterine fetal death (IUFD)

Question 3

Define gestational HTN (1)

Answer 3

• sBP ≥140 or dBP ≥90 after 20 wk GA without proteinuria in a woman known to be normotensive before pregnancy

Question 4

Define: Preeclampsia (1)

Answer 4

pre-existing or gestational HTN with new onset proteinuria or adverse conditions (end organ dysfunction)

Question 5

Define: Eclampsia (1)

Answer 5

• the occurrence of ≥1 generalized convulsions and/or coma in the setting of preeclampsia and in the absence of other neurologic conditions

Question 6

Name: Ominous Symptoms of HTN in Pregnancy (3)

Answer 6

• RUQ pain
• headache
• visual disturbances

Question 7

Eclampsia prior to 20 wk of gestation is common or rare? (1)

Answer 7

is rare and should raise the possibility of an underlying molar pregnancy or antiphospholipid syndrome

Question 8

Name: Clinical Manifestation of Eclampsia (5)

Answer 8

• eclampsia is a clinical diagnosis
• typically tonic-clonic and lasting 60-75 s
• symptoms that may occur before the seizure include
  
  • persistent frontal or occipital headache
  • blurred vision
  • photophobia
  • right upper quadrant or epigastric pain
  • altered mental status
• in up to one third of cases, there is no proteinuria or blood pressure >140/90 mmHg prior to the seizure
• in general, women with typical eclamptic seizures who do not have focal neurologic deficits or prolonged coma do not require diagnostic evaluation including imaging

Question 9

Name MATERNAL Risk Factors for Hypertensive Disorders in Pregnancy (7)

Answer 9

• primigravida (80-90% of gestational HTN), first conception with a new partner, Past medical history PMHx or FHx of gestational HTN, or preeclampsia/eclampsia
• DM, chronic HTN, or renal insufficiency
• obesity
• antiphospholipid syndrome or inherited thrombophilia
• extremes of maternal age (<18 or >35 yr)
• previous stillbirth or intrauterine fetal death IUFD
• vascular or connective tissue disease

Question 10

Name FETAL Risk Factors for Hypertensive Disorders in Pregnancy (5)

Answer 10

• intrauterine growth restriction IUGR or oligohydramnios
• gestational trophoblastic neoplasia (GTN)
• multiple gestation
• fetal hydrops “mirror syndrome”
• abruptio placentae

Question 11

Name adverse maternal conditions that cause hypertension in pregnancy (5)

Answer 11

• HELLP (life-threatening liver disorder thought to be a type of severe pre-eclampsia)
• Cerebral hemorrhage
• Renal dysfunction: oliguria <500 mL/d
• Left ventricular failure, pulmonary edema
• Placental abruption, disseminated intravascular coagulation (DIC)

Question 12

Name symptoms of Hypertension in Pregnancy (4)

Answer 12

• Abdominal pain, N/V
• Headaches, visual problems
• Shortness of breath (SOB), chest pain
• Eclampsia: convulsions

Question 13

Name adverse fetal conditions that cause hypertension in pregnancy (4)

Answer 13

• intrauterine growth restriction (IUGR)
• Oligohydramnios
• Absent/reversed umbilical artery end diastolic flow
• Can result in:
  
  • Fetal disability and/or death

Question 14

Describe: Clinical Evaluation of mother of Hypertensive Disorders in Pregnancy (10)

Answer 14

• body weight
• central nervous system
  
  • presence and severity of headache
  • visual disturbances – blurring, scotomata
  • tremulousness, irritability,and somnolence
• hematologic: bleeding, petechiae
• hepatic:
  
  • RUQ or epigastric pain
  • severe N/V
• renal: urine output and colour
• evaluation of fetus: fetal movement
• fetal heart rate tracing – NST
• U/S for growth
• BPP
• Doppler flow studies

Question 15

Describe: Laboratory Evaluation of Hypertensive Disorders in Pregnancy (6)

Answer 15

• CBC
• PTT, INR, fibrinogen – if abnormal LFTs or bleeding
• ALT, AST
• creatinine, uric acid
• 24 h urine collection for protein or albumin:creatinine ratio
• may consider placental growth factor (PlGF) testing as an early screening test for suspected preeclampsia

Question 16

Name MATERNAL Complications of Hypertensive Disorders in Pregnancy (7)

Answer 16

• liver and renal dysfunction
• seizure - “eclampsia”
• abruptio placentae
• left ventricular failure/pulmonary edema
• DIC (release of placental thromboplastin consumptive coagulopathy)
• HELLP syndrome
• hemorrhagic stroke (50% of deaths)

Question 17

Name FETAL Complications of Hypertensive Disorders in Pregnancy (4)

Answer 17

2° to placental insufficiency

• intrauterine growth restriction (IUGR)
• prematurity
• abruptio placenta
• intrauterine fetal death (IUFD)

Question 18

For non-severe HTN (149-159/90-105), target what BP? (2)

Answer 18

• without comorbidities: 130-155/80-105
• with comorbidities: <140/90

Question 19

For both pre-existing and gestational HTN, name medication to manage HTN (3)

Answer 19

• labetalol 100-400 mg PO bid-tid
• nifedipine XL preparation 20-60 mg PO od
• α-methyldopa 250-500 mg PO bid-qid

Question 20

For severe HTN (BP>160/110), how to treat? (2)

Answer 20

• labetalol 20 mg IV then 20-80 mg IV q30min (max 300 mg) (then switch to oral)
• nifedipine 5-10 mg capsule q30min
  
  • hydralazine 5 mg IV, repeat 5-10 mg IV q30min or 0.5 to 10 mg/h IV, to a maximum of 20 mg IV (or 30 mg IM)

Question 21

Describe the management of preeclampsia if stable and no adverse factors?

Answer 21

• if stable and no adverse factors (GA 24-33+6 wk), expectant management, ± delivery as approaching 34-36 wk (must weigh risks of fetal prematurity vs. risks of developing severe preeclampsia/eclampsia)
• antenatal corticosteroids should be considered if GA ≤ 34 wk

Question 22

Describe the management of preeclampsia if >37wk (1)

Answer 22

if >37 wk, immediate delivery is recommended

Question 23

Describe the management of severe preeclampsia (1)

Answer 23

for severe preeclampsia, stabilize and deliver, regardless of GA

Question 24

Describe monitoring of severe preeclampsia during labour. (4)

Answer 24

increase maternal monitoring:

• hourly input and output
• urine dip q12h
• hourly neurological vitals
• increase fetal monitoring (continuous FHR monitoring)

Question 25

Describe antihypertensive therapy of preeclampsia (2)

Answer 25

* labetalol 20 mg IV, then 20-80 mg IV q30min (max 300 mg) (then switch to oral) * nifedipine 5-10 mg capsule q30min * hydralazine 5 mg IV, repeat 5-10 mg IV q30min or 0.5-10 mg/h IV, to a maximum of 20 mg IV (or 30 mg IM)

Question 26

For preeclampsia prevention among increased risk women, what is recommended? (1)

Answer 26

low-dose ASA (75-100 mg/d) is recommended until delivery.

Question 27

\_\_\_\_ Doppler velocimetry should be part of the antenatal fetal surveillance in preeclampsia.

Answer 27

**Umbilical artery Doppler velocimetry** should be part of the antenatal fetal surveillance in preeclampsia.

Question 28

Initial antihypertensive therapy for severe HTN (sBP \>160 or dBP ≥110) should be with what? (3)

Answer 28

* labetalol * nifedipine * hydralazine.

Question 29

Initial antihypertensive therapy for non-severe HTN (BP 140-159/90-109 mmHg) should be with what? (3)

Answer 29

* methyldopa * β-blockers * calcium channel blockers.

Question 30

For fetal lung maturation, what should be considered for all women with preeclampsia before 34 wk gestation? (1)

Answer 30

Antenatal corticosteroids

Question 31

In a planned vaginal delivery with an unfavourable cervix, what should be used? (1)

Answer 31

cervical ripening should be used.

Question 32

\_\_\_ should be used as part of the management of HTN during the third stage of labour, particularly in the presence of thrombocytopenia or coagulopathy.

Answer 32

Oxytocin 5 units IV or 10 units IM

Question 33

\_\_\_ is the recommended first-line treatment for eclampsia.

Answer 33

**Magnesium sulfate** is the recommended first-line treatment for eclampsia.

Question 34

\_\_\_ is the recommended eclampsia prophylaxis in severe preeclampsia.

Answer 34

**Magnesium sulfate** is the recommended eclampsia prophylaxis in severe preeclampsia.

Question 35

Name: Preeclampsia Investigations (6)

Answer 35

* CBC * AST, ALT * INR and aPTT (if abn LFTs or bleeding) * Cr * Urine (24 h protein collection or albumin/ creatinine ratio) * Uric acid

Question 36

Describe seizure prevent in preeclampsia (6)

Answer 36

* magnesium sulfate: 4 g IV loading dose, followed by 1g/h * postpartum management * risk of seizure highest in first 24 h postpartum – continue MgSO₄ for 12-24 h after delivery * vitals q1h * consider HELLP syndrome * most return to normotensive BP within 2 wk

Question 37

Describe HELLP Syndrome (3)

Answer 37

* **H**emolysis * **E**levated **L**iver Enzymes * **L**ow Platelets

Question 38

Describe: Management of Eclampsia (8)

Answer 38

* **ABCs** * roll patient into **left lateral decubitus position** LLDP * **supplemental O₂** via face mask to treat hypoxemia due to hypoventilation during convulsive episode * **aggressive antihypertensive therapy** for sustained dBP ≥105 mmHg or sBP ≥160 mmHg with **hydralazine** or **labetalol** * prevention of recurrent convulsions: to prevent further seizures and the possible complications of repeated seizure activity (e.g. rhabdomyolysis, metabolic acidosis, aspiration pneumonitis, etc.) * **MgSO4** is now the drug of choice * the definitive treatment of eclampsia is **DELIVERY**, irrespective of gestational age, to reduce the risk of maternal morbidity and mortality from complications of the disease * mode of delivery is dependent on clinical situation and fetal-maternal condition