HT in pregnancy

Question 1

HT in pregnancy can be split into how many categories?

Answer 1

3
Pre-existing
Gestational/pregnancy induced
Pre-eclampsia

Question 2

What is HT defined as in pregnancy?

Answer 2

BP>140/90 on 2 occasions 
OR 
160/110 on 1 occasion
OR 
>30/15 mmHg compared to 1st trimester BP

Question 3

What is the likely diagnosis if HT is present in early pregnancy and why?

Answer 3

Pre-existing HT

Because these diseases are usually of 2nd half of pregnancy if that is the cause

Question 4

What does PE HT increase risk of?

Answer 4

Pre-eclampsia
Intra-uterine growth
Restriction
Abruption

Question 5

What HT drugs are Teratogenic and should be stopped?

Answer 5

ACEis
ARBs
Diuretics

Question 6

First line HT therapy during pregnancy?

Answer 6

Oral labetalol

Question 7

What is orla labetalol?

Answer 7

Joint alpha and beta blocker

Question 8

2nd line agents for HT in pregnancy?

Answer 8

Methyldopa

Nifedipine

Question 9

Women who are at mod-high risk of -re-eclampsia should be given what and for how long/when?

Answer 9

Aspirin from 12 weeks until birth if moderate or high risk

Question 10

Are HT drugs safe for breast feeding?

Answer 10

Yes- well some are
ACEi, B blockers and nifedipine are all safe

Methyldopa should be avoided

Question 11

What drug should be avoided in Breast feeding and why?

Answer 11

Methyldopa

Risk of depression

Question 12

Definition of gestational HT?

Answer 12

BP> 140/90mmHg after 20 weeks gestation in previously normotensive woman

Question 13

When does gestational HT normally resolve?

Answer 13

6 weeks after delivery

Question 14

Are there any other features accompanying gestational HT?

Answer 14

NO features of pre-eclampsia (Proteinuria)

although 15% do progress to pre-eclampsia

Question 15

Rate of gestational HT recurrence?

Answer 15

High

Question 16

Blood tests for gestational HT?

Answer 16

-FBC 
U&Es 
-Serum creatinine 
-Calcium 
-Liver biochem
-LFTs

Question 17

What should be tested for in urine in gestational HT?

Answer 17

Urine tests for protein to check for pre-eclampsia

Question 18

Mod gestational HT treated with?

Answer 18

Oral labetalol

Question 19

When would a woman need admitted to hospital in gestational HT?

Answer 19

BP>160/110

Question 20

What is pre-eclampsia?

Answer 20

Condition seen after 20 weeks of pregnancy characterized by pregnancy induced HT and proteinuria and oedema

Question 21

Pathogenesis of pre-eclampsia?

Answer 21

• Thought to be multifactorial (genetic&environment)
• Stage 1: abnormal placental perfusion
• Stage 2: maternal syndrome where mother responds to decreased placental perfusion and this = systemic disease

Question 22

Why does abnormal placental perfusion happen in stage 1 of pre-eclampsia?

Answer 22

Abnormal trophoblastic invasion

Question 23

Stage 2 causes what of pre-eclampsia?

Answer 23

Systemic disease

Question 24

RFs for developing pre-eclampsia?

Answer 24

Age >40 
BMI> 30 
Fam Hx 
Multiple pregnancy 
Primiparity 
Previous Pre-eclamp
Long birth interval 
Molar pregnancy 
Pre-existing HT 
Renal disease 
Diabetes 
APS 
RA 
Sickle cell disease

Question 25

Presentation of pre-eclampsia? (symptoms)

Answer 25

- Headache - visual disturbance - Epigastric pain/RUQ pain - N&V - Rapidly progressive oedema

Question 26

Signs of pre-eclampsia?

Answer 26

``` HT Proteinuria Oedema Abdo tenderness Disorientation SGA Itra0uterine fetal death Hyper-reflexia/involuntary movements/clonus ```

Question 27

Investigations for pre-eclampsia?

Answer 27

``` U&Es Serum urate LFTs FBCs Coag screen Urine creatinine ration Cardiotocography US Bilateral uterine notching on doppler US= rf for onset of pre-eclamp ```

Question 28

What is an investigation finding that is a RF for onset of pre-eclampsia?

Answer 28

Bilateral uterine notching on doppler US

Question 29

Management of pre-eclampsia when BP=140/90-159-109mmHg?

Answer 29

Admit if clinical concerns of well being Offer drugs if BP remains above 140/90 (labetalol) Aim for BP <135/85 BP monitor every 48 hours Measure FBCs, LFT, Renal function 2 times week Fetal heart auscultation US at diagnosis and then every 2 weeks

Question 30

Treatment of pre-eclampsia where BP is >160/110?

Answer 30

Admit to hospital Drugs for all women BP 135/85 or less = target Monitor BP every 15-35 mins until below 160/110 Measure FBCs, liver function, renal function 3 times a week Fetal heart auscultation US at diagnosis then every 2 weeks

Question 31

Only cure for pre-eclampsia?

Answer 31

Birth

Question 32

When to deliver baby in a mother with pre-eclampsia?

Answer 32

Most women delivered within 2 weeks of diagnosis

Question 33

Indications for birth include?

Answer 33

``` Term gestation Inability to control BP Rapidly deteriorating biochem/haem Eclampsia Fetal compromise on US or CTG ```

Question 34

Crises in pre-eclmapsia?

Answer 34

``` Eclampsia HELLP syndrome Pulmonary syndrome Placental abruption Cerebral haemorrhage Cortical blindness DIC Acute renal failure Hepatic rupture ```

Question 35

What is eclampsia?

Answer 35

Tonic clonic seizures occuring with feature of pre-eclampsia

Question 36

Management of eclampsia?

Answer 36

Control BP with IV labetalol or IV hydralazine Stop/prevent seizures with magnesium sulphate Fluid balance (PO= big cause of death therefore run ptnt dry) Delivery aim for vaginal if possible

Question 37

What is HELLP Syndrome?

Answer 37

Haemolysis Elevated liver enzymes Low platelets

Question 38

Why is there haemolysis in HELLP syndorme?

Answer 38

Endothelial damage in pre-eclampsia results in formation of tiny thrombi which damage red cells as they circulate

Question 39

Clinical features of HELLP?

Answer 39

Patients complain of epigastric/RUQ pain, N&V, jaundice

Question 40

Treatment of HELLP?

Answer 40

Similar to pre-eclampsia | may also be given blood transfusions to treat anaemia and low platelets

Question 41

If symptoms are severe in HELLP what is advised?

Answer 41

Prompt delivery in patients who are beyond 34 weeks gestation

Question 42

Secondary prevention of Pre-eclampsia?

Answer 42

Low dose aspirin at 12 weeks gestation to reduce risk

Question 43

Why would secondary prevention be done>

Answer 43

Done in women with history of pre-eclampsia or risk of factors for pre-eclampsia