HTN in Pregnancy

Question 1

A G1PO presents to antenatal clinic at 32 weeks GA with BP 180/110. Approach to diagnosis and management.

Answer 1

Impression
Salient feature is elevated severe HTN (>170/110) in 3rd trimester pregnancy. Concerned about pre-eclampsia. Would want to rule out other potential causes of the elevated BP including;
- gestational HTN (HTN onset after 20wks gestation)
- essential/primary
- secondary causes: endocrine (pheo, thyroid), OSA

Goals

• thorough Hx/Ex/Ix to determine risk factors, underlying aetiology
• counselling and patient education
• rule out red flags including HELLP syndrome and Eclampsia.
• appropriate intervention and management

Question 2

HTN in Pregnancy - History

Answer 2

History

• pre-eclampsia sx: visual change, headache, epigastric pain, dyspnoea, oedema, proteinuria, IUGR, any seizures?
• PC: chronic HTN (if known, when diagnosed), results from previous antenatal visits
• RISK: age, thrombophiliia, nulliparity, previous pre-eclampsia, hydatidiform moles in prev pregnancies, obesity
• O&G Hx: GTPAL, yellow book, scans results, Rh status if known, EDD and current GA
• PMHx, PSHx
• Meds/ allergies
• Psychosocial Hx

Question 3

HTN in Pregnancy - Examination

Answer 3

Examination

• general appearance + vital signs
• antenatal assessment, recheck BP (conduct 3 times across consult), FHR doppler
• Neurological exam: clonus, hyperreflexia
• Peripheral oedema, cardiorespiratory examination, abdo examination (epigastric tenderness)
• CTG

Question 4

HTN in Pregnancy - Investigations

Answer 4

Investigations

• Bedside: uACR, urinalysis
• Bloods: FBC, haemolysis screen, UEC, LFT
• Imaging: abdo ultrasound: FHR, AFI, umbilical artery dopplers, CTG

Question 5

HTN in Pregnancy - Management

Answer 5

Management
Need to emergently manage mothers BP to lower, then subsequent mx depends on outcomes of investigation on fetal condition/complications of HTN/pre-eclampsia/eclampsia.

HTN mx:

• admission and O&G referral for review and input
• antihypertensives (hydralazine, labetalol, methyldopa, nifedipine) - target BP 130-150
• IV fluids, as contracted plasma volume due to pre-eclampsia and extravasation of fluid.

Supportive:

• VTE prophylaxis
• CTG monitoring
• admission
• referral to tertiary centre if appropriate

in Eclampsia/Pre-eclampsia, definitive mx is delivery and removal of placenta.

Would consult with O&G regarding fetal compromise, IUGR/placental insufficiency for decisions regarding early delivery etc, balance risks to mother and baby for continuing pregnancy vs delivery.
- put in place additional management

ongoing
- CVD risk management and screening, LDA in subsequent pregnancies before 16wks gestation to reduce risk of subsequent pre-eclampsia