Hypertension in Pregnancy

Question 1

What % of primigravid women are affected by mild pre eclampsia?

Answer 1

10%

Question 2

How does the plasma volume change in pregnancy?

Answer 2

increases 45%

Question 3

How does the cardiac output change in pregnancy?

Answer 3

increases 30-50%

Question 4

How does the stroke volume change in pregnancy?

Answer 4

increases 25%

Question 5

How does the heart rate change in pregnancy?

Answer 5

increases 15-25%

Question 6

How does the peripheral vascular resistance change in pregnancy?

Answer 6

decreases 15-20%

Question 7

How is hypertension in pregnancy defined?

Answer 7

> /= 140/90 on 2 occasions OR
160/110 once OR
30/15 compared to first trimester reading

Question 8

If a woman has hypertension in the first half of pregnancy, what is it likely to be?

Answer 8

undiagnosed hypertension

Question 9

What are the risks of pregnancy for those with pre existing hypertension?

Answer 9

2x increase in PET
intrauterine growth restriction
abruption

Question 10

What is pregnancy induced hypertension?

Answer 10

second half of pregnancy

resolved within 6 weeks of delivery

Question 11

In PIH - what % progresses to pre eclampsia?

Answer 11

15%

Question 12

What are the symptoms/signs of pre eclampsia?

Answer 12

hypertension
proteinuria (>/= 0.3g/l)
oedema

Question 13

Can PET be asymptomatic?

Answer 13

YES

Question 14

What is early PET?

Answer 14

<34 weeks

higher risk of maternal and foetal complications

Question 15

What is late PET?

Answer 15

> 34 weeks
most common
more likely to lead to eclampsia and maternal death

Question 16

What is seen in the placenta in early PET?

Answer 16

extensive villious and vascular lesions

Question 17

What is seen in the placenta in late PET?

Answer 17

minimal placental lesions

Question 18

How is the placenta affected in PET, and why?

Answer 18

abnormal placental perfusion leads to ischaemia -> endothelial dysfunction
endothelial activation leads to increased capiliary permeability, expression of CAM, prothrombic fators, platelet aggregation and vasoconstriction

Question 19

What puts you at a higher risk of PET?

Answer 19

x3 risk if mother or sister had it

Question 20

What is HELLP syndrome?

Answer 20

PET induced liver disease

Question 21

What are the features of HELLP syndrome?

Answer 21

HELLP: haemolysis, elevated liver enzymes, low platelets

Epigastric/RUQ pain
high morbidity/mortality

Question 22

What is PET induced placental disease?

Answer 22

fetal growth restriction
placental abruption
intrauterine death

Question 23

What are the symptoms of hypertension?

Answer 23

headache
visual disturbance
epigastric/RUQ pain
rapidly progressing oedema
nausea/vomiting
visual disturbance

Question 24

What investigations should you do for a mother with hypertension?

Answer 24

U+Es, FBC, coagulation scree, LFTs, serum urate, protein creatinine ratio, CTG
USS foetus

Question 25

How do you manage a mother with hypertension?

Answer 25

hypertension <20 weeks - look for secondary cause treat hypertension antenatal screening - BP, urine, MUAD (maternal uterine artery doppler) at 20-24 weeks time the delivery

Question 26

What are the risk factors that cause hypertension?

Answer 26

``` age >40 BMI >30 FH - 40% if sister, 25% if mother first pregnancy - 2-3x twins - 2x previous PE - 7x birth interval >10 yrs x2 molar pregnancy/triploidy pre existing renal disease/hypertension diabetes connective tissue diseases thrombophillia ```

Question 27

What is the action of aspirin?

Answer 27

inhibits COX2 which prevents TXA2 synthesis

Question 28

When should low dose aspirin be commenced?

Answer 28

before 16 weeks

Question 29

How can LDA help PET?

Answer 29

causes a 15% reduction in it

Question 30

If you have 2 of these moderate risk factors you should take LDA 75mg/day from 12weeks-> birth. What are they?

Answer 30

``` first pregnancy age >40 pregnancy interval >10years BMI >/= 35 FH of PET multiple pregnancy ```

Question 31

If you have 1 of these high risk factors you should take LDA 75mg/day from 12 weeks-> birth. What are they?

Answer 31

``` hypertensive disease in previous pregnancy chronic kidney disease autoimmune disease T1DM or T2DM chronic hypertension ```

Question 32

When should you admit someone to hospital with hypertension?

Answer 32

if BP >/= 170/110 OR >/= 140/90 with ++ proteinuria and significant symptoms/signs of foetal comprimise

Question 33

What does MAP >/= 150 put you at risk of?

Answer 33

cerebral haemorrhage

Question 34

What should a pregnant womans BP aims be?

Answer 34

140-150/90-100

Question 35

What are 1st line antihypertensives used in pregnancy?

Answer 35

Methyl dopa - alpha agonist Labetalol - alpha and beta agonist Nifedipine - ca channel blocker

Question 36

What are 2nd line antihypertensives used in pregnancy?

Answer 36

Hydralazine - vasodilator | Doxazocin - alpha antagonist

Question 37

What antihypertensive drug is not safe for breastfeeding?

Answer 37

Doxazocin + Methyl dopa

Question 38

When is Labetalol contraindicated?

Answer 38

asthma

Question 39

When should you aim to deliver a baby after a PET diagnosis?

Answer 39

within 2 weeks

Question 40

What is Eclampsia?

Answer 40

tonic clonic seizure occuring with features of PET - many have seizures before the onset of proteinuria/hypertension

Question 41

When does eclampsia most commonly occur?

Answer 41

post partum - 44% | antepartum - 38%

Question 42

Who is most likely to have eclampsia?

Answer 42

teenagers

Question 43

How do you treat eclampsia?

Answer 43

control BP - IV labetalol or hydralazine seizure treatment - magnesium sulfate IV 4g, if persistent diazepam 10mg IV fluid balance

Question 44

How should labour be managed in eclampsia?

Answer 44

aim for vaginal birth epidural and control BP avoid ergometrine continous foetal monitoring