Hypertensive disorders of pregnancy

Question 1

What is the definition of HTN in pregnancy?

Answer 1

SBP >140mmHg, DBP >90mmHg based upon >1 measurements, at least 4h apart

Question 2

What is the definition of severe HTN in pregnancy?

Answer 2

After 2 measurements of SBP >160mmHg, DBP >110mmHg

Question 3

What is the BP threshold to initiate treatment for HTN in pregnancy?

Why? - primary outcomes and safety outcomes

Answer 3

Controversial, but studies show that treating at lower threshold of 140/90 rather than 160/110 resulted in:

• Lower incidence of primary outcomes (negative outcomes)
• No significant difference in safety outcomes (to fetus and mother)

Question 4

What are the 4 categories of HTN disorders in pregnancy

Answer 4

1. Chronic HTN
2. Gestational HTN
3. Preeclampsia HTN
4. Chronic HTN with superimposed preeclampsia

Question 5

Describe chronic HTN

Answer 5

Preexisting HTN or new onset HTN before 20 weeks gestation

Question 6

Describe gestational HTN

Answer 6

New onset of HTN after 20 weeks gestation, WITHOUT proteinuria

Question 7

Describe preeclampsia

Answer 7

New onset of HTN after 20 weeks gestation, WITH any of the following:

1. Proteinuria
2. Signs of end-organ dysfunction
3. Uteroplacental dysfunction (fetal growth restricted)

Question 8

Describe chronic HTN with superimposed preeclampsia

Answer 8

New onset proteinuria in a woman with chronic HTN but no proteinuria, before 20 weeks gestation

Question 9

What are the markers for preeclampsia?

Answer 9

1. Proteinuria

• 24h urinary protein (URP) >= 300mg
• Dipstick protein >=2+
• Urine protein to creatinine ratio (uPCR) >0.3mg/dL

2. Signs of end-organ damage

• Platelet count <100
• LFTs >2x ULN (liver)
• Doubling of SCr in absence of other renal disease
• Pulmonary edema (cardiac, lung)
• Neurological complications (severe symptoms of preeclampsia: altered mental status, new onset headache, visual disturbances, seizures)

Question 10

Preeclampsia is a complex multisystem disease, may progress rapidly to ______

Answer 10

Eclampsia
- New onset tonic-clonic, focal, multifocal seizures
- *Medical emergency (risk to both mother and fetus)

Question 11

What treatment option is used for the prevention of preeclampsia?

Recommended for?

Answer 11

Low dose Aspirin (100mg or more daily)

• recommended for high risk pts: HTN on previous pregnancy, multifetal gestation, autoimmune disease, DM, CKD, etc.
• to be started after 12 weeks, ideally before 16 weeks, and continued until delivery

Postulated MOA: improve uteroplacental blood flow by inhibiting thromboxane A2 (TXA2) that is thought to contribute to preeclampsia

Question 12

List the treatment options for HTN in pregnancy

Answer 12

1. Methyldopa
2. Labetalol
3. Nifedipine ER
4. Hydrochlorothiazide
5. Hydralazine

*Recall that ACEi and ARBs are teratogenic

Question 13

Describe the efficacy of Methyldopa for HTN in pregnancy

Answer 13

Alpha-2 adrenergic agonist

Safe in pregnancy, but not commonly used due to:

• Low potency
• Increased adverse effects (sedation, dizziness)

Question 14

Describe the efficacy of Labetalol for HTN in pregnancy

Answer 14

Alpha-1, Beta-1, Beta-2 blocker

Commonly used, preferred over other BB as it has less adverse effects on uteroplacental blood flow and fetal growth

Monitor for bronchoconstrictive effects, bradycardia

Question 15

Describe the efficacy of Nifedipine for HTN in pregnancy

Answer 15

Calcium Channel Blocker

Commonly used, safe and well studied

Monitor for pedal edema, flushing, headache

Question 16

Describe the efficacy of Hydrochlorothiazide for HTN in pregnancy

Answer 16

Thiazide diuretic

Generally 2nd, 3rd line, concerns for potential interference with normal blood volume expansion during pregnancy

Question 17

Describe the efficacy of Hydralazine for HTN in pregnancy

Answer 17

Vasodilator

Not commonly used

Adverse effects mimic symptoms associated with severe preeclampsia and imminent eclampsia (e.g., nausea, vomiting, palpitations, flushing, headache, tremor, *neurological symptoms?)