What is the BP definition in HTN in pregnancy?
Systolic BP > 140
Diastolic BP > 90
ASA 81-162mg
Given before 16 weeks gestation
Until 36 weeks gestation
What is the target BP in the management of HTN in pregnancy?
135-140/85-90
Who should receive Mg SO4?
2. Adverse maternal conditions
3. Eclampsia
True or False: uric acid testing is not routinely recommended
True! Although associated with increased placental dysfunction, its usefulness in practice is unclear.
Differentiate between:
1. Gestational hypertension
2. Pre-existing (chronic) hypertension
3. Pre-eclampsia
Gestational hypertension: HTN that starts after 20 weeks gestation
Pre-existing HTN: Develops before pregnancy or before 20 weeks gestation
Pre-eclampsia: G HTN plus proteinuria, and/or 1+ adverse conditions
28 yo G2P1 seeing you in your office with a positive pregnancy test. LMP was 9 weeks ago.
Name 3 high risk, and 3 low/moderate risk factors potentially obtained on history that increase the risk of pre-eclampsia in this pregnancy
1. High: prior pre-eclampsia, obesity (pre-pregnancy BMI>30), chronic HTN, pre-gestational DM, chronic kidney disease, SLE/APA, IVF/ICSI
2. Low/Moderate: prior history of placental abruption, prior stillbirth, prior IUGR, maternal age >40, twins
Name 3 1st line drugs in the management of BP in pregnancy and their starting and maximum doses
1. Labetalol 100mg TID, to 400mg TID
2. Adalat XL 30mg OD, to 60mg BID
3. Methyldopa 250mg TID to 750mg TID
What is the loading and maintenance dose of MgSO4?
4mg IV loading, then 1g/hour
or
5g IM into EACH buttock, then 5gIM in ONE buttock per 4 hours
Until 24 hours after birth (or seizure)
Who should be screened at antenatal visits for proteinuria? Choose none, one, or multiple answers.
1. All women
2. Women with HTN
3. Women for risk factors for pre-eclampsia
4. Only at the first visit, to obtain a baseline
5. Only women with kidney disease
2, and 3.
Low-risk normotensive women do not need to be screened for proteinuria
Name 6 Adverse Conditions (Organs affected and the parameters)
1. CNS (severe HA, visual symptoms)
2. Cardioresp: chest pain/dyspnea, O2 Sat <97%
3. Hematalogic Low platelets
4. Renal: Elevated Cr
5. Liver: elevated AST or ALT, RUQ pain
6. Fetal: uteroplacental dysfunction (AEDF, oligo, IUGR)
Besides ASA, name 2 other modifiable prevention measures that have evidence of efficacy (to prevent pre-eclampsia)
1. Calcium supplementation
2. Exercise
For each 1st line drug, name 1-2 contraindications or precautions
1. Labetalol: contraindicated in poorly-controlled asthma, caution with hypoglycemia unawareness in DM, may cause neonatal bradycardia, hypoglycemia
2. Adalat XL: CI w aortic stenosis
3. Methyldopa: may cause maternal depression
What are the signs of Mg SO4 toxicity and what is the antidote?
Signs: flushed skin, metallic taste in mouth, sweating, nausea and vomiting, chest heaviness, palpitations, Low BP
Antidote: Calcium gluconate 10% (10mL in 100mL of NS IV over 3 min)
True or False:
Women with BMI>30 should be offered ASA 81-162mg in order to prevent pre-eclampsia
True
Name 4 Medical causes of possible causes of HTN in pregnancy that are NOT gestational-related (secondary HTN)
1. OSA
2. Renovascular disease (renal stenosis)
3. Primary aldosteronism
4. Pheo
5. thyroid issues
6. Cushing's
7. Coarctation of the aorta
8. Drugs
True or False. A SIPS screen for protein markers should be obtained to risk-stratify a woman with risk factors for pre-eclampsia (and not just for aneuploidy screening)
False. Unproven benefit and high enough sensitivity and specificity.
What is severe HTN? What is the risk?
> 160/110
Risk of stroke
Timing of delivery:
1. Gestational HTN
2. Pre-eclampsia
1. Can be offered at 38 to 39+6WGA, should be advised from 40WGA
2. Discussed at 34-35+6WGA (increased neonatal risk), and considered at 36-36+6WGA
True or False: For women with chronic HTN, the diagnosis of superimposed pre-eclampsia can be made if the systolic BP rises >20mmHg
False. The diagnosis of pre-eclampsia is made on the basis of new proteinuria, or new adverse features.
Give 3 definitions for proteinuria
1. Spot urine PCR >30mg/mmol
2. Spot ACR >8mg/mmol
3. 24 hour urine protein >0.3g
Name 3 complications of ASA
1. antepartum bleeding
2. postpartum hemorrhage
3. 0.06% absolute increased risk of neonatal intracranial hemorrhage
Name 4 agents and their dose that can be used in severe HTN (to bring down the BP quickly)
1. Labetalol
a. 200mg po (q60min),
b. 10-20mg IV (then 20-40 after 30min, then 40-80mg after another 30min, then repeat q30min),
c. 0.5-2mg/min infusion
2. Adalat bite and swallow 5-10mg
3. Methyldopa 1000mg
4. Hydralazine 5mg
What were the differences in neonatal outcomes in the PHOENIX versus HYPITAT II trials and why was there this difference potentially?
Delivery was not associated with increased neonatal respiratory morbidity in the PHOENIX trial, but was in HYPITAT II.
60% of women in PHOENIX received antenatal corticosteroids, whereas only 1% of the women in HYPITAT II did.
The best models to predict pre-eclampsia use 4 factors, and this seems to have the highest sensitivity and specificity. Name these 4 factors
1. clinical risk factors
2. BP
3. Uterine artery pulsatility
4. Biochemical markers (PLGF: placental growth factor)