Transcript pregnancy hypertension

Mini-OSCE simulation
Hypertensive disorders in
pregnancy
Done by: Muhammad Samir Zuaiter
• What is the right way to measure blood pressure?
1. Patient should be in recumbent position (or 30 degrees
from horizontal); to avoid supine hypotension syndrome.
2. The cuff of the sphygmomanometer should be at the
level of the heart.
3. Cuff of appropriate size should be used.
4. 2 measurements of high blood pressure (6 hours apart)
are needed to confirm hypertension.
• What are the predisposing factors to Pre-eclampsia?
1.
2.
3.
4.
Primigravidity
Age <20 or >35
Genetic or familial factors
Hyperplacentosis (e.g. multiple gestations, diabetes,
hydrops fetalis).
5. Hydatidiform mole
6. Polyhydramnios, chronic hypertension, chronic renal failure.
• What is the etiology of Pre-eclampsia?
1.
2.
3.
4.
Immunologic maladaptation.
Placental ischemia.
Genetic.
Prostaglandin imbalance.
• What is the Pathophysiology of Pre-eclampsia?
1. Loss of sensitivity to vasoactive substances as
angiotensin.
2. Increase in the vasoconstrictor thromboxane and
decrease in vasodilator prostacyclin.
3. This will lead to decrease perfusion to most organs
(placenta, kidneys, liver, brain, and heart)
4. Capillary injury leads to subsequent edema.
• What are the complications of Pre-eclampisa on the mother?
Increases maternal mortality.
• What are the complications of Pre-eclampisa on the fetus?
1. Prematurity (because in severe cases we have to
terminate the pregnancy).
2. Acute and chronic utero-placental insufficiency  IUGR,
fetal distress, and still birth.
• A 19 year old primigravida is seen in the outpatient prenatal clinic for
routine visit. She is 32 weeks’ gestation. She has no complaints. She
has gained 1 kilogram since her last visit 2 weeks ago. On examination
her BP is 155/95, which is persistent. A spot urine dipstick is negative.
• What is your diagnosis?
Gestational Hypertension.
• What is your management?
Conservative outpatient management, but monitored closely to
rapidly identify pre-eclampsia.
(if severe  anti-hypertensive medications)
• A 21 year old primigravida is seen in the outpatient prenatal clinic
for a routine visit. She is 32 weeks’ gestation. On examination her
BP is 155/95 which is persistent. Her fingers appear swollen, a
spot urine dipstick shows 2+ protein.
• What is your diagnosis?
Mild pre-eclampsia.
• What are the lab abnormalities that you may see in this patient?
Hemoconcentration (elevation of: Hb, Hct, BUN, serum
creatinine, serum uric acid).
• What is your management?
Since she is more than 36 weeks’ gestation  conservative and
observation for progression to severe pre-eclampsia.
If >36 weeks’ gestation 
-Stabilization (IV hydralazine (if needed) & IV MgSO4)
-Delivery (if mother and fetus are stable, by induction of labour).
• What are the signs and symptoms of severe pre-eclampsia?
• Oligouria
• Altered consciousness, headache, blurred vision.
• Epigastric pain
• BP >160/110, Proteinuria of 5 grams or more
• Elevated liver enzymes.
• DIC
• Pulmonary edema
• Microangiopathic hemolysis
• Elevated creatinine level
• IUGR or oligohydramnios.
How do you manage severe pre-eclampsia?
1. Stabilization (by IV hydralazine & IV Mg SO4)
2. Delivery
• A 21 year old primigravida is brought to the ER after suffering
from generalized tonic-clonic seizure at 32 weeks’ gestation. She
lost control of her bowel and bladder. Her BP is 185/115 and a
spot urine dipstick shows 4+ protrein.
• What is your diagnosis?
Eclampsia.
• What is your management?
1. ABC
2. Stabilization (IV MgSO4 & IV hydralazine)
3. Delivery (C/S if mother and fetus are unstable)
• What are the complications of Eclampsia?
1.
2.
3.
4.
5.
6.
CVA
Accidental hemorrhage
DIC
Renal failure
Pulmonary edema, heart failure
Liver hemorrhage and rupture
• A 35 year old multigravida is seen in outpatient clinic for her first
prenatal visit. She is 12 weeks’ gestation with a BP of 155/95. She
has 2+ urine dipstick.
• What is your diagnosis?
Chronic hypertension
• What is your management?
1. Conservative (unless her diastolic BP >100 then we
give  methyl-dopa).
2. Follow-up
1. Serial U/S (to check for IUGR)
2. Serial BP and urine protein (to check superimposed
pre-eclampsia)
• A 31 year old primigravida is seen in outpatient clinic. She was
previously diagnosed to have hypertension. She is 30 weeks’
gestation with a BP of 155/95. She has 2+ urine dipstick.
• What is your diagnosis?
Chronic hypertension with superimposed pre-eclampsia.
• What is your management?
1. Stabilization (IV hydralazine & IV MgSO4 )
2. Delivery (C/S if mother and fetus are unstable)
• A 32 year-old multigravia is at 32 weeks’ gestation. At a routine
prenatal visit her BP was noted to be 160/105. Previous BP
readings were norrmal. Her workup revealed: elevated total
bilirubin, LDH, ALT, and AST. Her platelet count was 85,000. she
has no complaints of headache or visual changes.
• What is your diagnosis?
HELLP syndrome.
• What is your DDX?
TTP, hemolytic uremic syndrome, and HTN
• What is your management?
1. Stabilization
2. Delivery (at any gestational age)
• What complications may arise?
DIC, abruptio placenta, fetal demise, ascites, and hepatic rupture.
Management in general
1. Admit the patient for assessment.
• Assessing maternal well-being:
1. CBC (blood group, Rh)
2. Platelet count
3. Renal function test
4. Liver function test
• Assessing fetal well-being:
1. Kick chart
2. CTG
3. U/S
2. Give Betamethasone if less than 35 weeks’ gestation.
3. Monitor the condition
1. 6 hourly blood chart
2. Daily urine protein
3. Platelet count 2x/week
4. Uric acid 2x/week
5. Watch for symptoms of severe disease
4. Medications:
1. Hydralazine (S/E: flushing, headache, dizziness)
2. Labetalol
3. Nifedipine (S/E: severe headache and flushing)
This presentation is only to practice the mini-OSCE, do
NOT depend on it as your only source of information
for this topic.
The End
Good luck…
Done by: Muhammad S. Zuaiter