Hypertensive disorders in pregnancy Done by: Muhammad Samir Zuaiter Mini-OSCE simulation

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.Primigravidity 2.Age 35 3.Genetic or familial factors 4.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? What is the Pathophysiology of Pre-eclampsia? 1.Immunologic maladaptation. 2.Placental ischemia. 3.Genetic. 4.Prostaglandin imbalance. 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? What are the complications of Pre-eclampisa on the fetus? Increases maternal mortality. 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? What is your management? Gestational Hypertension. 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? What are the lab abnormalities that you may see in this patient? What is your management? Mild pre-eclampsia. Hemoconcentration (elevation of: Hb, Hct, BUN, serum creatinine, serum uric acid). 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? How do you manage 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. 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? What is your management? Eclampsia. 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.CVA 2.Accidental hemorrhage 3.DIC 4.Renal failure 5.Pulmonary edema, heart failure 6.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? What is your management? Chronic hypertension 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? What is your management? Chronic hypertension with superimposed pre-eclampsia. 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? What is your DDX? What is your management? What complications may arise? HELLP syndrome. TTP, hemolytic uremic syndrome, and HTN 1.Stabilization 2.Delivery (at any gestational age) DIC, abruptio placenta, fetal demise, ascites, and hepatic rupture.

Management in general 1.Admit the patient for assessment. Assessing maternal well-being: Assessing fetal well-being: 1.CBC (blood group, Rh) 2.Platelet count 3.Renal function test 4.Liver function test 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)

The End Good luck… Done by: Muhammad S. Zuaiter This presentation is only to practice the mini-OSCE, do NOT depend on it as your only source of information for this topic.