1. Case Discussion HTN Disorders in Pregnancy Module 1 Priscilla Auguston, MD Continue

2.  Differentiate between Gestational HTN and Pre-eclampsia using the current ACOG guidelines (November 2013)  Recognize the risk factors, and signs and symptoms of HTN disorders in pregnancy  Identify the management of HTN disorders in pregnancy in the outpatient setting. Objectives

3. Patient is a 28 YO G1P0 African American female presents for routine prenatal visit at 36 0/7wks. You have been seeing her since her first trimester. she has had no complications along the way. She weighs 220 lbs, smokes 4-5 cigarettes a day and has gained 25 lbs this pregnancy. She has no history of HTN and no renal disease. Today her BP is 140/85 mmHg. Her previous blood pressure readings have been in the normal range. What are some of her risk factors for preeclampsia? Case of S.H. ANSWER

4.  Nulliparity  Family history of preeclampsia  Obesity  Multifetal gestation  Black women have as much as twice the relative risk of whites of developing preeclampsia  Age: teens and women over 40  Smoking Risk Factors for Preeclampsia Continue

5.  Preeclampsia in previous pregnancy  Intrauterine growth retardation, abruptio, fetal death  Preexisting medical—genetic conditions  Chronic hypertension  Renal disease  Type 1 (insulin-dependent) diabetes mellitus  Thrombophilias- Antiphospholipid antibody syndrome, Protein C/S, antithrombin deficiency, Factor V Leiden Other Risk Factors Continue

6. You enter the room and proceed to ask her some standard questions. She has had no vaginal bleeding or discharge, no loss of fluid, no contractions, no dysuria and positive fetal movement. She denies any headaches, changes in vision, no epigastric or RUQ pain. She however complains of some swelling of her feet which she notices at the end of the day and improves by morning. June 2004 Case of S.H. Answer

7. What is your most likely diagnosis at this point? A. Preeclampsia B. Gestational Hypertension C. Chronic Hypertension D. White-coat Hypertension June 2004 Case of S.H. Answer

8.  Hypertension in pregnancy with onset after 20 weeks) and all of following:  - absence of proteinuria  - absence of severe features Answer is B. Gestational Hypertension Continue

9. Initial Physical Exam Your initial Physical exam shows: VS: T 98.9 P 84 BP 140/85 RR 16. Lungs: CTAB, no basilar crackles. Abd: gravid uterus at 39 cm above suprapubic notch. Fetus vertex by Leopold manuevers. No RUQ or epigastric tenderness. Neuro: DTRs 2+ at bilateral patella, achilles, bicipital tendon. No nystagmus. Ext: No peripheral edema, strong peripheral pulses. Fetal Heart Tones: 140-160 bpm Urine: trace protein, trace leukocytes, trace ketones, trace bilirubin Which of the following findings above are important to note if you are suspicious of pre-eclampsia? June 2004 Answer

10. Initial Physical Exam Signs of preeclampsia VS: T 98.9 P 84 BP 140/85 RR 16BP 140/85 Lungs: CTAB, no basilar crackles.no basilar crackles Abd: gravid uterus at 39 cm above suprapubic notch. Fetus vertex by Leopold manuevers. No RUQ or epigastric tenderness.39 cm RUQ or epigastric tenderness Neuro: DTRs 2+ at bilateral patella, achilles, bicipital tendon. No nystagmus.DTRs 2+ Ext: No peripheral edema, strong peripheral pulses. Fetal Heart Tones: 140-160 bpm Urine: trace protein, trace leukocytes, trace ketones, trace bilirubintrace protein Continue

11. The Case of S.H. After your physical exam, you feel confident of your diagnosis of gestational hypertension. You explain to the patient that her blood pressure is elevated and that you need to do some further tests to see if she might have preeclampsia You take her to the lab for stat blood work June 2004 Answer

12. The Case of S.H. You order her labs stat and the results return to you in 2 hours: K: 3.8 Glucose: 98 H/H: H/H: 10/30 Platelets: Platelets: 195,000 AST/ALT: AST/ALT: 25/48 PT/PTT: PT/PTT: 12.3/15.6 Uric acid: Uric acid: 8.7 BUN/Cr: BUN/Cr: 15/0.6 Continue

13. She finds you after her blood tests and is carrying her container for the 24-hour urine. “ Can I go home now? ” she asks. What is your plan for her? A. You tell her to go home after her tests and wait for your call. You confirm that you have her correct and most accessible phone number. B. You ask her to wait in the waiting room until her labs are back. C. You send her to L&D for an NST and ultrasound. D. You schedule her for an induction the next day and send her home on an anti-hypertensive medication. June 2004 The case of S.H. Answer

14. Answer is C You decide to send her for an NST at St Anthony’s Hospital. Regardless of your choice, she requires close observation so you send her to L & D. Click below for more information on management of gestational hypertension. Continue

15. Gestational Hypertension Management Women with gestational hypertension are at risk for progression to either severe hypertension, preeclampsia, or eclampsia. Maternal evaluations require weekly prenatal visits, education about reporting pre-eclamptic symptoms, evaluation of CBC, Plt and liver enzymes. Fetal evaluation includes ultrasound examination of fluid and estimated fetal weight at time of diagnosis and weekly non-stress testing. Continue

16. The Case of S.H. You inform the patient that her labs are all within normal limits. You however stress the importance of follow up and ask her to follow up: A.When the 24-hour urine is completeWhen the 24-hour urine is complete A.The next dayThe next day A.If she has any symptoms of pre-eclampsia, as you previously discussed and review with her now.If she has any symptoms of pre-eclampsia, as you previously discussed and review with her now. A.Routine 1 week visitRoutine 1 week visit Answer

17. Answer is C You want to keep close tabs on her. You would like to confirm a diagnosis of gestational hypertension, re- check her urine and review symptoms of preeclampsia. She has several risk factors for developing preeclampsia Continue

18. The Case of S.H. She returns to clinic the next morning to drop off her 24-hour urine collection. she asks one of the nurses to tell you that she has had a really bad headache and abdominal pain. Her blood pressure in the clinic now is 165/105 HR 100, Temp 98.7 RR 18 You repeat her Blood pressure in 4 hours and it is still 162/105 Has your diagnosis changed? Continue

19.  Probably yes Continue Answer!

20. The Case of S.H. At this point in time, which of the following would qualify her as having preeclampsia with severe features other than her symptoms? A.24-hour urine protein showing 350 g B.Abnormal AST/ALT C.SBP measurement of >160 mmHg D.Body edema June 2004 Answer

21.  SBP measurement of >160 mmHg Answer is C

22. Criteria for Preeclampsia with severe features  Blood pressure of ≥160 mm Hg systolic or ≥110 mm Hg diastolic, recorded on at least two occasions at least 4 hours apart with patient at bed rest  Cerebral visual disturbances  Epigastric pain, persistent RUQ pain  Abnormal liver enzymes  Thrombocytopenia Continue

23. Let ’ s review You have now changed your diagnosis to diagnosed S.H. with preeclampsia with severe features based on her symptoms and her blood pressure. You obtain labs and the labs come back with elevated liver enzymes 2x normal and elevated uric acid. Patient is now 38 6/7days What will be the most appropriate step in management at this time? Answer

24. Reexamine the patient and admit her for induction of labor. Patient meets the criteria for preeclampsia with severe features. Patients with diagnosed preeclampsia most often should be hospitalized at the time of diagnosis for evaluation of maternal and fetal conditions. These pregnancies may be associated with reduced utero-placental blood flow jeopardizing the fetus. In addition, the mother is at a slightly increased risk for the development of abruptio placentae or convulsions, particularly in cases remote from term. Continue

25. Congratulations! THE END.

26. Gabbe: Obstetrics - Normal and Problem Pregnancies, 4th ed., Copyright © 2002 Churchill Livingstone, Inc. Sibai BM. Diagnosis and management of gestational hypertension and preeclampsia. Obstetrics & Gynecology. 102(1):181-92, 2003 Jul. Warden, M, Euerle, B. E-medicine website: Preeclampsia. May 13, 2003. Zamorkski MA, Green, LA. NHBPEP Report on High Blood Pressure in Pregnancy: A Summary for Family Physicians. American Family Physician 2001;64:263-70,273-4. National High Blood Pressure Education Program Working Group on High Blood Pressure in Pregnancy. Report of the National High Blood Pressure Education Program Working Group on High Blood Pressure in Pregnancy. American Journal of Obstetrics and Gynecology 2000; 183 (1). References