Hypertensive Disorders in Pregnancy MCQs

In the question, patient is presenting with Headache, Blurring of vision, B/P = 180/120 mm of Hg (later 174/110 mm of Hg) i.e. she is a case of severe pregnancy induced hypertension. First step in the management of this case would be to prevent seizures i.e. give MgSO4. Her B/P should be controlled with antihypertensive and since pregnancy is >34 weeks, therefore terminate pregnancy (which is the definitive management). Reference : Fernando Arias Practical Guide to High Risk Pregnancy and Delivery 3/e, pg 417, 420, 424

"Folic acid has been shown to effectively reduce the risk of neural tube defects (NTDs). A daily 4 mg dose is recommended for patients who have had a previous pregnancy affected by neural tube defects. It should be started at least 1 month (ideally 3 months) prior to pregnancy and continued through the first 6-12 weeks of pregnancy." -COGDT 10/e, p 197 Remember: Therapeutic dose of folic acid (to be given in females with a previous history of baby with NTD) - 4 mg. Prophylactic dose of folic acid = 0.4 mg i.e., 400 mg Duration: It should be started 1 month before conception and continued till 3 months of pregnancy. Note: Women with insulin dependent diabetes mellitus and those with seizure disorders treated by valproic acid and carbamazepine are also at greater risk for NTD's and should be given therapeutic dose of folic acid i.e 4 mg. Reference: Dutta Obs. 7/e, p 409; COGDT 10/e, p 197

Doppler ultrasound Presence of diastolic notch between 22-24 weeks by Doppler velocimetry in the uterine artery predicts the development of preeclampsia. It is probably the best available test. Reference : Arias 5 th edition pg no 192

The action of low-dose aspirin in the prevention of preeclampsia involves its effects on blood clotting and vascular function: Antiplatelet Effect:Aspirin inhibits platelet aggregation by blocking the enzyme cyclooxygenase-1 (COX-1), which reduces the production of thromboxane A2. This helps to prevent excessive blood clotting and improves blood flow. Vascular Protection: By inhibiting thromboxane A2, aspirin also helps to reduce endothelial cell activation and vasoconstriction, which can lower the risk of placental insufficiency and the development of preeclampsia. Overall, these effects contribute to improved placental blood flow and reduced risk of the complications associated with preeclampsia. As per ASPREE trial, 150 mg of aspirin is given from 12-36 weeks of pregnancy in patients with high risk of developing preeclampsia for prevention. Reference : Arias 5 th edition pg no 181

In preeclampsia, the focus is on monitoring renal function (A), liver function (B), and urine analysis (C) to assess the severity of the condition and its impact on the body. Anticardiolipin antibodies (D) are not typically part of the routine evaluation for preeclampsia; they are more relevant in the context of antiphospholipid syndrome. Investigations to be done in case of pre eclampsia are hemogram, platelet count, hematocrit, RFT, LFT, coagulation profile, electrolytes, serum uric acid, ECG, echocardiogram Reference : Arias 5 th edition pg no 180

In the Question patient has - Blood pressure = 160/110 mm Hg Platelet count = 80, 000/cubic mm} indicating severe Preeclampsia The gestational age is 36 weeks Management of severe preeclampsia in Gestational age > 34 weeks is delivery As far as mode of delivery is concerned, vaginal delivery is preferred. If the cervix is not ripe prostaglandins are used to refer to the cause. If it fails then cesarean is done. Betamethasone to hasten lung maturity is not required at 36 weeks as lungs are already mature by this time. 'Termination of pregnancy is the only cure for preeclampsia. Severe preeclampsia demands anti convulsant and usually antihypertensive therapy followed by delivery'. Reference: Williams obs 23 rd edition pg 729

Indications for termination of pregnancy irrespective of the weeks of gestation in case of preeclampsia are: Severe preeclampsia, with impending eclampsia Eclampsia (give MgSO4 first, followed by induction of labor) HELLP syndrome. Pulmonary edema Significant renal dysfunction, coagulopathy Abruption Previable fetus Fetal compromise A woman with a past history of eclampsia is at increased risk for developing eclampsia again in subsequent pregnancies. However, this is not considered an indication for termination of pregnancy in and of itself. Reference : Arias 5th edition pg no 197

Hypertensive disorders complicate 7-15% of all gestations and account for a quarter of all antenatal admissions. Reference : Arias 5 th edition pg no 172