Hypertensive Complications in Pregnancy PDF

OB2 OBSTETRICS 2 Hypertensive Complications in Pregnancy TRANS 11...

OB2 OBSTETRICS 2 Hypertensive Complications in Pregnancy TRANS 11 MODULE 5 May Nueva - Hipolito, MD, FPOGS, FPSMFM, FPSUOG September 5, 2024 LECTURE OUTLINE Superimposed Preeclampsia WITH severe features I Diagnosis of Hypertensive Disorders Eclampsia II Hypertensive Disorders A. Chronic Hypertension (CHTN) HELLP Syndrome B. Gestational Hypertension Tennessee classification C. Preeclampsia without Severe Features (most commonly used) D. Superimposed Preeclampsia Mississippi classification E. Superimposed Preeclampsia with Severe Features system F. Preeclampsia with Severe Features (Severe Preeclampsia) Source: Dr. Nueva-Hipolito’s Video Lecture on Hypertensive Disorders G. Preeclampsia Syndrome H. HELLP Syndrome I. Eclampsia NOTE: Berghella 4th Edition will be used because Williams 26th Edition does not have the full spectrum of hypertensive disorders in III Disturbances in the Different Organ Systems pregnancy. IV Etiopathogenesis of Hypertensive Disorders A. CHRONIC HYPERTENSION (CHTN) V Prediction Either a history of hypertension preceding the pregnancy with OR VI Prevention without anti-hypertensive medication OR a blood pressure > A. Low dose aspirin (ASA) 140/90 prior to 20 weeks AOG ○ Should have a long standing history of hypertension prior to VII Management of Hypertension the pregnancy A. Oral antihypertensive medication in pregnant patients 1–5% of pregnant women (Outpatient) Mostly develops as a complex quantitative trait affected both by genetics and the environment VIII Prevention of Seizures Most have essential or primary HTN (It is not brought about by any A. Magnesium Sulfate other disease conditions), around 10% may have underlying renal, B. Other Considerations vascular, or endocrine disease. C. Clinical management algorithm for severe pre-eclampsia D. Long term consequences Doctor’s Notes LECTURE OBJECTIVES Most of the chronic hypertension that you will encounter are primary hypertension. 1. N/A (no objectives mentioned) Primary or Essential Hypertension is a type of hypertension that 🧠 Must Know 📖 Book 📝 Previous Trans is not secondary to any other disease or condition. 1. RISK FACTORS I. DIAGNOSIS OF HYPERTENSIVE DISORDERS Hypertensive disorders in pregnancy complicate 5–10% of all pregnancies. Collagen vascular disease ( 📝 Renal disease - most common cause of secondary CHTN i.e. Systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), polyarteritis nodosa (PAN)) Hypertension, Hemorrhage & Infection: Deadly triad that Antiphospholipid syndrome (APS) contributes greatly to maternal morbidity and mortality rates Diabetes Hypertension is diagnosed empirically when systolic and diastolic Cushing’s disease blood pressures exceed 140 mmHg (systolic) and 90mmHg. Hyperaldosteronism (diastolic) Pheochromocytoma Korotkoff phase V - used to define the diastolic pressure Coarctation of the aorta Doctor’s Notes Doctor’s Notes Korotkoff phase V - silence that occurs when the cuff pressure is Whenever you encounter a very young patient who is very released enough to allow normal blood flow hypertensive, you can think that dyslipidemia is unlikely in this age group or if they do not have cardiac conditions or symptoms. HYPERTENSIVE DISORDERS ○ Thus, you need to investigate the probable cause and try to check the kidney function, as this may cause hypertension of Table 1. Hypertensive Disorders the patient. Polyarteritis nodosa (PAN) disease that affects the middle size TERMINOLOGY & DIAGNOSIS TERMINOLOGY & DIAGNOSIS blood vessels. It spares the blood vessels in the kidneys. (Williams 26th Ed.) (Berghella 4th Ed.) Cushing’s disease presents with moon facies, buffalo hump, Chronic Hypertension in truncal obesity, and purple striae. Chronic Hypertension Hyperaldosteronism - Aldosterone is produced in the adrenal Pregnancy cortex that is responsible for the levels of sodium and potassium. Gestational Hypertension Gestational Hypertension When sodium increases, potassium decreases. However, Preeclampsia Superimposed on Preeclampsia WITH Severe patients with hyperaldosteronism have hypokalemia and Chronic Hypertension features increased sodium. If you have high sodium, the blood pressure increases. For patients with chronic hypertension, diet should be Preeclampsia & Eclampsia Preeclampsia WITHOUT severe low-salt/low-fat. Syndrome features Pheochromocytoma is a tumor in the adrenal medulla that Superimposed Preeclampsia causes an increase in the production of epinephrine and norepinephrine. High levels of epinephrine can increase blood Group 8A & 9A | Hypertensive Complications in Pregnancy 1 of 12  pressure. For patients with decreasing blood pressure (for 1. COMPLICATIONS whatever reason) and for reviving patients, epinephrine can be Abruption (placental abruption) given. Preterm birth Small for gestational age (SGA) 2. COMPLICATIONS MATERNAL COMPLICATIONS Doctor’s Notes ○ Can affect almost all of the organ systems in the body, even In obstetrics, it is very important to know how to compute or at the eyes least estimate the patient’s AOG, since it is important in the Patients with long-standing hypertension are ideally determination of some diagnoses and management. referred to an ophthalmologist to be assessed or at least have an official fundoscopy. C. PREECLAMPSIA WITHOUT SEVERE FEATURES FETAL COMPLICATIONS Formerly known as Mild Pre-eclampsia ○ Preterm birth - Most common Sustained (at least 2x, 6 hours but not more than 7 days apart) BP Pregnancy is prematurely terminated because either the > 140/90 mmHg mother or the baby’s condition is in jeopardy. (+) Proteinuria (>300mg in 24 hours in a woman WITHOUT prior proteinuria) Table 2. Maternal & Fetal Complications of CHTN After 20 weeks AOG in a woman with previously normal BP MATERNAL COMPLICATIONS FETAL COMPLICATIONS Worsening CHTN Growth restriction (8–15%) D. SUPERIMPOSED PREECLAMPSIA Superimposed preeclampsia Oligohydramnios (AFI 300mg in 24 hours WITHOUT prior severe features Placental abruption proteinuria) after 20 weeks in a woman with chronic Eclampsia (0.7–1.5%) hypertension OR sudden increase in proteinuria in a woman HELLP syndrome Preterm birth (12–34%) - with known proteinuria before or early in pregnancy Gestational diabetes mellitus most common, usually Cesarean delivery indicated due to maternal 2 Sudden increase in hypertension previously well controlled or Pulmonary edema and fetal complication escalation of anti-hypertensive medication to control BP (this Hypertensive encephalopathy Perinatal death - always the means that the dosage of the current antihypertensive regimen Retinopathy end of the spectrum of the patient is increased due to BP spikes) Cerebral hemorrhage and Acute renal failure NOTE: Always remember that the diagnosis of superimposed preeclampsia is given to patients who have chronic hypertension, we Source: Dr. Nueva-Hipolito’s Video Lecture on Hypertensive Disorders usually phrase it as chronic hypertension with superimposed preeclampsia. [BATCH 2025] INFORMATION Oligohydramnios: Doctor’s Notes ○ AFI 24 cm If the caliber is really small because the tunica media is still there ○ SDP > 8 cm (and is not replaced by trophoblastic cells), it will not be AFI: amniotic fluid index (normal values: >5 to 2 to < 8 cm) Intrauterine growth restriction and oligohydramnios are bad when they happen simultaneously. Doctor’s Notes BP and the need for hypertensive medications decrease after Usually, if there are spikes or a sustained elevation of blood pregnancy but it will not go back to normal. pressure, we have to expedite delivery. If the patient can’t deliver vaginally within an hour, the baby is then delivered abdominally. E. SUPERIMPOSED PREECLAMPSIA WITH SEVERE Cerebrovascular accidents can either be hemorrhage or clot. FEATURES However, hemorrhage is worse since it is secondary to blood One or more of the following criteria: vessel rupture in the brain. Kidney injury and, subsequently, failure occur when there is low 1 Severe range OF BP (>160/110 mmHg) despite escalation of blood perfusion due to hypertension. antihypertensive medication. 2 Platelet count 140/90 limit normal concentration of a particular laboratory ○ After 20 weeks AOG 4 New onset or worsening renal insufficiency (creatinine ≥1.1 ○ (-) Proteinuria mg/dl or doubling of the serum creatinine) ○ (-) Other signs OR symptoms of preeclampsia ○ (-) Prior history of hypertension 5 Pulmonary edema Sustained hypertension - BP was elevated on at least 2 6 Persistent neurological symptoms (e.g. headache and visual occasions at least 6 hours apart changes) Doctor’s Notes IMPORTANT: We only use the term superimposed preeclampsia in What you have to watch out for in hypertensive diseases in patients with chronic hypertension. pregnancy is its abrupt onset or rapid progression in an unpredictable timeframe. Hence, they should be seen frequently. F. PREECLAMPSIA WITH SEVERE FEATURES (SEVERE PREECLAMPSIA) 6–17% of healthy nulliparous women develop GHTN. Any of the following criteria: Progression to preeclampsia: 1–3 weeks from diagnosis If it develops before 30 weeks, there is a 50% rate of progression 1 BP >160/110mgHg (2 occasions, >4 hours apart) to preeclampsia. 2 Thrombocytopenia (platelet 160/110mgHg (2 OCCASIONS, >4 HOURS APART) ○ Elevated serum hepatic transaminase levels can be one Shorter in diagnosing the subtype of hypertension compared to marker gestation hypertension which requires at least 6 hrs interval Thrombocytopenia: platelet activation, aggregation and between the radiance of the blood pressure. microangiopathic hemolysis ○ Overt thrombocytopenia 1.1 mg/dL or a doubling of the serum creatinine Renal involvement: proteinuria (in different degrees) Oliguria (urine output of 35 yo, you have to add in your diagnosis “advanced maternal age”. Group 8A & 9A | Hypertensive Complications in Pregnancy 3 of 12  Table 4. HELLP Syndrome Classifications the endothelial space. Pre-eclamptic women with severe hemoconcentration are very TENNESSEE CLASSIFICATION MISSISSIPPI CLASSIFICATION sensitive to blood loss during delivery that otherwise are Hemolysis Class 1: HELLP syndrome considered normal in normal pregnancies. ○ Abnormal peripheral (severe thrombocytopenia) Doctor’s Notes smear in addition to platelet count 600 IU/L Expected volume expansion during pregnancy for preparation Serum LDH > 600 and AST or ALT >70 IU/L for the delivery and bleeding. IU/L; OR Class 2: HELLP syndrome For patients with preeclampsia, volume expansion is severely Total bilirubin >1.2 (moderate thrombocytopenia) curtailed. mg/dL (>20.52 platelet count >50,000 ○ The expected 1.5L that is expected to be in excess is lost. umol/L) cells/mm3 but 600 IU/L ○ Intravascular volume is low, but extravascular space has a evidenced by an AST or ALT and AST or ALT >70 IU/L lot of water. (extravasation of water that should be contained 2x the upper limit of normal Class 3: HELLP syndrome inside the blood vessels, attracted by proteins due to oncotic concentration of a particular (mild thrombocytopenia) pressure) laboratory platelet count >100,000 ○ Since the blood vessels are broken due to vasospasm, the Platelets 40 IU/L Simple hydration does not suffice, as it may cause Source: Dr. Nueva-Hipolito’s Video Lecture on Hypertensive Disorders pulmonary edema and difficulty in breathing. ○ Significant blood loss → Blood Transfusion NOTE: HELLP (Hemolysis, Elevated liver enzymes, Low platelets) 2 Hematologic Doctor’s Notes Overt thrombocytopenia which is defined by a platelet count TENNESSEE CLASSIFICATION 300 mg; Faulty endovascular Trophoblastic remodeling A spot urine protein: creatinine ratio >0.3; OR ○ Stage 2 - Maternal Syndrome Persistent protein values of 30 mg/dL (+1 dipstick) in random Endothelial cell activation or inflammation through urine samples cytokines and free radicals You cannot diagnose the patient of preeclampsia WITHOUT the Increase in prostaglandins, endothelins and thromboxane presence of proteinuria. Decrease in nitric oxide (low vasodilation) If the patient has protein in the urine, you have to investigate. It is Which among the prostaglandins, endothelins, thromboxane, and possible that the patient has secondary UTI because when WBC nitric oxide are expected to be low in patients with hypertension is high, it can also cause proteinuria. or preeclampsia? ○ If proteinuria persists even in the treatment of UTI, maybe ○ Nitric Oxide because it is a vasodilator. the patient has a kidney problem. ↓Renal perfusion & GFR - due to ↑ Resistance in afferent III. DISTURBANCES IN THE arteriole (hindrance of flow to the kidneys due to hypertension) DIFFERENT ORGAN SYSTEMS ○ Reduction in renal perfusion flow or the glomerular filtration rate 1 Blood volume ○ Glomerular capillary endotheliosis: blocks filtration and cause increase in serum creatinine Hemoconcentration: Hallmark feature of preeclampsia; volume Morphological changes are characterized by glomerular expansion severely curtailed (1.5L excess volume is lost) - sensitive endotheliosis, which blocks filtration. Diminished filtration causes to blood loss serum creatinine to elevate to values seen in non-pregnant Normally expected volume of expansion seen in normal individuals 1mg/mL and sometimes higher. pregnancy is severely curtailed so it does not happen in patients Uric acid concentrations also increase because of reduced GFR with preeclampsia-eclampsia syndrome. and likely due to enhanced tubular reabsorption. The normal 4.5 L volume expansion in pregnant women with average size does not happen. The hemoconcentration is secondary to generalized vasospasm that follows endothelial activation and then from leakage of plasma into Group 8A & 9A | Hypertensive Complications in Pregnancy 4 of 12  Rule out retinal detachment; Instead, if there is amaurosis, refer the patient to an ophthalmologist for co-management. 5 Uteroplacental perfusion If compromised or if the blood flow going to the uterus is very low, it is a major contributor to increased perinatal morbidity and mortality, leading to fetal growth restriction which is a marker of severity. Uteroplacental perfusion: Defects in endovascular trophoblastic invasion: elevated mean arterial pressure, greater systemic vascular resistance and elevated uterine artery pulsatility index. ○ If there is increased resistance, expect the flow to be very slow or curtailed going to that particular organ. Intrauterine growth restriction: estimated fetal weight of less than the 10th percentile for gestational age Oligohydramnios: Amniotic Fluid Index 14 Arrest Figure 5. Cerebral Palsy in Very Low Birth Weight Newborns Source: Dr. Nueva-Hipolito’s Video Lecture on Hypertensive Disorders B. OTHER CONSIDERATIONS (Under Management of Preeclampsia/Eclampsia Syndrome Figure 3. Magnesium Sulfate in Water 50%, 500 mg/mL Injection Single Dose Vial 1. FLUID THERAPY Source: Dr. Nueva-Hipolito’s Video Lecture on Hypertensive Disorders Crystalloid solution is administered routinely at a rate between To achieve the anticonvulsant effect of Magnesium sulfate, the 60–125 mL/hr. level should be 4–7 mEq/L. ○ UNLESS fluid loss is unusual from vomiting, diarrhea, If the level of Magnesium sulfate reaches 10 mEq/L, there would diaphoresis, (insensible water loss) or excessive blood loss be loss of patellar reflex. Preferably, fluid administration/therapy should be conserved and If the level of Magnesium sulfate reached 12 mEq/L or more, the controlled in a typical woman with preeclampsia with severe patient would experience respiratory arrest. features because they have excessive extracellular fluid. Aside from monitoring the UO and magnesium sulfate, it is ○ Monitor for Intake and Output (I & O) of the patient. IMPORTANT to also check the deep tendon reflexes (DTR) or patellar reflex using a neurohammer. 2. ANALGESIA AND ANESTHESIA Serum level 8–10 mEq/L of magnesium sulfate = expected level to Neuraxial analgesia for women with pre-eclampsia has proved inhibit uterine contractions ideal. Magnesium sulfate was used as tocolytic in the past. Neuraxial analgesia induced hypotension and diminished ○ Complications and risks brought by its usage resulted in the uterine perfusion secondary to sympathetic blockade in discontinuance of using magnesium sulfate as a tocolytic preeclamptic women already have attenuated hypovolemia; these agent. can be remedied by slow induction of epidural analgesia with In recent obstetrics, magnesium sulfate does not have a role dilute solutions of anesthetic agents to counter the need for anymore as a tocolytic; serum level to achieve uterine quiescence rapid infusion of large volumes of crystalloid or colloid to prevent is almost the same level as when the patient loses her DTR. maternal hypotension (Hogg, 1999; Wallace, 1995). Just in case the patient experiences respiratory arrest ○ If we are talking about preeclampsia or discussing analgesia secondary to magnesium sulfate, one of the symptoms of and anesthesia, the common anesthesia is epidural. magnesium sulfate toxicity in pregnancy, an ANTIDOTE is Epidural blockade avoids general anesthesia, which causes given which is calcium gluconate/calcium chloride. stimulation of tracheal intubation that can lead to sudden severe ○ Calcium gluconate/ calcium chloride: 1 gram intravenously hypertension, or will definitely exacerbate the hypertension of the coupled with discontinuation of magnesium sulfate drip, in patient and may cause seizures or stroke during induction of order to reverse mild to moderate respiratory depression. anesthesia. C. CLINICAL MANAGEMENT ALGORITHM FOR SEVERE PRE-ECLAMPSIA If you have a patient with a BP of >160/110 mmHg: ○ Admit the patient. ○ Assess the mother and fetus. Do not forget the fetus. In OB, we have two patients: the mother and the baby, so always include the baby in your plan. ○ Consider magnesium sulfate. Watch out for convulsions. ○ Treat the dangers of hypertension or BP spikes. Table 5. Contraindications to conservative management: Figure 4. Calcium Gluconate Preservative Free 10%, 100 mg/mL Injection Single Dose Vial DELIVER THE BABY RIGHT AWAY Source: Dr. Nueva-Hipolito’s Video Lecture on Hypertensive Disorders 1 Persistent symptoms of severe hypertension such as headache, blurring of vision, epigastric pain, or dangerously high blood pressure IMPORTANT: Monitor for UO and check for Patellar reflex when administering MgSO4. 2 Patient that had seizure or is convulsing 3 Patient is with signs of pulmonary edema (i.e., crackles, MAGNESIUM SULFATE AS NEUROPROTECTION difficulty of breathing It has a protective effect against the development of cerebral palsy in very low birth weight newborns as noted in several studies in the past. Group 8A & 9A | Hypertensive Complications in Pregnancy 8 of 12  4 HELLP syndrome - Labs show hemolysis, low platelet, Steroids can have 2 purposes: elevated liver enzymes ○ Hasten maturation of the lungs of a preterm fetus Give steroids for HELLP syndrome to increase platelet count ○ HELLP syndrome for increasing the platelet count in severe pre-eclampsia: Dexamethasone 10mg IV q 6–12 hours. (insufficient evidence) Clinical management algorithm for severe pre-eclampsia: 5 Significant neural dysfunction STEROIDS 6 Coagulopathy 1 Hasten Dexamethasone: 6 mg IM q12 x 4 doses maturation of alternating deltoids 7 Evidence of bleeding the lungs of a Betamethasone: 12mg IM q24 hours x 2 8 Evidence of abruption (i.e., sudden decrease in heart rate, preterm fetus doses alternating deltoids panic contractions, vaginal bleeding, and really painful 2 Increase the Dexamethasone: 10mg IM q6–12 hours contractions) platelet count ○ Insufficient evidence hence not widely 9 Pre-viable fetus ( 12 B. Putscher’s Retinopathy C. HELLP Syndrome Magnesium sulfate acts as an anticonvulsant, neuroprotective, D. Severe Pre-eclampsia and avoids producing CNS depression. Women with preeclampsia or eclampsia are usually given magnesium 4 A 37-year-old primigravid, 10 weeks AOG consults the ER sulfate during labor and for 24 hours postpartum. However, for headache. Her BP is persistently elevated at 150/90 unusual problems are encountered when the values of MgSO4 mmHg but has no evidence of protein spillage on urine are exceeded. To achieve the anticonvulsant effect of MgSO4, dipstick. Her physical examination is unremarkable with the level should be 4-7 mEq/L. If the level reaches 12 mEq/L or good fetal heart tones at the left lower quadrant. What is more, the patient will experience respiratory arrest. the MOST plausible diagnosis for this patient? A. Gestational hypertension B is wrong because if the level of MgSO4 reached 10 mEq/L, B. Chronic hypertension there would be a loss of patellar reflex. C. Preeclampsia D. HELLP syndrome C and D are wrong because if the level of MgSO4 reached 4-7 5 What is the purpose of dexamethasone administration in mEq/L, the patient would have only achieved its anticonvulsant postpartum women diagnosed with HELLP syndrome? effect without showing signs of respiratory paralysis. A. Decrease incidence of renal failure B. Faster aspartate transferase recovery time Source: Batch 2025 Ratio C. To hasten lung maturity 3 CORRECT ANSWER: A. Option A D. Increase platelet count in severe thrombocytopenia 6 A 35 year old G3P2 (0202) at 27 weeks AOG presented with UTEROPLACENTAL PERFUSION a new onset severe headache. BP 180/110 mm Hg. Fetal If compromised, of if the blood flow going to the heart tones 150 bpm. What is the appropriate uterus is very low, it is a major contributor to management? increased perinatal morbidity and mortality can lead A. Magnesium sulfate and phenytoin to fetal growth restriction which is a marker of B. Magnesium sulfate and diazepam severity C. Magnesium sulfate alone Source: Mod5-OB2-T11-Hypertensive Complications in Pregnancy D. Diazepam 7 A patient on MgSO4 drip lost her patellar reflexes but does not exhibit respiratory depression. What is the probable plasma magnesium level (mEq/L) of the patient? A. 6-7 B. 10-11 C. 4-5 D. 8-9 8 At what AOG in weeks will pregnancy induced hypertension appear the earliest? A. 16 B. 20 C. 18 D. 22 9 A 39-year-old primigravid at 37 weeks AOG consulted at a lying-in clinic with blurring of vision and epigastric pain, BP 200/120 mmHg and urine dipstick was +2. What is the appropriate management? A. Give magnesium sulfate for neuroprotection B. Do serial determination of CBC, AST, ALT, LDH, and creatinine C. Refer to a hospital for delivery D. Give steroids to hasten lung maturity Group 8A & 9A | Hypertensive Complications in Pregnancy 10 of 12  4 CORRECT ANSWER: B. Chronic hypertension 6 CORRECT ANSWER: C. Magnesium sulfate alone The patient has chronic hypertension due to her only being 10 Magnesium sulfate is used as an anticonvulsant, weeks AOG and having a BP of 150/90. Chronic hypertension neuroprotective, and avoids CNS depression. Patients with is defined as a history of hypertension preceding the pregnancy severe pre-eclampsia or eclampsia are usually given with a BP of ≥ 140/90 mmHg prior to 20 weeks AOG. magnesium sulfate during labor and for 24 hours postpartum. It is used as neuroprotection against the development of cerebral A is wrong because gestational hypertension occurs after 20 palsy in very low birthweight newborns at the gestational age of weeks AOG. Gestational hypertension is defined as sustained 24-34 weeks (premature) and is given at 4gIV loading dose BP ≥ 140/90 mmHg (at least 2x, 6 hours but not more than 7 followed by 1g/hr infusion. If you have a patient at the days apart) without proteinuria, prior history of HPN, or other emergency room with a BP of > 160/110 mmHg, we must admit signs of preeclampsia. BP returns to normal 12 weeks the patient, assess the mother and fetus, and consider postpartum magnesium sulfate to watch out for convulsions. C is wrong because the patient has no protein spillage on urine A is wrong because phenytoin is a teratogenic and could cause dipstick. Pre-eclampsia is defined as sustained BP ≥ 140/90 fetal hydantoin syndrome (cleft lip, cleft palate, congenital heart mmHg (at least 2x, 6 hours but not more than 7 days apart) and disease, slowed growth, mental deficiency) proteinuria (≥ 300 mg in 24 hour in a woman without prior proteinuria) after 20 weeks AOG in a woman in previously B and D is wrong because while diazepam is an anti-seizure normal BP. Essentially it is gestational hypertension with medication, it is not given to pregnant women due to its proteinuria. teratogenic effect causing increased cleft lip and cleft palate development. D is wrong because HELLP syndrome is an acronym for Source: Batch 2025 Ratio hemolysis, elevated liver enzymes, and low platelet count. It is 7 CORRECT ANSWER: B. 10-11 a severe manifestation of preeclampsia. The most commonly used classification for HELLP syndrome is the Tennessee classification: Tennessee Classification → Abnormal peripheral smear in addition to either serum LDH > 600 IU/L or total bilirubin greater than or equal to 1.2 mg/dL (greater than or equal to 20.52 umol/L). → Evidenced by an AST or ALT 2x the upper limit of normal concentration of a particular laboratory. → 160/110 mmHg) IF there are no contraindications to conservative management. Diagnosis for pregnancy-induced hypertension, such as Contraindications include: persistent symptoms of severe Gestational Hypertension (GTHN) and Preeclampsia, is made if hypertension (headache, blurring of vision, epigastric pain, the patient has sustained blood pressure of ≥ 140/90 mmHg dangerously high BP), seizures, pulmonary edema, HELLP after 20 weeks AOG in a woman with previously normal BP. syndrome, renal dysfunction, bleeding, abruption, previable Preeclampsia has (+) proteinuria, while GTHN has (-) fetus, and fetal compromise. proteinuria. Source: Batch 2025 Ratio Choice D is wrong because 22 weeks AOG is not the earliest possible time pregnancy induced hypertension appears Choice A and C are wrong. Elevated BP prior to 20 weeks AOG can be considered as chronic hypertension Source: Batch 2025 Ratio Group 8A & 9A | Hypertensive Complications in Pregnancy 11 of 12  9 CORRECT ANSWER: C. Refer to a hospital for delivery The signs of blurring of vision, epigastric pain, BP 200/120mmHg (hypertensive), and urine dipstick +2 shows severe pre-eclampsia. Conservative management is contraindicated and the baby should be delivered right away. A is incorrect because giving magnesium sulfate will only serve as an effective anticonvulsant or for neuroprotection in preterm babies. This is usually given during labor or 24 hours postpartum in women with severe pre-eclampsia and will not aid in the patient’s current condition. B is incorrect because serial determination of CBC, AST, SLT, LDH, and creatinine is done for conservative management and is contraindicated. In this patient, measures to address severe pre-eclampsia are more appropriate. Furthermore, ordering this may take time and increase harmful effects for bith the mother and baby. D is incorrect since giving corticosteroids for fetal lung maturation is only done for conservative management. Source: Batch 2025 Ratio 10 CORRECT ANSWER: A. sFlt-1 This is due to the pathogenesis of preeclampsia, wherein endothelial dysfunction and imbalance of angiogenic factors occurs. As a response to hypoxia, the placenta releases factors into the maternal circulation, which causes an imbalance in the angiogenic and anti-angiogenic factor levels. Two placenta-derived antiangiogenic factors are markedly elevated in women with pre-eclampsia and they are: sFLT-1 (Soluble FMS-like tyrosine kinase) and endoglin. The elevation of both antiangiogenic factors have an effect on VEGF, TGF-B, and PIGF as explained below; B is wrong because elevated endoglin inhibits its effect (meaning endoglin elevates first, then takes effect on TGF-B) C is wrong because elevated sFLT-1 antagonizes its effect (meaning sFLT-1 elevates first, then takes effect on VEGF) D is wrong because sFLT-1 also antagonizes its biological effect by binding to PIGF and preventing it from actually binding to their respective endogenous receptors (again, sFLT-1 elevates first then takes an effect on PIGF1). Source: Batch 2025 Ratio XII. FREEDOM WALL Group 8A & 9A | Hypertensive Complications in Pregnancy 12 of 12