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QuestionChoice
This patient had hypertension during a previous pregnancy which puts her at high risk of pre-eclampsia. For women at high risk of pre-eclampsia, NICE recommend that aspirin 75—150 mg daily is prescribed from 12 weeks' gestation until birth. Women are considered to be high risk of pre-eclampsia if they have at least one of the following risk factors: a history of hypertensive disease during a previous pregnancy, chronic kidney disease, autoimmune disease such as systemic lupus erythematosus or antiphospholipid syndrome, type 1 or type 2 diabetes, or chronic hypertension.
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Aspirin
QuestionChoice
Insulin therapy should be considered in patients with gestational diabetes, guided by a specialist. Gestational diabetes is diagnosed if the woman has either a fasting plasma glucose level of 5.6 mmol/L or above or a 2‑hour plasma glucose level of 7.8 mmol/litre or above. This patient has a normal fasting plasma glucose.
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Insulin therapy
QuestionChoice
This patient is at high risk of pre-eclampsia, therefore she should be started on aspirin.
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No medication required
QuestionChoice
Labetalol is used in the management of women with hypertensive disease in pregnancy. This patient has a normal blood pressure at this visit so does not require anti-hypertensive therapy at this time.
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Labetalol
QuestionChoice
Folic acid supplementation should be started pre-conception in women who are planning a pregnancy, or in women who are in the early stages of pregnancy and should be continued until 12 weeks gestation. This is to reduce the risk of neural tube defects. The woman here is already at 12 weeks gestation so folic acid supplementation is no longer required.
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Folic acid
Concept
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# Summary

Pre-eclampsia is a placental condition that often affects pregnant women from around 20 weeks of gestation, characterised by hypertension and proteinuria. Other symptoms include peripheral oedema, severe headache, drowsiness, visual disturbances, epigastric pain, nausea/vomiting and hyperreflexia. The exact aetiology is not entirely understood, but it may be due to dysfunctional trophoblast invasion of the spiral arterioles. Key investigations include blood pressure and urine protein measurements. Management strategies include anti-hypertensive treatment, with labetalol as the first-line agent. Magnesium sulphate is used to prevent and treat eclamptic seizures, but the ultimate curative treatment is delivery of the placenta.

# Epidemiology



Pre-eclampsia affects a significant percentage of pregnancies worldwide, although the exact number varies significantly between different populations and healthcare settings. Risk factors include nulliparity, a previous history or family history of pre-eclampsia, increasing maternal age, pre-existing diseases such as hypertension, diabetes, renal disease, autoimmune disease, obesity, and multiple pregnancies.


# Aetiology



The exact aetiology of pre-eclampsia remains unclear. However, it's believed to be related to dysfunctional trophoblast invasion of the spiral arterioles, which results in decreased uteroplacental blood flow and subsequent endothelial cell damage.


# Signs and Symptoms


Pre-eclampsia is characterised by:

- Hypertension
- Proteinuria
- Peripheral oedema
- Severe headache
- Drowsiness
- Visual disturbances
- Epigastric pain
- Nausea/vomiting
- Hyperreflexia

# Maternal complications

- Eclampsia (seizures due to cerebrovascular vasospasm)
- Organ failure
- Disseminated intravascular coagulation (DIC)
- HELLP syndrome (the presence of haemolysis (H), elevated liver enzymes (EL) and low platelets (LP))

# Foetal complications

- Intrauterine growth restriction
- Pre-term delivery
- Placental abruption
- Neonatal hypoxia


# Differential Diagnosis


The differential diagnosis for pre-eclampsia includes other conditions that can present with hypertensive disorders in pregnancy, such as chronic hypertension, gestational hypertension, and HELLP syndrome. Key signs and symptoms for these conditions include persistent high blood pressure, proteinuria, and various combinations of haemolysis, elevated liver enzymes, and low platelet levels.

# Investigations


Key investigations for pre-eclampsia include:

- Blood pressure measurement: To confirm hypertension.
- Urinalysis: To confirm proteinuria.
- Blood tests: To assess kidney function, liver function, and clotting status.

# Management

Aspirin is used for prophylaxis against the development of pre-eclampsia. It is given from 12 weeks gestation until birth to women with one high risk factor or two (or more) moderate risk factors. 

Management of pre-eclampsia primarily involves anti-hypertensive treatment, with labetalol being the recommended first-line agent. Other agents that can be used include Nifedipine, Methyldopa and hydralazine. 

Magnesium sulphate can be administered for the prevention and treatment of eclamptic seizures. 

The only definitive curative treatment is the delivery of the placenta. It is also crucial to monitor the mother and foetus closely for complications.

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Obstetrics
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Quesmed Tutorial: Obstetrics 2
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Hypertension without proteinuria in pregnancy
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Aspirin may be indicated in pregnancy to reduce the risk of preeclampsia, particularly in women with high-risk factors such as a history of preeclampsia, chronic hypertension, or certain medical conditions like diabetes.
A 36-year-old female presents for her 12-week scan after a positive pregnancy test at 6 weeks. She has had one previous pregnancy, during which she had hypertension with no proteinuria. She has felt well so far throughout this pregnancy. On examination, her blood pressure is 121/74 mmHg. Urine dipstick is negative and her fasting blood glucose is 5.5mmol/L.

What is the next best step in management?
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