Name:
A 36-Year-Old Pregnant Woman with Hypertension
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A 36-Year-Old Pregnant Woman with Hypertension
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Upload Date:
2022-02-28T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
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CATHY: Hi. Welcome to Harrison's Podclass where we discuss important concepts in internal medicine. I'm Cathy Handy.
CHARLIE: And I'm Charlie Wiener and we're coming to you from the Johns Hopkins School of Medicine. Welcome to Episode 31: A 36-Year-Old Pregnant Woman with Hypertension. And here's the question: a 36-year-old nulliparous woman is found to have a blood pressure of 150/95 on a routine prenatal screening examination at 25 weeks gestation. Prior to this visit, her blood pressure was typically 125/80.
CHARLIE: She has a history of well-controlled diabetes and hyperlipidemia. Her examination is notable for a body mass index of 28, a 3 out of 6 systolic flow murmur, and 2-plus pretibial edema. Laboratories are notable for normal electrolytes, a serum creatinine of 1.0 mg/dL, and a urine protein to creatinine ratio of 0.4. Which of the following findings in this patient is necessary to confirm the diagnosis of pre-eclampsia?
CHARLIE: Actually, Cathy, before we get to the answer choices, why is pre-eclampsia such an important diagnosis in pregnant women?
CATHY: So, it's important because these pregnancies are at increased risk for maternal and/or fetal mortality or serious morbidity. And in addition, especially for the primary care physician, women with pre-eclampsia are at increased risk for future cardiovascular disease later in life.
CHARLIE: Okay, so back to the question. The question asks, which of the following is necessary to confirm the diagnosis of pre-eclampsia? Option A is diabetes; option B is hyperlipidemia; option C is obesity; option D is pedal edema; and option E is the protein to creatinine ratio.
CATHY: This question really just requires knowledge about how to make the diagnosis of pre-eclampsia. So, to go over it, the major points is that the diagnosis is made after 20 weeks gestation. And a patient needs to be hypertensive, and this is defined as a blood pressure greater than 140/90 in a previously normotensive patient. And you also have to see proteinuria or end-organ dysfunction.
CHARLIE: How do we define proteinuria?
CATHY: So, in a normal case, there should be no protein in the urine and the typical cut-off is less than 20 mg/dL. Typically, proteinuria is assessed in an office with just a dipstick test and 1+ correlates roughly to 30 mg/dL. However, it's dependent on how dilute the urine is. So, really, a better test is the protein to creatinine ratio, and that's a more accurate measurement, and that should be less than 0.3 in a normal patient.
CHARLIE: So, is that all that's necessary to diagnosis pre-eclampsia-- proteinuria and hypertension?
CATHY: So, it's no longer required just to have the proteinuria. So, if a patient has hypertension and any end-organ dysfunction, and this can mean other things, like platelets less than 100, a serum creatinine that's increased to greater than 1.1 mg/dL, or if there's been a doubling of the serum creatinine, or if there are elevated LFTs that are twice the upper limit of normal. Those factors, as well, can still be diagnostic of pre-eclampsia, even in the absence of a change in the protein to creatinine ratio.
CHARLIE: Okay, so the answer to this question is E, the protein-creatinine ratio, plus the hypertension, in this case, made the diagnosis of pre-eclampsia. For the sake of completeness, let's go through the other options and discuss how they're relevant to pre-eclampsia.
CATHY: Alright, so answer choice A was diabetes, and if that develops during pregnancy, we call it gestational diabetes, but it can also be pre-existing. As pregnancy progresses, glycemic control may be more difficult to achieve due to an increase in insulin resistance. And when you have a pregnancy complicated by diabetes, it's associated with higher maternal and perinatal morbidity. So, some of the findings that you can get are neural tube defects, congenital anomalies, like sacral agenesis or renal agenesis, or VSDs, or ventricular septal defects.
CATHY: There are also higher mortality rates, so it's something that we monitor for.
CHARLIE: What about the other choices, Cathy?
CATHY: Hyperlipidemia and obesity are risk factors for pre-eclampsia, but they aren't diagnostic, so wouldn't answer this question. And just to round out the rest of the answer choices, pedal edema is common in pregnancy and it can be seen in patients with pre-eclampsia, but it also happens for a number of other reasons and isn't specific to pre-eclampsia.
CHARLIE: Okay, let's do a second but related question. So, the patient we just talked about with pre-eclampsia is being managed with aspirin.
CATHY: Oh, let me just say a word about that. So, when we're screening for pre-eclampsia, we really just use clinical factors, and these include things like age, personal and family history, and comorbidities, like I mentioned before, including kidney disease, hypertension, obesity, lupus, and others. Now, prevention is recommended for some people. It's a U.S. Preventive Services Task Force recommendation of grade B for a low-dose aspirin as a preventive medication after 12 weeks of gestation in women who are considered to be at high risk for pre-eclampsia.
CATHY: So, it sounds like this patient that we mentioned in the question was considered to be at high risk and, presumably, would have started aspirin at 81 mg per day, or at the lower dose of aspirin, around 12 weeks of gestation.
CHARLIE: Okay, so she's being managed with aspirin and labetalol for her blood pressure. The question now asks: all of the following findings characterize pre-eclampsia with severe features, except for: option A says, asthma; option B says, hemolysis; option C says, hepatocellular injury; option D says, a seizure; and option E says, thrombocytopenia.
CHARLIE: So, what is pre-eclampsia with severe features?
CATHY: Pre-eclampsia with severe features is the presence of new-onset hypertension and proteinuria, accompanied by end-organ damage. So, some of the features that we would include for this are severe elevation of blood pressure. So, this would be defined as blood pressures greater than 160/110 mmHg. Any evidence of central nervous system dysfunction. Examples of this include headaches, blurred vision, seizures-- which is option D in this case-- or coma.
CATHY: Renal dysfunction gets included in this. Examples would be oliguria or creatinine greater than 1.5 mg/dL. Pulmonary edema, hepatocellular injury. Here, we're looking for ALT levels more than twice the upper limit of normal. And then, finally, we're looking for hematologic dysfunctions. So, this could be defined as a platelet count less than 100,000, or any evidence of disseminated intravascular coagulation, or DIC.
CHARLIE: So, is pre-eclampsia with severe features the same as the HELLP syndrome?
CATHY: The HELLP syndrome-- which you'll recall stands for hemolysis, elevated liver enzymes, and low platelets-- is a special subtype of severe pre-eclampsia, and it's a major cause of morbidity and mortality in this disease. Platelet dysfunction and coagulation disorders further increase the risk of stroke. So, if we go back to what the answer choices are for the following findings characterizing pre-eclampsia with severe features, we mentioned that hemolysis is characteristic, hepatocellular injury can be included, seizures can be included, and thrombocytopenia can be included.
CATHY: So, asthma is not a finding, although patients can have pulmonary symptoms. This tends to be, though, from pulmonary edema. So, the answer to the question would be A.
CHARLIE: So, you mentioned before that patients at risk of pre-eclampsia receive aspirin to ameliorate the symptoms. But what about treatment of pre-eclampsia with severe features?
CATHY: You have to deliver the baby.
CHARLIE: Alright. So, the teaching point of these two questions is that pre-eclampsia is diagnosed in a pregnant woman with new-onset hypertension that is associated with either proteinuria or evidence of end-organ damage. Severe pre-eclampsia includes severe elevation of blood pressure and evidence of end-organ disease, such as at the central nervous system, the kidneys, the lungs, hepatocellular injury, or hematologic dysfunction.
CATHY: And to learn more about this, you can read more in Harrison's chapter on Medical Disorders During Pregnancy. This is found in General Considerations in Clinical Medicine. We also refer to the U.S. Preventive Services Task Force, which you can go to their website. And also ACOG, or the American College of Obstetrics and Gynecology, also has guidelines on pre-eclampsia. ♪ (music) ♪