Presenting Complaint

• Headache – SOCRATES:
  • Site – across the front of the head, bilateral
  • Onset – sudden-onset, she was watching TV when the headache started, can’t think of any triggers for the headache
  • Character – throbbing pain
  • Radiates – the pain does not radiate anywhere
  • Associated Symptoms – associated with nausea and vomiting and feeling generally unwell
  • Time/duration – duration is 2 weeks, the headaches usually start in the morning when she firsts wakes up and then last all day, the headaches have been occurring more frequently since their onset (occurred 2-3 times last week, have occurred every day this week) 
  • Exacerbating and Relieving Factors – headaches are not relieved by painkillers 
  • Severity – 8/10 
• Nausea and Vomiting:
  • She has been feeling constantly nauseous over the past 2-3 weeks
  • She has vomited 3 times in the last week
  • No haematemesis (blood in the vomit)
• She is up to date with her pregnancy scans, all of which have been normal

Obstetric History:

• 24+1 weeks gestation

• This is her first pregnancy
• No previous miscarriages or terminations
• She was tested for STIs when she found she was first pregnant, the results of which were negative. She has had no new sexual partners since then.

Systems Review

• On direct questioning, she reports:
  • Right upper quadrant pain just below the ribs – occurred yesterday for the first time, aching in nature, lasted for a few hours, thought it was caused by indigestion
  • Swelling of hands and feet – for the past 2 weeks
• She denies the following symptoms:
  • Visual disturbance e.g. blurry vision or flashing before the eyes
  • Urinary symptoms or changes to bowel habits
  • Fever
  • Reduced foetal movements

Previous Medical History

• No past medical history of note

Drug History

• Currently taking no medications

Allergies

• NKDA

Social History

• Stopped drinking alcohol since finding out she was pregnant
• Has never smoked or taken recreational drugs
• Lives with her husband and their 2 dogs

Family History

Father has hypertension, which was diagnosed 2 years ago at the age of 62

Full Neurological Examination – normal

Auscultation of Foetal Heart – normal

Examiner Questions

1. What are your most likely differentials?

• Pre-eclampsia (due to pregnant women over 20 weeks gestation presenting with headache, vomiting, feeling generally unwell and swelling of hands and feet alongside hypertension and proteinuria)
• Hypertensive Headache
• Tension Headache

2. What further investigations would you like to order?

• Bedside:
  • Blood Pressure (to check for hypertension)
  • Urinalysis (to check for proteinuria)
• Lab:
  • FBC, U&Es, LFTs (to check for signs of severe eclampsia and HELLP syndrome e.g. low haemoglobin due to haemolysis, thrombocytopaenia, raised creatinine due to AKI, and raised LFTs)  
• Imaging:
  • Foetal Ultrasound Scan (to assess foetal growth)

3. What are the different types of Hypertension in pregnancy?

• There are 5 main types of hypertension in pregnancy:
  • Chronic Hypertension: Hypertension that predates pregnancy and is diagnosed before 20 weeks of gestation. It is not caused by dysfunction in the placenta.
  • Gestational Hypertension: Pregnancy-induced hypertension that develops after 20 weeks of gestation without proteinuria.
  • Pre-eclampsia: Pregnancy-induced hypertension that develops after 20 weeks of gestation with signs of end-organ damage, notably proteinuria.
  • Eclampsia: Pre-eclampsia plus seizures.
  • Chronic Hypertension with Superimposed Pre-eclampsia/Eclampsia: Chronic hypertension as defined above that worsens and develops signs and symptoms of pre-eclampsia/eclampsia after 20 weeks of gestation.

4.  What is HELLP syndrome?

Delivering the baby, regardless of gestational age. This is the definitive management for HELLP syndrome.

HELLP syndrome is a rare and potentially life-threatening severe form of pre-eclampsia and eclampsia. It is an acronym for Haemolysis, Elevated Liver enzymes, and Low Platelets. HELLP syndrome is a medical emergency that requires immediate intervention. Management strategies include:

The use of antihypertensive medications (e.g. labetalol or hydralazine) to control the patient’s blood pressure 

Seizure prophylaxis (e.g. magnesium sulphate) to prevent eclampsia

Transfusion of blood products (e.g. red cells, platelets, or plasma)

What is Pre-eclampsia?

Pathophysiology

• The pathophysiology of pre-eclampsia is poorly understood. However, it is believed to result from abnormal placentation and subsequent systemic inflammatory responses, leading to end-organ damage.
• In normal pregnancy, trophoblast cells invade the maternal spiral arteries within the endometrium. This transforms them into wider blood vessels with low vascular resistance to ensure adequate blood flow to the placenta and foetus. However, in pre-eclampsia, this invasion is abnormal or incomplete, resulting in narrower, high-resistance spiral arteries. This leads to reduced placental perfusion.
• Hypoxic conditions in the placenta results in the release of various inflammatory molecules, which contribute to systemic inflammation and widespread endothelial dysfunction. This can subsequently cause end-organ damage, affecting organs such as the kidneys, liver, and brain.

Risk Factors

There are several risk factors for pre-eclampsia, which can be subcategorised into high-risk and moderate risk as per the NICE guidelines. 

• High-Risk:
  • Hypertension during a previous pregnancy
  • Chronic Hypertension
  • Chronic Kidney Disease
  • Diabetes (type 1 and type 2)
  • Autoimmune disease
• Moderate Risk:
  • First pregnancy
  • Age ≥40 years
  • >10 years since previous pregnancy
  • BMI ≥35 kg/m² at first visit
  • Family history of pre-eclampsia
  • Multiple pregnancy

Clinical Presentation

Signs and Symptoms of pre-eclampsia include:

• Severe headache
• Visual disturbance e.g. blurry vision or flashing before the eyes
• Upper abdominal or epigastric pain (due to liver damage)
• Vomiting
• Sudden swelling of the face, hands, or feet
• Reduced urine output
• Brisk reflexes

Diagnosis

Diagnosing pre-eclampsia is based on the following criteria:

• Hypertension (blood pressure of ≥140 mmHg systolic and/or ≥90 mmHg diastolic)
• Proteinuria:
  • Urine dipstick +1 or higher
  • Urine protein:creatinine ratio (>30mg/mmol is significant)
  • Urine albumin:creatinine ratio (>8mg/mmol is significant)
  • NB – 24-hour urine collection should NOT be routinely used to quantify proteinuria in pregnant women
• Signs of end-organ damage in the absence of proteinuria:
  • Thrombocytopaenia
  • Renal insufficiency (raised creatinine due to AKI)
  • Liver dysfunction (raised LFTs)
  • Acute pulmonary oedema
  • New-onset headache, visual disturbances, or seizures that cannot be accounted for by other diagnoses
• If a woman is suspected to have pre-eclampsia (e.g. with gestational hypertension or chronic hypertension), the NICE guidelines (2019) recommend the use of placental growth factor (PlGF) testing to help rule out the possibility of pre-eclampsia.
  • PlGF is a hormone that is released by the placenta and stimulates angiogenesis (formation of new blood vessels)
  • The levels of PlGF will be low in pre-eclampsia
  • The test should be offered between 20 weeks and 36 weeks and 6 days of pregnancy

Management

Here is a comprehensive overview of the management of all hypertensive disorders in pregnancy, including chronic hypertension, gestational hypertension, and pre-eclampsia:

Complications

If Hypertension in pregnancy is left unmanaged, it can lead to maternal and foetal complications. 

Foetal Complications: Intrauterine growth restriction, premature birth, and stillbirth due to inadequate blood supply to the placenta.

Maternal Complications: Disseminated Intravascular Coagulation (DIC), liver rupture or haematoma, acute kidney injury (AKI), pulmonary oedema, placental abruption, and, in severe cases, maternal death.