Voiceover: Welcome to NP certification Q&A presented by Fitzgerald Health Education Associates. This podcast is for students studying to pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Dr. Margaret Fitzgerald shares her knowledge and experience to help you dissect the anatomy of a test question, so you can better understand how to arrive at the correct test answer. 

So, if you're ready, let's jump right in. 

 Margaret Fitzgerald: A 25-year-old woman, gravida 2 para 1, is 24 weeks pregnant, and is being seen for an urgent care visit. She reports a constant headache over the past 2 days, along with ankle swelling. Her BP today is 162/86, which is a significant elevation from her pre-pregnancy blood pressure of 122/68. Laboratory results indicate 2+ proteinuria, as well as elevated ALT and AST. 

 Platelets and LDH are within normal limits, as is fundoscopic and neurological exams. The most likely diagnosis is: 

A: HELLP syndrome. 

B: Gestational hypertension. 

C: Preeclampsia. 

D: Hypertensive emergency. 

And the correct answer is C: Preeclampsia. Where do we start with this question? First, determine what kind of a question this is. Clearly it is a diagnosis question because we're given her clinical presentation and then being asked what's the most likely diagnosis. 

 First, some background information. Hypertensive disorders of pregnancy is an umbrella term that includes preexisting hypertension, in other words, a woman who enters a pregnancy with previous primary hypertension; gestational hypertension, where obviously the high blood pressure develops during the pregnancy; plus pre-eclampsia and eclampsia. These complicate up to 10% of all pregnancies and represent a significant cause of maternal and perinatal morbidity and mortality. 

 There are a number of types of the hypertensive disorders, such as I mentioned, the chronic hypertension woman enters the pregnancy with elevated blood pressure. And then the others are what are considered to be acquired hypertensive disorders. Preeclampsia, which is what we're talking about here, is defined as new-onset hypertension and with evidence of nuance at target organ dysfunction and is noted after 20 weeks of gestation. 

While proteinuria is a common finding in preeclampsia, the condition can be diagnosed in its absence, but only when there are additional TOD findings, including elevated hepatic enzymes, evidence of renal insufficiency, edema, and neurological alterations including headache. Now, the blood pressure threshold in preeclampsia is 140/90 or higher on two readings at least 4 hours apart, or 160/110 or higher on a single reading. 

When proteinuria is noted, it's usually on the UA dip, and it will be 2+ or greater. The pathophysiology of preeclampsia is not fully understood, but it's believed to be the interplay of abnormal placental development and endothelial dysfunction in immunologic alterations, particularly in the face of genetic susceptibility. In an upcoming podcast, I'll go over the major risk factors for the development of preeclampsia. 

 With this background in mind, let's take a look at this question one more time. A 25-year-old woman, gravida 2 para 1, is 24 weeks pregnant, and is being seen for an urgent care visit. She reports a constant headache over the past 2 days, as well as ankle swelling. Her blood pressure today is 162/86, which is a significant elevation from her pre-pregnancy blood pressure of 122/68. 

 Laboratory results include 2+ proteinuria, as well as elevated ALT and AST. Platelets are within normal limits and fundoscopic and neuro exams are unremarkable. The most likely diagnosis is A: HELLP syndrome. The HELLP, which is spelled h, e, l, l, p in HELLP syndrome, stands for hemolysis, elevated liver enzymes, and low platelets. We're told that her platelets are within normal limits, as is their LDH. 

 And just keep in mind that the red blood cell contains a lot of LDH. And when red blood cells hemolyze, the LDH will take a real spike up. So, the fact that she has normal platelets in a normal LDH really leans away from her having HELLP syndrome. By the way, there are a couple of schools of thought with HELLP syndrome, and one of them is that the condition represents severe preeclampsia or that in fact, HELLP syndrome is an entirely different disorder that is simply seen more often in people who already have preeclampsia. 

 B: Gestational hypertension. This is incorrect. Gestational hypertension is defined as the de novo presence of elevated blood pressure during pregnancy, with de novo being Latin for ‘anew’. In other words, nuance at elevated blood pressure during pregnancy but no evidence of renal, cardiac, or neurological dysfunction. That is noted with preeclampsia. So yeah she's got a headache. She's got protein in her urine. 

 This is not simply gestational hypertension. C: Preeclampsia of course this is the correct answer. The most important intervention in preeclampsia is to maintain that high index of suspicion in individuals who are considered at risk, promptly recognize the condition when it occurs, and referral to a provider with expertise in maintaining this complex condition that could threaten both life of the mother and the fetus is critical. 

 And you know what I want to say that last sentence a little louder for the people in the back. Do not let this slide, because intervention does work. And that when we look at maternal mortality, preeclampsia is one of the issues that is raised about late intervention in it. And we just don't want that to happen. So D: Hypertensive emergency. 

 This is of course incorrect. Hypertensive emergency most often occurs in patients with established hypertension who have marked blood pressure elevation usually greater than 180/greater than 120, accompanied by hypertensive target organ dysfunction. This TOD can include pulmonary edema, hypertensive retinopathy, which we were told she does not have an accelerated renal dysfunction. The other thing that's key this patient was normotensive prior to pregnancy. 

 And therefore we're looking at a pregnancy-related hypertensive disorder. Key takeaway: pregnancy is not a disease. It is not. In the majority of pregnancies, you do not have potential life-threatening complications like preeclampsia. But at the same time, youvmust be vigilant and be able to quickly recognize this condition and provide the means for appropriate intervention. 

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