28/29. preclampsia.Eclampsia , eclampsia sine eclampsia and HELLP syndrome. Etiology , symptoms , diagnosis and treatment.

Question 1

what is eclampsia ?

Answer 1

Preeclampsia when complicated with onset of seizures (generalized tonic-clonic convulsions) and/or coma

Question 2

risk factors for eclampsia/preeclampsia

Answer 2

Risk factors for eclampsia is preeclampsia

etiology of preeclampsia unknown

Risk factors for pre eclampsia :
> primigravida!

> family history

> diabetes

> molar pregnancy

> multiple gestation

> obesity

> smoking

> preexisting vascular disease - antiphospholipd syndrome

> Kidney disease

> thrmbophilia - protein C,S deficiency

Question 3

when does elampsia occur

Answer 3

Onset may be before, during, or after delivery. (going in order of most to least)

Most often in third trim and More often, labor starts soon after and at times, it is impossible to differentiate it from intrapartum eclampsia

Question 4

describe the eclampsia seizures ?

Answer 4

4 stages
stage 1 – Unless the woman is aware and watching for this stage, it is generally missed. In stage one the woman will simply roll her eyes, and simultaneously, her hand a face muscles will slightly twitch.

Stage 2 tonic – teeth will clench,
the arms and legs will go rigid,
biting of tongue,
face and hand muscles that where twitching will now be clenching.
the woman will also experience loss of breath for approximately 30 seconds.

clonic -Stage 3 – The muscles will begin to jerk violently,
while frothy and slightly bloody saliva will appear.
2 minutes of this until it stops

Stage 4 – If not dead, the woman will fall into a deep unconscious coma state. This can persist for hours, or pass quickly

Following the seizure there is typically either a brief period of confusion or coma

temperature also rises

when the fits happen in quick succession =status eclampticu

Question 5

diagnosis of eclampsia ?

Answer 5

through seizure
If the systolic blood pressure is greater than 160 or the diastolic pressure is greater than 110, the hypertension is considered to be severe
proteinurea

Question 6

how can we prevent eclampsia ?

Answer 6

proceeded by severe preeclampsia = early detection

magnesium sulfate

and termination of pregnancy during preeclampsia state

Prevent preeclampsia - by taking aspirin,
and calcium supplements

eclampsia can occur bypassing the preeclamptic state and as such, it is not always a preventable condition

Question 7

what are the monitoring constantly done in eclampsia ?

Answer 7

pulse

repsiration

blood pressure

oximetry

urinary output - though foley catheter catheter insertion
total

fetal heart rate monitored - bradycardia is common after convulsion

Question 8

what is the clinical managment of eclampsia ?

Answer 8

magnesium sulfate - continued for 24 hours after the last seizure
(refectory -midazolam IV is given )

maintain airways and ensure oxygenation 
intubation - unconscious after post seizure 
aspiration 
persistant hypoxia 
uncontrolled seizures 

kept in a railed cot. tongue blade is inserted between the teeth.
She is kept in the lateral decubitus position to avoid aspiration.
Vomitus and oral secretions are removed by frequent suctioning

blood pressure medications - methyl dopa , nifedipine ,labetolol

diuretics if pulmonary edema

emergency delivery of the baby
if fits controlled then vaginally or not controlled by cesarean section

fluids
crystalloid - ringer solution (who knows)

Question 9

when should magnesium sulphate be stopped ?

Answer 9

magnesium toxicity

Loss of deep tendon reflexes
 Decreased respiratory rate (<12 per minute)
 Urine output (< 30 mL/h)
 Chest pain, heart block

give calcium gluconate

Question 10

what is the management in status eclampticus ?

Answer 10

Thiopentone sodium dissolved in 5% dextrose is given intravenously very slowly

Question 11

what are the complication in eclampsia on fetus and placenta?

Answer 11

intrauterine growth restriction - child appearing small for gestational age or being born with low birth weight.

The placenta may bleed (hemorrhage) or it may begin to separate from the wall of the uterus.

placental insufficiency - reduced blood flow to fetus is a key mechanism in eclampsia

Question 12

what is the complication from eclampsia to the mother?

Answer 12

aspiration pneumonia,

cerebral hemorrhage

kidney failure - anuria - dopamine infusion given

hyperpyrexia

psychosis - Chlorpromazine

cardiac arrest

blurry vision,

one-sided blindness- ether temp or perm due to retinal detachment

Question 13

Pregnancy-induced hypertensions (PIH)?

and not pregnancy induced

Answer 13

gestational hypertension,

preeclampsia and eclampsia.

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chronic hypertension in pregnancy

Question 14

what is preeclampsia ?

Answer 14

multisystem disorder of unknown etiology

hypertension to the extent of 140/90 mm Hg or more with proteinuria after the 20th week in a previously normotensive and nonproteinuric woman

Question 15

what are the clinical signs and symptoms of precemplampsia ?

Answer 15

occur in the following order
- earliest rapid gain in weight

-pitting edema over the ankles after 12hrs bed rest
swelling may extend to the face, abdominal wall, vulva

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pulmonary edema - dyspnea

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Alarming symptoms- acute onset of the syndrome
(1)Headache — located over the occipital or frontal region
(2) Disturbed sleep
(3) Diminished urinary output— of less than 400 mL in 24
(4) Epigastric pain—associated with vomiting
(5) Eye symptoms—there may be blurring, scotomata, dimness of vision

Question 16

diagnostic criteria for preeclampsia ?

Answer 16

ophthalmic - rental edema and capillary hemorrhage , retinal arteriole contrition

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blood - serum uric acid level (biochemical marker of preeclampsia) of more than 4.5 mg/dL

increase in hepatic enzymes

thrombocytopenia and abnormal coagulation profile

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Antenatal fetal monitoring-
daily fetal kick count,

ultrasonography for fetal growth and amniotic fluid pocket pockets,

cardiotocography,

umbilical artery flow velocimetry biophysical profile

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**
atleast 140/90
on atleast two separate occasions, 6 hours apart and in a woman after twenty weeks of pregnancy

last feature of PRECLAMSIA TO OCCUR
proteinurea dipstick - >0.3g in 24hr

Question 17

screening for prediction of preeclampsia ?

Answer 17

Doppler ultrasound high resistance index in the uterine artery,

Presence of diastolic notch at 24 weeks’ gestation in the uterine artery possible development of preeclampsia

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Development of renal dysfunction: Rise
of serum uric acid
of microalbuinuria are observed to be the

 Average mean arterial pressure (MAP) in second trimester > 90 mm Hg may predict the onset.

 Maternal serum level of SFlt-1 is increased in women with preeclampsia.

Question 18

what is the uteroplacental bed and hematological pathophysiological changes in preeclampsia ?

Answer 18

uteroplacental bed : premature aging of the placenta

acute red infarcts and white infarcts are visible on the maternal surface of the placenta

normal endovascular invasion of cytotrophoblast into the spiral arteries fails to occur beyond decidua-myometrial junction
which should make large vessels of low resistance

musculoelastic media in the myometrial segment remains responsive to vasoconstrictor stimuli resulting in decreased blood flow

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increase in blood volume in normal pregnancy is not evident
in severe preeclampsia.

Due to vasospastic state, the intravascular fluid is forced out into the extravascular space.

Thus, there is hemoconcentration with increased hematocrit values.

Question 19

what is the neurological pathophysiology on the brain due to pre-eclampsia ?

Answer 19

Posterior (Occipital and Parietal Lobes) Reversible Encephalopathy Syndrome (PRES) is a

transient neuroradiological entity due to hypertension

generalized seizures, altered mental status, headache and vision changes.

The hallmark of diagnosis is bilateral symmetrical vasogenic edema in the occipital and posterior parietal lobes. It is evident on T2-weighted MRI images

Question 20

clinical types of preeclampsia ?

Answer 20

mild -sustained rise of blood pressure more than 140/90 mm Hg but less than 160 mm Hg /110 mm Hg
and without significant proteinuria.

severe -persistent systolic blood pressure above or equal to 160/110 mm Hg.

(2) Protein excretion of more than 5 g/24 h
(3) Oliguria (<400 mL/24 h).
(4) Platelet count less than 100,000/mm3.
(5) HELLP syndrome.
(6) Cerebral or visual disturbances.
(7) Persistent severe epigastric pain.
(8) Retinal hemorrhages, exudates or papilledema.
(9) Intrauterine growth restriction of the fetus.
(10) Pulmonary edema

Question 21

what is the pathophysiological changes in the kidney due to preeclampsia ?

Answer 21

kidney -glomerular endotheliosis). Endothelial cells swell up lumen may be occluded.

fibrin-like deposits occur in the basement membrane.

mesangial cells in between the capillaries proliferate.

spasm of the afferent glomerular arterioles.

damage of the tubular epithelium due to anoxia

. The net effects are reduced renal blood flow and glomerular filtration rate , and impaired tubular reabsorption or secretory function. Recovery is likely to be complete following delivery.

Question 22

what is the pathophysiological changes in the liver due to preeclampsia ?

Answer 22

liver : Periportal hemorrhagic necrosis of the liver occurs due to thrombosis of the arterioles. The necrosis starts at the periphery of the lobule. There may be subcapsular hematoma

Question 23

Preventive measures against pre-eclampsia

Answer 23

Low-dose aspirin- inpotentially high risk patients

Calcium supplementation of at least 1 gram per day is recommended

diet rich in protein

stop smoking if they do

Question 24

management of preeclampsia

Answer 24

Partial control of the preeclampsia but the blood pressure maintains a steady high level
and
If the pregnancy is beyond 37 completed weeks
do the definitive treatment for pre-eclampsia is the delivery of the baby and placenta.

If less than 37 weeks treatment may be extended at least up to 34 week

Persistently increasing BP to severe level, despite the use of antihypertensive
Termination of pregnancy considered irrespective of duration of gestation. Seizure prophylaxis (magnesium sulfate) should be started Steroid therapy is considered if the duration of pregnancy is less than 34 weeks. It prevents neonatal RDS, IVH and maternal thrombocytopenia

= c section
Epidural anesthesia is preferred, unless there is coagulopathy
safe if the platelet count is >50,,000/mm3
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Rest- in left-lateral position as much as possible, to lessen the effects of vena caval compression

high-protein diet

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diuretics only prescribed when - Cardiac failure, Pulmonary edema, Massive edema

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antihypertensives used when
diastolic pressure is over 110 mm Hg
more urgent if associated with proteinuria.

methyl-dopa
Labetalol,
Hydralazine and Nifedipine are commonly

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intrapartum and postpartum administration of magnesium sulfate is recommended in severe pre-eclampsia for the prevention of eclampsia

Question 25

what is the HELLP syndrome ?

Answer 25

Hemolysis (H),
Elevated Liver enzymes (EL)
Low Platelet count (LP) (<100,000/mm3)

rare complication of preeclampsia

develop even without maternal hypertension.

Question 26

manifestations of the HELLP syndrome ?

Answer 26

nausea,
vomiting,
epigastric or right upper quadrant pain

Question 27

management for HELLP?

Answer 27

prophylaxis with magnesium sulfate

Administration of corticosteroid
(↑ thrombocyte count, ↑ urinary output)

c-section mode of delivery

Platelet . fresh frozen plasma transfusion should be given if the count is <50,000/mm3

blood transfusion - anemia

blood pressure reduction

Question 28

complication of preclampsia ?

Answer 28

maternal :

Eclampsia

PROM / preterm labour

Cerebral hemorrhage

HELLP syndrome

placental abruption

cardiac failure

renal failure

PPH

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Fetal
Intrauterine death— spasm of uteroplacental circulation leading to accidental hemorrhage or acute red infarction,

Intrauterine growth restriction— due to placental insufficiency,

Asphyxia

Prematurity—due to spontaneous preterm onset of labor

Question 29

what is the management of labour in preeclampsia

Answer 29

Blood pressure tends to rise during labor and convulsions may occur due to stress hormone

Antihypertensive drugs are given if the blood pressure becomes high

Prophylactic MgSO4 is started when systolic BP >160 diastolic >110, MAP >125 mm Hg

Labor duration is reduced by low rupture of the membranes in the first stage;

and forceps or ventouse in second stage.

Intravenous ergometrine following the delivery of the anterior shoulder is withheld! as it may cause further rise of blood pressure

no contraindication of syntocinon IM or slow IV

Question 30

preeclampsia patients should be watched how long after delivery ?

Answer 30

watched closely for at least 48 hours, the period during which convulsions usually occur. Antihypertensive drug treatment should be continued if the BP is high

Question 31

what is gestational hypertension ?

Answer 31

sustained rise of blood pressure to 140/90 mm Hg or more on at least two occasions 4 or more hours apart ,after the 20th week of pregnancy or within the first 48 hours of delivery in a previously normotensive woman

generally not associated with
edema or proteinuria or any of the other pathophysiological changes in preeclampsia

Majority of cases more than or equal to 37 weeks pregnancy

and it goes after 12 weeks following delivery

Question 32

what is the management of gestational hypertension ?

Answer 32

no longer any real differences in management between PE and gestational HTN, in terms of BP management and in the decision to deliver.

Question 33

what is chronic hypertension in pregnancy ?

Answer 33

defined as the presence of hypertension of 140/90 or more before the 20th week of pregnancy and beyond the 12 weeks after delivery

Question 34

what is atypical preeclampsia ?

Answer 34

development of preeclampsia (even eclampsia) without fulfilling the standard criteria (hypertension or proteinuria).

The common presentations are:

Early onset preeclampsia/eclampsia in less than 20 weeks

Late postpartum preeclampsia, eclampsia more than 48 hours postpartum