Case 4 - Pre eclampsia

Question 1

What extra questions do you ask in history?

What examinations and investigations do you wish to carry out?

Differential diagnosis

Treatment plan

Answer 1

• Visual changes
• Headaches
• upper abdo pain
• Swelling of legs
• bleeding (placental abruption)

Exam

• uterine and liver tenderness
• oedema
• hyperreflexia
• fundal height

tests - urine protein

Management 
-delay delivery till 38 weeks w careful monitoring until then 
-MG sulfate if neurological symptoms
-BP lowering meds
-Platelet infusion 
-

Question 2

How are hypertensive disorders in pregnancy defined?

Answer 2

GHTN - new onset HTN >20weeks gestation
Chronic HTN - prior to preg, or <20 weeks
Pre-eclampsia - HTN >20 weeks + involvement of more than one organ system

Question 3

Risk factors for gestational HTN, Preeclampsia

Answer 3

Chronic HTN
Previous pre eclampsia 
Fam history 
Obesity 
Diabetes 

Nulliparity 
Extremes of age
multiple pregnancies
renal or autoimmune disease
fetal hydrops or molar pregnancy

Question 4

Complications of pre-eclampsia for mother and baby

Answer 4

-preterm birth, fetal growth restriction

Question 5

Important features in history and exam will help assess the severity of disease?

Answer 5

• Visual changes
• Headaches
• upper abdo pain
• Swelling of legs
• bleeding (placental abruption)
• ask about fetal movements

Exam

• uterine and liver tenderness
• oedema
• hyperreflexia
• funal height
• BP high
• position of baby (sometimes not cephalic)
• fundoscopy

Question 6

What investigations for women and fetus are useful in assessing severity and progression of preeclampsia?

Answer 6

• FBC, platelets
• Uric acid, creatinine
• LFT - AST, ALT
• Urinary protein creatine ration 24 hr

Investigations - Fetal growth, amniotic fluid volume, umbilical artery doppler –> fetal wellbeing CTG

Question 7

How might some laboratory values (important in assessing preeclampsia) differ during pregnancy?
What is the pathophysiological basis behind abnormal results?

Answer 7

Creatinine is different - due to increased blood flow, increase GFR and decrease creatinine, so normal range is lower than normal

Haemoglobin - also decreased

Question 8

What drugs do we use to lower blood pressure during pregnancy and what is the rationale behind
their use?

Answer 8

BP >160/100 - methyldopa, labetolol, oxprenolol, nifedipine
>170/110 - short acting nifedipine, IV labetolol, hydralazine for emergency
-ACE inhibitors and diuretics are contraindicated in pregnancy

Question 9

Treatment

Answer 9

-Mgsulfate - prevention of eclampsia seizure in women with neurological symptoms and to prevent seizures.

Question 10

Why do we reduce BP in severe hypertension?

Answer 10

• To preventmaternal intracerebral haemorrhage and encephalopahty

Question 11

Why do we reduce BP in severe hypertension?

Answer 11

• To prevent maternal intracerebral haemorrhage and encephalopathy

Question 12

Prevention in high risk women

Answer 12

Aspirin 100mg started before 20weeks gestation.

Give to women with

• previous preeclampsia
• chronic hypertension
• renal disease
• preexisitng diabetes
• autoimmune disease
• pregnancy from oocyte donation
• combination of mod risk factors for preeclampsia