disorders of pregnancy

Question 1

Which countries is pre-eclampsia more common in?

Answer 1

africa & asia

Question 2

What is pre-eclampsia defined as?

Answer 2

New-onset hypertension (previously normotensive) >140mmHg systolic and /or >90mmHg diastolic, most often after 20wks gestation

Question 3

What are common symptoms seen with pre-eclampsia?

what could you see on ultrasound? what symptoms are linked with high risk of developing severe PE/eclampsia?

Answer 3

• Reduced fetal movement &/or amniotic fluid volume on ultrasound (30% of cases).
• Oedema common.
• Headahce (40% of severe PE)
• visual disturbances, seizures, breathlessness associated with severe PE & risk of eclampsia (seizures)

Question 4

what is eclapsia?

Answer 4

seizures

Question 5

What does the presence of protein in urine show?

Answer 5

Important to differentiate between pre-eclampsia and gestational hypertension (but not always)

Question 6

What are the subtypes of pre-eclampsia and what is each subtype associated with?

Answer 6

1. early onset <34 wks is associated with both fetal & maternal symptoms and changes in placental structure.
2. late onset > 34 wks - more common and mostly maternal symptoms with fetus generally ok, less overt/no placental changes

Question 7

What are maternal risk factors for pre-eclampsia?

Answer 7

Previous pregnancy with pre-eclampsia, BMI>30 (esp. >35), family history, increased maternal age (>40, maybe <20), gestational hypertension or previous hypertension, diabetes, PCOS, renal disease, sub-fertility, autoimmune disease, non-natural cycle IVF

Question 8

What are the risks to the mother with pre-eclampsia?

Answer 8

• Damage to kidneys, brain, liver etc.
• placental abruption (separation of placenta from endometrium)
• might progress to eclampsia (seizures, loss of consciousness)

Question 9

What are the risks to the fetus with pre-eclampsia?

Answer 9

• Reduced fetal growth,
• pre-term birth,
• pregnancy loss/stillbirth

Question 10

What do extra-villous trophoblast cells (EVT) do usually and what happens in Pre-eclampsia?

Answer 10

• EVT cells usually invade maternal spiral arteries for endothelial & smooth muscle breakdown. Spiral arteries despiralise to become high capacity low resistance vessels for better exchange.
• In early PE, EVT invasion of spiral arteries limited to decidual layer so spiral arteries not remodelled completely and cant keep up with demands so placental perfusion restricted.
• In late PE, normal remodelling so fetus is ok.

Question 11

What is PLGF (placental growth factor) and what does it do?

Answer 11

• PLGF is VEGF related.
• pro-angiogenic factor released in large amounts by placenta).
• These leave placenta to get into maternal circulation and are bioavailable signalling endothelial cells for anti-coagulant/vasodilatory factors.

Question 12

What is FLt1?

Answer 12

Soluble receptor for VEFG-like factors, binding soluble angiogenic factors limiting their availability (PLGF, VEGF)

Question 13

In terms of Flt1 and PLGF, what happens in pre-eclampsia?

Answer 13

-Excess production of Flt1 and less of PLFG so reduction in available pro-angiogenic factors in maternal circulation leads to maternal endothelial dysfunction (pro-coagulant & vasoconstrictive factors).

Question 14

What is the role of extra-cellular vesicles on pre-eclampsia?

Answer 14

Something about them alters normal physiology (maybe for late-onset form)

Question 15

What can be used to predict the onset of PE?

Answer 15

• PLGF alone (triage test) - if low high risk of PE (normal is 100, <12 highly abnormal). Rules out PE in next 14 days in women 20-36wks.
• sFLt-1/PLGF ratio if less than 38 normal, if greater than 38 risk of PE.

Question 16

What is management for pre-eclampsia?

Answer 16

• Delivery of placenta.
• If <34 wks try to maintain pregnancy if possible for fetus health.
• If >37wks delivery preferable.
• In between case-to-case.
• Try treating with anti-hypertensives (carefully because may affect fetus).
• Can give corticosteroids for <34wks to promote fetal lung development before delivery.

Question 17

What can be done for prevention of pre-eclampsia?

Answer 17

Weight loss (esp >35 BMI), exercise throughout pregnancy independent of BMI, low dose aspirin from end of 1st trimester (11-14 wks) for high risk groups (may only prevent early onset)

Question 18

What are the long-term impacts of pre-eclampsia on the mother after pregnancy?

Answer 18

High risk of CV disease, T2D, renal disease because of endothelial dysfunction and hypertensive episode.
- Risk of further PE pregnacy. If early onset PE bigger risk.