Medical Disorders

Question 1

What is pre-eclampsia?

Answer 1

A hypertensive disorder that can occur during pregnancy.
A placental disease which affects up to 5% of women in their first pregnancy.
In its most severe form, can result in catastrophic maternal and/or foetal compromise.

Question 2

Describe the pathophysiology of pre-eclampsia.

Answer 2

Poor placental perfusion secondary to abnormal placentation.
Remodelling of spiral arteries incomplete resulting in a high-resistance, low-flow uteroplacental circulation as the constrictive muscular walls of the spiral arteries are maintained.
Results in increased BP, hypoxia and oxidative stress from poor uteroplacental perfusion and resultant systemic inflammatory response and endothelial cell dysfunction resulting in leaky blood vessels.

Question 3

What are the moderate risk factors for pre-eclampsia?

Answer 3

Nulliparity
Maternal age 40+
Maternal BMI 35+ at initial presentation 
Pregnancy interval over 10 years
Multiple pregnacy

Question 4

What are the high risk factors for pre-eclampsia?

Answer 4

Chronic hypertension
HTN, pre-eclampsia or eclampsia in previous pregnancy
Pre-existing CKD
Diabetes mellitus
Autoimmune disease (SLE, antiphospholipid etc.)

Question 5

When is prophylaxis given for pre-eclampsia and what is given?

Answer 5

1 high risk factor or 2+ moderate risk factors
Low dose aspirin (75mg) a day
Should be continued from 12 weeks gestation until birth

Question 6

What are the clinical features of pre-eclampsia?

Answer 6

Hypertension (sys > 140, dia > 90) on 2 occasions 4 hours apart
Significant proteinuria - >300 in a 24-hour urine sample/>30 protein:creatinine
In a woman over 20 weeks gestation
Asymptomatic
Headaches (usually frontal)
Visual disturbances
Epigastric pain (due to hepatic capsule distension/infarction)
Sudden onset non-dependent oedema
Hyper-reflexia

Question 7

What is the classification of pre-eclampsia?

Answer 7

Mild: BP 140/90 - 149/99
Moderate: 150/100-159/109
Severe: BP>160/110 + proteinuria > 0.5g
Or
BP > 140/90 + proteinuria + symptoms

Question 8

What are the maternal complications of pre-eclampsia?

Answer 8

HELLP syndrome 
Eclampsia
AKI
DIC
ARDS
HTN
Cerebrovascular haemorrhage
Death

Question 9

What is HELLP syndrome?

Answer 9

Haemolysis
Elevated liver enzymes
Low platelets

Question 10

Onset of pre-eclampsia before how many weeks gestation is associated with poorer prognosis?

Answer 10

34 weeks

Question 11

What are the foetal complications of pre-eclampsia?

Answer 11

Prematurity (iatrogenic and idiopathic)
Intrauterine growth restriction
Placental abruption
Intrauterine foetal death

Question 12

What are the differentials for pre-eclampsia?

Answer 12

Essential HTN (prior to 20 weeks)
Pregnancy induced HTN (new onset HTN presenting after 20 weeks without significant proteinuria)
Eclampsia (pre-eclampsia + seizure) - this is an obstetric emergency

Question 13

What investigations are done for pre-eclampsia?

Answer 13

Diagnosed by the presence of HTN and proteinuria so need to do BP and urine dip (HTN quantify through a 24-hour urinary collection)
Other tests for organ dysfunction:
- FBC - low Hb and platelets
- U&Es - high urea, creatinine and urate; low urine output
- LFTs - raised ALT and AST

Question 14

What are the aims of management for pre-eclampsia?

Answer 14

Prevent development of eclampsia

Minimise risk of complications to the mother and foetus

Question 15

What monitoring is required for pre-eclampsia?

Answer 15

Monitor foetal and maternal wellbeing through regular BP, urinalysis, blood tests, foetal growth scans and CTG.
The degree and frequency of monitoring increases with the severity.

Question 16

Outline the management for pre-eclampsia.

Answer 16

VTE prevention (LMWH)
Anti-HTN (reduce risk of maternal haemorrhagic stroke)
- severity of HTN correlates with stroke risk
Delivery (only definitive cure) - prolonging pregnancy only benefits the foetus
- if delivery under 35 weeks - IM steroids t aid foetal lung development

Question 17

Which anti-hypertensives are used in pregnancy?

Answer 17

Labetalol (1st line)
Nifedipine
Methyldopa (alpha agonist)

ACEi contraindicated in pregnancy due to association with congenital abnormalities

Question 18

What is the post-natal care for pre-eclampsia?

Answer 18

Pre-eclampsia resolves following delivery of the placenta
Monitor mother for 24 hours (still at risk of eclamptic seizures)
Safe by day 5
BP monitored daily for the first 2 days then once every 3-5 days post-partum and need for anti-HTN assessed.
Advice on risk of developing pregnancy-induced HTN/pre-eclampsia in subsequent pregnancies

Question 19

What is hyperemesis gravidarum?

Answer 19

Persistent and severe vomiting during pregnancy leading to weight loss, dehydration and electrolyte imbalance

Question 20

What is NVP?

Answer 20

Starts between 4 and 7 weeks gestation and reaches a peak on the 9th week.
Settles by week 20 in 90%.

Question 21

When is hyperemesis gravidarum diagnosed?

Answer 21

Over 5% pre-pregnancy weight loss
Dehydration
Electrolyte imbalances

Question 22

What is the pathophysiology of hyperemesisi gravidarum?

Answer 22

Rapidly increasing beta HCGreleased by the placenta
Stimulates the chemoreceptors trigger zone in the brainstem
Feeds into the vomiting centre of the brain

Question 23

What are the risk factors for hyperemesis gravidarum?

Answer 23

First pregnancy
Previous history
Raised BMI
Multiple pregnancy
Hydatidiform mole

Question 24

What scoring system is used to classify the severity of HG?

Answer 24

Pregnancy-unique quantification of emesis (PUQE)
6 - mil
7-12 - moderate
13-15 - severe

Question 25

What questions should be asked in the history for HG?

Answer 25

Age, parity, gestation
HPC
Frequency of vomiting
Oral intake
Weight loss
Urinary symptoms
Bowel habit
PMH of HG/thyroid disease
DHx including antiemetic used

Question 26

What should you look for on examination of someone with HG?

Answer 26

Obs
Signs of dehydration
Signs of uncle wasting
Abdo exam
Etc.

Question 27

What are the differentials for hyperemesis gravidarum?

Answer 27

NV in pregnancy
Gastroenteritis
Cholecystitis
Hepatitis
Pancreatitis
Chronic h pylori infection
Peptic ulcers
UTI/pyelonephritis
Metabolic conditions
Neurological conditions
Drug-induced

Question 28

What are the investigations for HG?

Answer 28

Weight
Urine dip (quantify ketonuria)
Midstream urine
FBC (anaemia, infection, haematocrit)
U+Es (hypokalaemia, hyponatraemia, dehydration, renal disease)
LFTs (exclude liver disease e.g. hepatitis, gallstones and monitor malnutrition)
Amylase (exclude pancreatitis)
TFTs (hypo/hyperthyroid)
ABG (exclude metabolic disturbances, monitor severity)
USS (confirm viability, confirm gestation, exclude multiple pregnancy and trophoblastic disease)

Question 29

What is the management for mild HG?

Answer 29

Managed in the community with oral antiemetics, oral hydrate, dietary advice and reassurance.

Question 30

What is the management of moderate HG/cases where community management has failed?

Answer 30

Managed with ambulatory daycare
IV fluids, parenteral antiemetics and thiamine
Managed until ketonuria resolves

Question 31

What is the management for severe HG?

Answer 31

Inpatient management.

IV rehydration with 0.9% saline (potassium chloride added as guided by electrolyte monitoring)

Question 32

What are some of the additional therapies for HG?

Answer 32

H2 receptor antagonists/PPi - for reflux, oesophagitis or gastritis
Thiamine- for prolonged vomiting to prevent Wernicke’s encephalopathy
Thromboprophylaxis for all women requiring admission

Question 33

What are the recommended antiemetic therapies?

Answer 33

First line:
- cyclizine, prochlorperazine, promethazine, chlorpromazine

Second line:
- metoclopramide (max 5 days due to EPSE risk), domperidone, ondansetron

Third line:
IV hydrocortisone (once symptoms improve, convert to prednisolone PO and gradually reduce dose until maintenance dose is reached)