Medical Disorders Flashcards by S V

What is pre-eclampsia?

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.

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Describe the pathophysiology of pre-eclampsia.

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.

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What are the moderate risk factors for pre-eclampsia?

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

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What are the high risk factors for pre-eclampsia?

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

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

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

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What are the clinical features of pre-eclampsia?

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

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What is the classification of pre-eclampsia?

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

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What are the maternal complications of pre-eclampsia?

HELLP syndrome 
Eclampsia
AKI
DIC
ARDS
HTN
Cerebrovascular haemorrhage
Death

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What is HELLP syndrome?

Haemolysis
Elevated liver enzymes
Low platelets

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

34 weeks

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What are the foetal complications of pre-eclampsia?

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

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What are the differentials for pre-eclampsia?

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

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What investigations are done for pre-eclampsia?

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

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What are the aims of management for pre-eclampsia?

Prevent development of eclampsia

Minimise risk of complications to the mother and foetus

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What monitoring is required for pre-eclampsia?

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.

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Outline the management for pre-eclampsia.

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

Which anti-hypertensives are used in pregnancy?

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

ACEi contraindicated in pregnancy due to association with congenital abnormalities

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

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

What is hyperemesis gravidarum?

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

What is NVP?

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

When is hyperemesis gravidarum diagnosed?

Over 5% pre-pregnancy weight loss
Dehydration
Electrolyte imbalances

What is the pathophysiology of hyperemesisi gravidarum?

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

What are the risk factors for hyperemesis gravidarum?

First pregnancy
Previous history
Raised BMI
Multiple pregnancy
Hydatidiform mole

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

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

What questions should be asked in the history for HG?

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

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

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

What are the differentials for hyperemesis gravidarum?

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

What are the investigations for HG?

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)

What is the management for mild HG?

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

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

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

What is the management for severe HG?

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

What are some of the additional therapies for HG?

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

What are the recommended antiemetic therapies?

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) ```