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Y5 Gynae & Obstetrics > PET > Flashcards

PET Flashcards

1
Q

What is PET?

A

Hypertension of at least 140/90mmHg recorded on 2 separate occasions min 4h apart
+ presence of min 300mg protein in 24h collection of urine

arising de novo after 20th week of pregnancy
in prior normotensive woman
resolving spontaneously by 6th week pp

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2
Q

What investigation is done more commonly to detect proteinuria?

A

Protein: creatinine ratio

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3
Q

What level of protein:creatinine ratio is abnormal

A

> 0.3mg/dL

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4
Q

What is proteinuria an indication of?

A

Renal damage

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5
Q

When does PET become eclampsia??

A

When she has a seizure

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6
Q

What are RF for PET?

A

High RF:

  • prior HTN in prior pregnancy
  • chronic HTN
  • CKD
  • AI disease
  • T1/T2 DM

Moderate RF:

  • FH PET
  • First pregnancy OR >10 years from first baby
  • Age > 40
  • BMI> 35
  • Booking diastolic >80
  • Multiple pregnancy
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7
Q

What abnormal types of pregnancy can PET occur in, and what does this suggest?

A

PET can occur in pregnancies lacking a foetus (MOLAR PREGNANCIES)
This means it is a TROPHOBLAST issue

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8
Q

Explain the stages of PET

A
  1. Spiral arteries maintain their muscular wall > poorly implanted placenta > uteroplacental ischaemia
  2. Uteroplacental ischaemia causes oxidative and inflammatory stress > involvement of secondary mediators > endothelial dysfunction, vasospasm, activation of coal system
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9
Q

What systems are affected in the mother by PET? (Go top to bottom)

A

PET is a SYSTEMIC disease:

Neuro
CV 
Resp
Liver 
Renal
Haem
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10
Q

How is Neuro system affected by PET?

A

cerebral irritation, vasospasm, cerebral oedema
- hyperreflexia, clonus
.- ECLAMPSIA (tonic clonic seizures)

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11
Q

How is the CV system affected by PET?

A
  • peripheral vasoconstriction > hypertension

- HTN + loss of endothelial cell integrity > generalised oedema

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12
Q

How is the resp system affected by PET?

A

Endothelial permeability > pulmonary oedema > ARDS

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13
Q

How is the liver system affected by PET?

A

Endothelial cell injury > thrombi in microvasculature > damage to liver
causes epigastric pain, N&V
EXCLUDE HELLP

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14
Q

How is the renal system affected by PET?

A

glomeruloendotheliosis

> impaired glomerular filtration, selective protein ,.oss, proteinuria

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15
Q

How is the haem system affected by PET?

A

Diffuse vascular damager > abnormal clotting > reduced platelet count, increased fibrin deposition

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16
Q

Explain HELLP syndrome

A

Haemolysis
Elevated Liver enzymes
Low Platelets

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17
Q

What are sx of HELLP syndrome?

A

All sx of PET
+ severe epigastric pain
+ dark urine

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18
Q

What are sx of PET?

A

Neuro: frontal headache, blurred vision, scotoma,
Liver: epigastric pain, nausea and vomiting
Renal: reduced urinary output (oliguria), dark urine
CV: generalised oedema

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19
Q

Why does epigastric pain occur in PET?

A

Reduced blood flow to liver > liver injury > liver enzymes are released > stretched liver capsurle

20
Q

How do you categorise PET complications?

A

maternal
foetal

Can cause maternal or foetal death

21
Q

What are maternal complications of PET?

A

MATERNAL:

  • Eclampsia
  • Haemorrhagic stroke (CV accident)
  • Pulmonary oedema
  • HELLP
  • DIC
  • Liver failure
  • Renal failure
  • Placental abruption
22
Q

What are foetal complications of PET?

A

IUGR
Preterm birth
Foetal hypoxia
Stillbirth

23
Q

What is condition - specific tx for HELLP?

A

+ IV mg sulphate

+ anti HTN therapy

24
Q

what investigations are necessary to confirm PET?

A 
Pregnant abdomen exam 
Neuro exam (hyperreflexia, clonus)
  • Obs (BP)
  • urine dipstick ++ (then exclude UTI by urine culture)
  • > 24 h urine collection OR protein : creatinine ratio (to quantify proteinuria)
25
Q

What investigations are necessary to monitor maternal complications?

A

Maternal:

  • FBC: high haematocrit and Hb, low platelets
  • Clotting, coagulation screen: for DIC
  • U&E / serum renal profile: AKI
  • LFTs: raised in HELLP
  • FREQUENT REPEAT OF PROTEINURIA QUANTIFICATION
26
Q

What investigations are necessary to monitor foetal complications?

A
  • USS (TA/TV depending on gestation): monitor foetal growth
  • umbilical artery doppler scan
  • antenatal CTG
27
Q

When do you admit patient presenting with PET?

A

ALWAYS

28
Q

How do you manage PET pt with mild HTN?

A

admit to hospital
Measure BP min 4x daily
Monitor U&E, LFT, FBC, transaminases and bilirubin x2 weekly

29
Q

How do you manage PET pt with moderate HTN?

A

Admit to hospital
Give oral labetalol, aiming for BP <150/100
Monitor BP min 4x daily
Monitor U&E, LFT, FBC, transaminases and bilirubin x3 weekly

30
Q

How do you manage PET pt with severe HTN?

A

Admit to hospital
Give oral labetalol, aiming for BP <150/100
Monitor BP more than 4x daily depending on circumstances
Monitor U&E, LFT, FBC, transaminases and bilirubin x3 weekly

31
Q

How do you manage PET medically in pregnancy?=

A 
Oral labetalol (beta blocker)
OR Nifedipine / Methyldopa
32
Q

Who is labetalol contraindicated in?

A

Asthmatics (assess if poorly controlled)

33
Q

What do you give to manage PET after pregnancy=

A

Atenolol (alpha blocker)

34
Q

How do you manage eclampsia? (condition specific tx)

A

magnesium sulphate IV
loading bolus of 4g over 5 minutes
1g/h over 24h

35
Q

What medication given normally during labour is contraindicated in PET and why?

A

ERGOMETRINE - do NOT give in PET

Because it increases BP > can cause hypertensive crisis

36
Q

What medication can you give to prevent PET in high risk women?

A

low dose aspirin (75mg)

37
Q

What other management should you consider in someone with PET?

A

VTE risk!

Give TED stockings + consider prophylactic SC heparin (clean)

38
Q

What do you do about delivery in PET if the woman is responding well to tx prior to 34 weeks?

A

Iatrogenic premature delivery if often required

Manage pregnancy conservatively <34 weeks
Set maternal and foetal threshold for elective birth <34 wks
Write plan for foetal monitoring during birth

39
Q

When do you recommend delivery in PET?

A
  • severe HTN: after 34 weeks (if BP is under control and corticosteroid course given)
  • mild/moderate HTN: at 34-37 weeks depending on foetal/maternal condition
  • mild-moderate HTN >37 wks: in 24/48h !!!
40
Q

When after birth should PET resolve?

A

Within 6 weeks

Otherwise consider chronic HTN / renal disease

41
Q

What women can be managed as outpatients?

A

If mild-moderate HTN, no proteinuria

42
Q

How do you manage pregnant women with mild-moderate HTN, no proteinuria

A

Repeat BP and urinalysis x2 weekly

TAUSS every 2-4wks

43
Q

How do you deliver babies in PET?

A

<34 weeks: ELCS

>34 weeks: IOL

44
Q

What can you give during labour for PET to help keep down BP?

A

Epidural

45
Q

What must you be aware of if PET lady has vaginal delivery?

A

Avoid maternal pushing if BP reaches 160/110 in second stage
As this means high ICP > high risk cerebral haemorrhage

46
Q

What do you use in third stage for PET lady, and instead of what?

A

Use oxytocin instead of ergometrinew

Y5 Gynae & Obstetrics (34 decks)

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