PET Flashcards
What is PET?
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
What investigation is done more commonly to detect proteinuria?
Protein: creatinine ratio
What level of protein:creatinine ratio is abnormal
> 0.3mg/dL
What is proteinuria an indication of?
Renal damage
When does PET become eclampsia??
When she has a seizure
What are RF for PET?
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
What abnormal types of pregnancy can PET occur in, and what does this suggest?
PET can occur in pregnancies lacking a foetus (MOLAR PREGNANCIES)
This means it is a TROPHOBLAST issue
Explain the stages of PET
- Spiral arteries maintain their muscular wall > poorly implanted placenta > uteroplacental ischaemia
- Uteroplacental ischaemia causes oxidative and inflammatory stress > involvement of secondary mediators > endothelial dysfunction, vasospasm, activation of coal system
What systems are affected in the mother by PET? (Go top to bottom)
PET is a SYSTEMIC disease:
Neuro CV Resp Liver Renal Haem
How is Neuro system affected by PET?
cerebral irritation, vasospasm, cerebral oedema
- hyperreflexia, clonus
.- ECLAMPSIA (tonic clonic seizures)
How is the CV system affected by PET?
- peripheral vasoconstriction > hypertension
- HTN + loss of endothelial cell integrity > generalised oedema
How is the resp system affected by PET?
Endothelial permeability > pulmonary oedema > ARDS
How is the liver system affected by PET?
Endothelial cell injury > thrombi in microvasculature > damage to liver
causes epigastric pain, N&V
EXCLUDE HELLP
How is the renal system affected by PET?
glomeruloendotheliosis
> impaired glomerular filtration, selective protein ,.oss, proteinuria
How is the haem system affected by PET?
Diffuse vascular damager > abnormal clotting > reduced platelet count, increased fibrin deposition
Explain HELLP syndrome
Haemolysis
Elevated Liver enzymes
Low Platelets
What are sx of HELLP syndrome?
All sx of PET
+ severe epigastric pain
+ dark urine
What are sx of PET?
Neuro: frontal headache, blurred vision, scotoma,
Liver: epigastric pain, nausea and vomiting
Renal: reduced urinary output (oliguria), dark urine
CV: generalised oedema
Why does epigastric pain occur in PET?
Reduced blood flow to liver > liver injury > liver enzymes are released > stretched liver capsurle
How do you categorise PET complications?
maternal
foetal
Can cause maternal or foetal death
What are maternal complications of PET?
MATERNAL:
- Eclampsia
- Haemorrhagic stroke (CV accident)
- Pulmonary oedema
- HELLP
- DIC
- Liver failure
- Renal failure
- Placental abruption
What are foetal complications of PET?
IUGR
Preterm birth
Foetal hypoxia
Stillbirth
What is condition - specific tx for HELLP?
+ IV mg sulphate
+ anti HTN therapy
what investigations are necessary to confirm PET?
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)
What investigations are necessary to monitor maternal complications?
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
What investigations are necessary to monitor foetal complications?
- USS (TA/TV depending on gestation): monitor foetal growth
- umbilical artery doppler scan
- antenatal CTG
When do you admit patient presenting with PET?
ALWAYS
How do you manage PET pt with mild HTN?
admit to hospital
Measure BP min 4x daily
Monitor U&E, LFT, FBC, transaminases and bilirubin x2 weekly
How do you manage PET pt with moderate HTN?
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
How do you manage PET pt with severe HTN?
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
How do you manage PET medically in pregnancy?=
Oral labetalol (beta blocker) OR Nifedipine / Methyldopa
Who is labetalol contraindicated in?
Asthmatics (assess if poorly controlled)
What do you give to manage PET after pregnancy=
Atenolol (alpha blocker)
How do you manage eclampsia? (condition specific tx)
magnesium sulphate IV
loading bolus of 4g over 5 minutes
1g/h over 24h
What medication given normally during labour is contraindicated in PET and why?
ERGOMETRINE - do NOT give in PET
Because it increases BP > can cause hypertensive crisis
What medication can you give to prevent PET in high risk women?
low dose aspirin (75mg)
What other management should you consider in someone with PET?
VTE risk!
Give TED stockings + consider prophylactic SC heparin (clean)
What do you do about delivery in PET if the woman is responding well to tx prior to 34 weeks?
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
When do you recommend delivery in PET?
- 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 !!!
When after birth should PET resolve?
Within 6 weeks
Otherwise consider chronic HTN / renal disease
What women can be managed as outpatients?
If mild-moderate HTN, no proteinuria
How do you manage pregnant women with mild-moderate HTN, no proteinuria
Repeat BP and urinalysis x2 weekly
TAUSS every 2-4wks
How do you deliver babies in PET?
<34 weeks: ELCS
>34 weeks: IOL
What can you give during labour for PET to help keep down BP?
Epidural
What must you be aware of if PET lady has vaginal delivery?
Avoid maternal pushing if BP reaches 160/110 in second stage
As this means high ICP > high risk cerebral haemorrhage
What do you use in third stage for PET lady, and instead of what?
Use oxytocin instead of ergometrinew
