PIH, Pre-eclampsia and HELLP

Question 1

When do we class hypertension as pregnancy induced?

Answer 1

If it occurs AFTER 20 WEEKS

Before that it is just essential hypertension or ‘pre-existing hypertension)

Question 2

How serious are PIH and pre-eclampsia in pregnancy?

Answer 2

They are the second highest cause of indirect maternal mortality in the UK

Question 3

How should a woman with pre-existing hypertension’s medications change for pregnancy?

Answer 3

She should stop ACE-is and be started on B-blockers e.g. LABETALOL or CCB e.g. Nifedipine if the B-B is CI’d

Question 4

What is the difference between PIH and pre-eclampsia/

Answer 4

Pre-eclampsia is hypertension PLUS PROTEINURIA

Question 5

What is thought to be an associated etiological factor in pre-eclampsia?

Answer 5

Poor trophoblast infiltration into the placenta during the first half of pregnancy
Impaired placental dysfunction and widespread vascular endothelial dysfunction

Question 6

What are the two phases of the pathophysiology of pre-eclampsia?

Answer 6

1. Poor trophoblast infiltration. During normal development trophoblasts invade maternal spiral arteries causing them to increase their diameter so that the flow of blood becomes low resistance and high flow - doesn’t happen as well in pre-eclampsia
2. Reduced placental perfusion leads to placental ischaemia. This leads to endothelial dysfunction which causes changes such as maternal inflammatory response and reduced perfusion to the organs. Also over-activation of the coagulation system

Question 7

Why does pre-eclampsia only really occur after 20 weeks?

Answer 7

Due to the physiological drop in blood pressure in the first trimester of pregnancy

Question 8

How much protein has to be in the urine for it to be classed as proteinuria?

Answer 8

> 300mg/L

Question 9

What are some risk factors for pre-eclampsia?

Answer 9

First pregnancy
FH (mother or sister with pre-eclampsia)
Extremes of maternal age
Obesity
PMH (Pre-existing HTN, Renal disease, thrombohphilias, SLE and DM)
Obstetric Hx: Multiple pregnancies, previous pre-eclampsia, hydatidiform mole, triploids, hydros fetalis, inter-pregnancy interval of >10y

Question 10

What is eclampsia?

Answer 10

A seizure state associated with the feature of pre-eclampsia

Question 11

How does blood pressure change in the normal pregnancy?

Answer 11

Fall slightly during first trimester (due to drop in SVR), reach lowest point at 22-24 weeks after which is steadily increases

Question 12

How do we define hypertension in pregnancy?

Answer 12

> 140/90mmHg on more than 2 occasions more than 4 hours apart

OR >160/>110 mmHg on one occasion

OR Systolic >30mmHg above the booking blood pressure

Question 13

What are some indications for admission in women with pre-eclampsia?

Answer 13

Blood pressure >170/110mmHg or >140/90 with 2+ protein
Those with significant symptoms: Headaches, visual disturbances, epigastric pain, oedema
Abnormal biochemistry
Need for treatment
Signs of fetal compromise

Question 14

What are the principles of management in pre-eclampsia?

Answer 14

Get maternal BP <110mmHg with labetalol, nifedipine, hydralazine or methyl-dopa
Make regular assessment of the woman’s fluid balance- pre-eclampsia can change vascular permeability
MgSO4 can be given to reduce seizure risk

Question 15

What is the cure for pre-eclampsia? When is this done?

Answer 15

DELIVERING THE BABY

Usually it is tried to get the woman to 34 weeks before delivering her

Question 16

What can we do to help prevent the development of pre-eclampsia?

Answer 16

Prophylactic aspirin treatment

Calcium supplementation

Question 17

How should and eclamptic seizure be managed?

Answer 17

Turn the woman to her Left to prevent aorta-caval compression
Secure airway and administer oxygen
MgSO4 IV and monitor for signs of toxicity (Calcium gluconate can be given as reversal for MgSO4)
URGENT DELIVERY

Question 18

When/how do we give the aspirin prophylaxis therapy?

Answer 18

75mg aspirin from 12w delivery

Also reduces the risk of pre-term birth and neonatal mortality

Question 19

What does HELLP stand for?

Answer 19

Haemolysis, Elevated Liver enzymes, Low Platelets

Question 20

Levels of what will we seeing rising in HELLP that we can measure?

Answer 20

Lactate Dehydrogenase - LDH (a key breakdown product during haemolysis - high levels as well as low Hb suggests breakdown of blood cells)

AST - this is the first liver enzyme to become elevated and the rest will follow (remember ALP will be high anyway as it is produced by the placenta)

Question 21

How might HELLP syndrome present and who is it more common in?

Answer 21

Multiparous women - complication of pre-eclampsia

Usually it is found incidentally before symptoms start in women who are known to be pre-eclamptic and have their liver enzymes and platelets monitored but symptoms could include:

RUQ pain, epigastric tenderness and N&V

Question 22

What are some complications of HELLP?

Answer 22

Acute renal failure
DIC
Increased incidence of placental abruption

Question 23

How should HELLP be managed?

Answer 23

Try and correct disorder with coagulation and consider delivery as soon as possible