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 (asthmatic or Afro-Caribbean)

Question 4

What is the difference between PIH and pre-eclampsia/

Answer 4

Pre-eclampsia is hypertension PLUS PROTEINURIA (delivery is cure)

Question 5

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

Answer 5

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 6

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

Answer 6

Due to the physiological drop in blood pressure in the first trimester of pregnancy (due to drop in SVR)
-Reach lowest point at 22-24 then steadily increase

Question 7

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

Answer 7

> 300mg/L in 24 hours

(>0.3g)

Question 8

What are some risk factors for pre-eclampsia?

Answer 8

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 9

What is eclampsia?

Answer 9

A seizure state associated with the features of pre-eclampsia

Question 10

Explain pathophysiology of eclampsia

Answer 10

• increase in peripheral resistance
• increase vascular permeability (proteinuria/odema)
• reduce placental flow (IUGR, oligohydraminos)
• reduce cerebral perfusion (seizures)

Question 11

How do we define hypertension in pregnancy?

Answer 11

> 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 OR > 15 mmHg diastolic

Question 12

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

Answer 12

• Severe HTN >160/110mmHg
• HTN >140/90 with proteinuria
• Evidence of IUGR on USS
• New proteinuria
• Those with significant symptoms: Headaches, visual disturbances, epigastric pain, oedema

Question 13

What are the principles of management in moderate pre-eclampsia?

Answer 13

Moderate (<160/110)
>37 weeks then deliver
<37 weeks control HTN with antihypertensives, close observations (fluid balance, BP, protein)

• 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 prophylactically for vaginal births (>34 weeks)

Question 14

What are the principles of management in severe pre-eclampsia?

Answer 14

Plan urgent delivery

• antihypertensives
• IV magnesium sulfate to prevent seizure risk (bolus then infusion)
• obsetric HDU

Fetal care

• CTG monitoring
• IV dex if <34 weeks

Question 15

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

Answer 15

-Prophylactic ASPIRIN (75mg from 12w-delivery) if risk factors (diabetes/HTN/previous gestational HTN/CKD/antiphospholipid/SLE)

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

-Calcium supplementation

Question 16

How should and eclamptic seizure be managed?

Answer 16

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

Question 17

What is a side effect of MgSO4 toxicity?

How do you treat?

Answer 17

MgSO4 toxicity

-loss of reflexes and respiratory depression (give calcium gluconate)

Question 18

What does HELLP stand for?

Answer 18

Haemolysis, Elevated Liver enzymes, Low Platelets (complication of eclampsia)

Question 19

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

Answer 19

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 20

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

Answer 20

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 21

What are some complications of HELLP?

Answer 21

Acute renal failure
DIC
Increased incidence of placental abruption

Question 22

How should HELLP be managed?

Answer 22

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

Question 23

What is target for BP in pregnancy?

Answer 23

135/85 is target for BP in pregnancy

Question 24

What value is severe hypertension in pregnancy, what would you do?

Answer 24

• Severe HTN is >160/110

- Admit them

Question 25

What are symptoms and signs of eclampsia

Answer 25

symptoms

• assymptomatic
• headaches
• vision changes
• odema
• RUQ pain
• PV bleeding
• SOB
• N and V

signs

• hyperreflexia
• clonus