Pre-eclampsia Flashcards
What is the definition of pre-eclampsia?
- new hypertension in pregnancy with end-organ dysfunction
- it most notably presents with proteinuria
When does pre-eclampsia typically present?
after 20 weeks gestation
Why is it important to recognise and treat pre-eclampsia?
without treatment it can result in:
- seizures
- early labour
- intrauterine growth restriction
- maternal organ damage
- death
Why is it important to recognise and treat pre-eclampsia?
without treatment it can result in:
- seizures
- early labour
- intrauterine growth restriction
- maternal organ damage
- death
What is the classic triad of pre-eclampsia?
- hypertension
- proteinuria
- oedema
(oedema is no longer used in diagnosis as this is a normal feature of pregnancy)
What is the difference between pre-eclampsia and pregnancy-induced hypertension?
pregnancy-induced HTN:
- HTN occurring after 20 weeks gestation
- WITHOUT proteinuria
pre-eclampsia:
- HTN occurring after 20 weeks gestation
- this is associated with organ damage - most notably proteinuria
What is the underlying cause of pre-eclampsia?
- there is high vascular resistance in the spiral arteries
AND
- there is poor perfusion of the placenta
- oxidative stress in the placenta releases inflammatory chemicals
- there is systemic inflammation + impaired endothelial function in blood vessels
What are the high risk factors for pre-eclampsia?
- previous HTN in pregnancy
- pre-existing HTN
- diabetes
- chronic kidney disease
- existing autoimmune conditions (e.g. SLE)
What are the moderate risk factors for pre-eclampsia?
- age > 40
- BMI > 35
- more than 10 years since last pregnancy
- multiple pregnancy
- first pregnancy
- FHx of pre-eclampsia
Why is it important to identify the RFs for pre-eclampsia?
- they are used to determine who is offered prophylaxis with aspirin 150mg
- women are offered aspirin from 12 weeks gestation if they have 1 high RF or 2+ moderate RFs
it is better to take aspirin at night
What are the symptoms of pre-eclampsia?
- visual disturbances / blurriness
- headache
- facial oedema
- reduced urine output
- brisk reflexes / clonus
- N&V
- upper abdominal / epigastric pain
pain is due to swelling of the liver
How is pre-eclampsia diagnosed?
- systolic BP > 140 mmHg
AND
- diastolic BP > 90 mmHg
PLUS ANY OF:
- proteinuria
- organ dysfunction
- placental dysfunction
How can placental dysfunction be identified?
- foetal growth restriction
- abnormal Doppler studies
How can organ dysfunction be identified?
- raised creatinine
- elevated liver enzymes
- seizures
- thrombocytopenia
- haemolytic anaemia
What test should be used on ONE occassion during pregnancy in suspected pre-eclampsia?
placental growth factor (PlGF)
- this is released by the placenta to stimulate development of new blood vessels
- levels will be LOW in pre-eclampsia
When should PlGF testing be performed?
- it should be performed on one occasion
- between 20 and 35 weeks gestation
- to RULE OUT pre-eclampsia
How can proteinuria be quantified?
urine protein:creatinine ratio:
- above 30mg/mmol is significant
urine albumin:creatinine ratio:
- above 8mg/mmol is significant
How are women monitored for pre-eclampsia?
at every antenatal appointment, the following are performed:
- blood pressure
- assessment of symptoms
- urine dipstick for proteinuria
What is the management for gestational HTN (without proteinuria)?
- urine dipstick at least weekly
- blood tests weekly (FBC, U&Es, LFTs)
- monitoring foetal growth with serial growth scans
- PlGF testing on one occasion
- the aim is for BP < 135/85 mmHg
- admission is needed when BP > 160/110 mmHg
What is the difference in management when pre-eclampsia is diagnosed?
- BP monitored at least every 48 hours
- urine dipstick NOT required as diagnosis is made
- US of fetus, amniotic fluid & dopplers every 2 weeks
What is used to help determine whether to admit someone with pre-eclampsia?
scoring systems - fullPIERS or PREP-S
What are the 1st, 2nd and 3rd line treatments for pre-eclampsia?
- labetalol is first line
- nifedipine (MR) is second-line
- methyldopa is third-line
!! beta blockers are contraindicated in asthma !!
methyldopa MUST be stopped within 2 days of birth
What may be used in severe pre-eclampsia?
IV hydralazine
- used in critical care in severe pre-eclampsia or eclampsia
What is the additional management for pre-eclampsia during labour?
IV magnesium sulphate:
- given during labour and for 24 hours afterwards
- used to prevent seizures
fluid restriction:
- used in severe pre-eclampsia / eclampsia to avoid fluid overload
If the blood pressure cannot be controlled with pre-eclampsia, what may be done?
- planned early birth may be necessary
- corticosteroids should be given to help mature the fetal lungs
Following delivery, how should pre-eclampsia be managed?
- enalapril is first line
- nifedipine / amlodipine are first line in black African or Caribbean patients
- labetalol / atenolol are third line
the BP will return to normal over time once the placenta is removed
What is eclampsia?
How is it treated?
- this refers to seizures associated with pre-eclampsia
- IV magnesium sulphate is used to manage the seizures
What syndrome can occur as a result of pre-eclampsia / eclampsia?
HELLP syndrome:
- Haemolysis
- Elevated Liver enzymes
- Low Platelets
monitored through regular blood tests - FBC, LFTs, coagulation
When should labour be induced where there is HTN in pregnancy?
- induce labour at 37 weeks in pre-eclampsia
- induce labour at 40 weeks in pregnancy-induced HTN (without proteinuria)
