Pre-eclampsia

Question 1

Pre-eclampsia is a complication of pregnancy characterised by hypertension and … with or without ….

Answer 1

Pre-eclampsia is a complication of pregnancy characterised by hypertension and proteinuria with or without oedema.

Question 2

According to NICE CKS, pre-eclampsia affects how many pregnancies?

Answer 2

According to NICE CKS, pre-eclampsia affects around 1.5-7.7% of pregnancies.

Question 3

Risk stratification for pre-eclampsia
High risk if one of…

Answer 3

History of hypertensive disease during a previous pregnancy
Chronic kidney disease
Autoimmune disease (e.g. systemic lupus erythematosus or antiphospholipid syndrome)
Type 1 or type 2 diabetes
Chronic hypertension

Question 4

Risk stratification for pre-eclampsia
High risk if two of…

Answer 4

First pregnancy
Aged 40 years or older
Pregnancy interval of more than 10 years
BMI of 35 kg/m2 or greater at the first visit
Family history of pre-eclampsia
Multiple pregnancy

Question 5

Women with one high risk or two moderate risk factors for pre-eclampsia should be offered…

Answer 5

Women with one high risk or two moderate risk factors should be offered aspirin prophylaxis.

Question 6

NICE advise the use of Aspirin 75mg-150mg once daily from 12 weeks until birth in at-risk women to reduce the chance of developing …

Answer 6

NICE advise the use of Aspirin 75mg-150mg once daily from 12 weeks until birth in at-risk women to reduce the chance of developing pre-eclampsia.

Question 7

Onset of pre-eclampsia is most common at what stage of pregnancy?

Answer 7

Onset is after 34 weeks in around 85% of patients. The development of pre-eclampsia before 34 weeks is considered ‘early onset’. Pre-eclampsia occurring before 20 weeks is rare and may be associated with a molar pregnancy or antiphospholipid syndrome.

Question 8

Symptoms of pre-eclampsia

Answer 8

Headache
Visual disturbance
Oedema (facial, peripheral)
Abdominal pain (typically upper abdominal/epigastric)
Vomiting

Question 9

Signs of pre-eclampsia

Answer 9

Altered mental status
Dyspnea
Clonus
Oedema

Question 10

Features of…

Answer 10

Pre-eclampsia

Question 11

The diagnosis of pre-eclampsia is made by the combination of hypertension (after 20 weeks) and ….

Answer 11

The diagnosis of pre-eclampsia is made by the combination of hypertension (after 20 weeks) and proteinuria.

Question 12

Bedside tests for pre-eclampsia

Answer 12

Blood pressure
Vital signs
Urine dipstick and culture
Albumin:creatinine ratio or protein:creatinine ratio
24-hour urinary collection (not routinely sent)

Question 13

Blood tests for pre-eclampsia

Answer 13

FBC: falling platelet counts may herald the development of HELLP syndrome.
Renal function: serum creatinine should be monitored for signs of developing acute kidney injury.
LFT: derangement of transaminases is common, also become elevated in HELLP syndrome.
Clotting screen: in severe cases, coagulopathy may develop.

Question 14

Imaging in pre-eclampsia

Answer 14

USS: allows assessment of foetal development.
CT/MRI: cerebral imaging may be considered if concern exists of an acute intracranial event (e.g. acute haemorrhage).

Question 15

Special test in pre-eclampsia

Answer 15

Placenta growth factor-based tests may be used between 20 and 34+6 weeks gestation, particularly in patients with pre-existing chronic hypertension or gestational hypertension, to help rule in or rule out pre-eclampsia.

Question 16

Conservative management of pre-eclampsia (140/90 - 159/109)

Answer 16

Place of care: admit if any clinical concerns for mother or baby, or if scores high risk on fullPIERS or PREP-S. In practice, most patients will be admitted for a period of observation.
Anti-hypertensives: if BP remains ≥ 140/90 offer antihypertensives. Labetalol is often offered first line with nifedipine if labetalol is not appropriate. Methyldopa may be offered if neither is appropriate.
BP monitoring: target BP < 135/85. BP should be measure at least every 48hrs and at a greater frequency if an inpatient.
Blood tests: repeat FBC, UE, LFT at least twice a week.
Foetal assessment: carry out USS and CTG at diagnosis. Repeat USS at 2 weekly intervals, auscultate foetal heart at every visit.

Question 17

Conservative management of severe hypertension (≥ 160/110) in pre-eclampsia

Answer 17

Place of care: admit to hospital. Consider discharge if falls below this under senior guidance.
Anti-hypertensives: offer antihypertensives to all women. Labetalol is often offered first line with nifedipine if labetalol is not appropriate. Methyldopa may be offered if neither are appropriate.
BP monitoring: target BP < 135/85. Monitor BP every 15-30 mins until <160/110 and then at least four times a day whilst an inpatient.
Blood tests: repeat FBC, UE, LFT at least three times a week.
Foetal assessment: carry out USS and CTG at diagnosis. Repeat USS at 2 weekly intervals, auscultate foetal heart at every visit.

Question 18

Where possible, in the absence of severe pre-eclampsia, patients should be managed conservatively until … weeks

Answer 18

Where possible, in the absence of severe pre-eclampsia, patients should be managed conservatively until 37 weeks.

Question 19

NICE guidelines recommend early birth (i.e. < 37 weeks) should be considered in the following instances (pre-eclampsia)

Answer 19

Inability to control maternal blood pressure despite using 3 or more classes of antihypertensives in appropriate doses
Maternal pulse oximetry less than 90%
Progressive deterioration in liver function, renal function, haemolysis, or platelet count
Ongoing neurological features, such as severe intractable headache, repeated visual scotomata, or eclampsia
Placental abruption
Reversed end-diastolic flow in the umbilical artery doppler velocimetry, a non-reassuring cardiotocograph, or stillbirth.

Question 20

Severe pre-eclampsia

Answer 20

Blood pressure: control is key and may require multiple agents such as labetalol, nifedipine and hydralazine.
Fluid balance: close monitoring of fluid balance is required. There is a risk of both renal impairment and pulmonary oedema.
Complications: a number of life-threatening complications may develop including HELLP syndrome, disseminated intravascular coagulation and adult respiratory distress syndrome.
Delivery: the decision should be lead by a consultant obstetrician and when possible taken in conjunction with the mother. A holistic view is required and must come from the most experienced decision-makers.

Question 21

… represent the onset of eclampsia

Answer 21

Seizures represent the onset of eclampsia. This is an obstetric emergency requiring an immediate response, commencement of oxygen and securing of the airway. The mother should be placed in the left lateral position. Magnesium sulphate is the first-line treatment for eclamptic seizures. Intubation may be required and cerebral imaging considered. Delivery is the definitive management.

Question 22

What is the first-line treatment for eclamptic seizures?

Answer 22

Magnesium sulphate

Intubation may be required and cerebral imaging considered. Delivery is the definitive management.

Question 23

Numerous complications can occur during pre-eclampsia including … syndrome and DIC.

Answer 23

Numerous complications can occur during pre-eclampsia including HELLP syndrome and DIC.

Question 24

HELLP Syndrome

Answer 24

Haemolysis Elevated Liver enzymes Low Platelets syndrome is a severe complication of pregnancy that normally occurs in patients suffering with pre-eclampsia.

Question 25

Disseminated intravascular coagulation

Answer 25

Life-threatening coagulopathy where wide-spread activation of the clotting system leads to micro-thrombi formation and consumption of clotting factors. It can lead to haemorrhage and multi-organ failure.