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Zero to finals obstetrics MARINA > Pre-eclampsia > Flashcards

Pre-eclampsia Flashcards

1
Q

What is pre-eclampsia?

A
  • refers to new high blood pressure (hypertension) in pregnancy with end-organ dysfunction, notably with proteinuria (protein in the urine)
  • occurs after 20 weeks gestation, when the spiral arteries of the placenta form abnormally, leading to a high vascular resistance in these vessels
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2
Q

What can pre-eclampsia lead to without treatment?

A
  • maternal organ damage
  • fetal growth restriction
  • seizures
  • early labour
  • in a small proportion, death
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3
Q

What are the triad of features in pre-eclampsia?

A
  • Hypertension
  • Proteinuria
  • Oedema
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4
Q

What is eclampsia?

A

-when seizures occur as a result of pre-eclampsia

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5
Q

What is the difference between gestational hypertension and pre-eclampsia?

A
  • Pregnancy-induced hypertension or gestational hypertension is hypertension occurring after 20 weeks gestation, without proteinuria.
  • while Pre-eclampsia is pregnancy-induced hypertension associated with organ damage, notably proteinuria.
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6
Q

What are high-risk factors of pre-eclampsia?

A
  • Pre-existing hypertension
  • Previous hypertension in pregnancy
  • Existing autoimmune conditions (e.g. SLE)
  • Diabetes
  • Chronic kidney disease
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7
Q

What are moderate-risk factors of pre-eclampsia?

A
  • Older than 40
  • BMI > 35
  • More than 10 years since previous pregnancy
  • Multiple pregnancy
  • First pregnancy
  • Family history of pre-eclampsia
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8
Q

What do the presence of these risk factors determine?

A
  • used to determine which women are offered aspirin as prophylaxis against pre-eclampsia
  • women are offered aspirin from 12 weeks gestation until birth if they have one high-risk factor or more than one moderate-risk factors
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9
Q

What are the symptoms of pre-eclampsia?

A
  • Headache
  • Visual disturbance or blurriness
  • Nausea and vomiting
  • Upper abdominal or epigastric pain (this is due to liver swelling)
  • Oedema
  • Reduced urine output
  • Brisk reflexes
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10
Q

What is needed for a diagnosis of pre-eclampsia to be made?

A

diagnosis can be made with a:

  • Systolic blood pressure above 140 mmHg
  • Diastolic blood pressure above 90 mmHg

PLUS any of:

  • Proteinuria (1+ or more on urine dipstick)
  • Organ dysfunction (e.g. raised creatinine, elevated liver enzymes, seizures, thrombocytopenia or haemolytic anaemia)
  • Placental dysfunction (e.g. fetal growth restriction or abnormal Doppler studies)
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11
Q

How can proteinuria be quantified?

A
  • Urine protein:creatinine ratio (above 30mg/mmol is significant)
  • Urine albumin:creatinine ratio (above 8mg/mmol is significant)
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12
Q

What is the placental growth factor (PlGF)?

A

Placental growth factor is a protein released by the placenta that functions to stimulate the development of new blood vessels

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13
Q

What are the levels of PlGF in pre-eclampsia?

A
  • the levels of PlGF are low

- NICE recommends using PlGF between 20 and 35 weeks gestation to rule-out pre-eclampsia

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14
Q

What is the initial management for pts at risk of preeclampsia?

A

-Aspirin is used for prophylaxis from 12 weeks gestation until birth to women with 1 high risk factor or more than 1 moderate risk factors

All pregnant women are routinely monitored at every antenatal appointment for evidence of pre-eclampsia, with:

  • Blood pressure
  • Symptoms
  • Urine dipstick for proteinuria
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15
Q

When gestational hypertension (without proteinuria) is identified, what is the general management?

A
  • Treating to aim for a blood pressure below 135/85 mmHg
  • Admission for women with a blood pressure above 160/110 mmHg
  • Urine dipstick testing at least weekly
  • Monitoring of blood tests weekly (full blood count, liver enzymes and renal profile)
  • Monitoring fetal growth by serial growth scans
  • PlGF testing on one occasion
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16
Q

When pre-eclampsia is diagnosed, what is the general management?

A

similar to gestational hypertension, except:

  • Scoring systems are used to determine whether to admit the woman (fullPIERS or PREP‑S)
  • Blood pressure is monitored closely (at least every 48 hours)
  • Urine dipstick testing is not routinely necessary (the diagnosis is already made)
  • Ultrasound monitoring of the fetus, amniotic fluid and dopplers is performed two weekly
17
Q

What is the medical management for pre-eclampsia?

A
  1. Labetolol is first-line as an antihypertensive
  2. Nifedipine (modified-release) is commonly used second-line (eg if asthmatic)
  3. Methyldopa is used third-line (needs to be stopped within two days of birth)
    - Intravenous hydralazine may be used as an antihypertensive in critical care in severe pre-eclampsia or eclampsia
    - IV magnesium sulphate (4g) is given during labour and in the 24 hours afterwards to prevent seizures
    - Fluid restriction is used during labour in severe pre-eclampsia or eclampsia, to avoid fluid overload
18
Q

If blood pressure cannot be controlled or complications occur what may be necessary in pre-eclampsia?

A
  • planned early birth

- Corticosteroids should be given to women having a premature birth to help mature the fetal lungs

19
Q

What is the management after birth for pre-eclampsia?

A
  • BP is monitored closely after delivery
  • BP will return to normal over time once the placenta is removed

For medical treatment, one or combined of:

  • Enalapril (first-line)
  • Nifedipine or amlodipine (first-line in black African or Caribbean patients)
  • Labetolol or atenolol (third-line)
20
Q

What is used to manage the seizures in eclampsia?

A

IV magnesium sulphate (4g)

21
Q

What is HELLP syndrome?

A

HELLP syndrome is a combination of features that occurs as a complication of pre-eclampsia and eclampsia. It is an acronym for the key characteristics:

  • Haemolysis
  • Elevated Liver enzymes
  • Low Platelets
22
Q

A 38 year old pregnant female at 32 weeks gestation presents to Maternity Triage with mild upper abdominal pain, vomiting and blurred vision. Her observations are normal, and cardiotocograph reveals no abnormalities with the foetus. Urinalysis is normal.

Which one of the following laboratory findings is most likely in HELLP (haemolysis, elevated liver enzymes, and low platelets) syndrome?

A. Low serum haptoglobin

B. Prolonged prothrombin time (PT)/activated partial thromboplastin clotting time (APTT)

C. Elevated ALP 2 times the upper limit of normal

D. Normal lactate dehydrogenase (LDH)

E. Peripheral blood film showing blister and bite cells

A

A. Low serum haptoglobin

Haptoglobin level is a specific marker of haemolysis, and a level of ≤25mg/dL would suggest haemolysis which occurs in HELLP syndrome

vs C: elevated ALP 2x upper limit of normal: (ALP in placenta & liver, bones, kidneys)
This is a normal physiologic finding in pregnancy. In HELLP syndrome, aspartate aminotransferase (AST) and alanine aminotransferase (ALT) are typically elevated ≥2 times the upper limit of normal

23
Q

when is immediate C-section indicated in PET:

A
  1. < 34 weeks
  2. labour is prolonged
  3. If fetal cardiotocography is non-reassuring with frequent and recurrent decelerations.

However, cesarean delivery is only recommended once the patient is stabilized and seizures have terminated (ie magnesium sulfate if had a seizure)

24
Q

what are complications of pre-eclampsia (maternal vs foetal):

A

Maternal complications:
-Eclampsia (seizures due to cerebrovascular vasospasm)
-Organ failure
-Disseminated intravascular coagulation (DIC)
-HELLP syndrome (the presence of haemolysis (H), elevated liver enzymes (EL) and low platelets (LP))

Foetal complications:
-Intrauterine growth restriction
-Pre-term delivery
-Placental abruption
-Neonatal hypoxia

25
Q

which of the following is high RF for PET development?
A. BMI of 36.5kg/m2
B. FH of 1st degree relative of PET
C. 1st pregnancy
D. Personal DVT history
E. T2DM

A
26
Q

which of the following is high RF for PET development?
A. BMI of 36.5kg/m2
B. FH of 1st degree relative of PET
C. 1st pregnancy
D. Personal DVT history
E. T2DM

A

E. T2DM

-moderate: BMI 35-39.9kg/m2
-FH of PET
-Age >=40 yrs
-1st prengnancy

27
Q

what are concerning features of PET?

A
  1. BP >160mmHg (admission for BP monitoring)
  2. Increasing creatinine (organ failure)
  3. Increasing ALT (HELPP)
  4. Decreased platelets (HELPP)
  5. foetal compromise (CTG)
28
Q

what are indications of immediate delivery (earlier than 37 weeks)?

A
  1. Inability to control BP (despite aggressive antihypertensives)
  2. SpO2 <90%
  3. deterioration in renal/liver function (Us & Es, LFTs especially ALT increasing and creatinine increasing)
  4. deterioration in platelet count
  5. neurological features
  6. placental abruption
29
Q

DIC complications and test results

A

-elevated PT
-elevated APTT
-low platelets (thrombocytopenia): especially in acute sepsis-associated DIC (but may be increased in malignancy-associated chronic DIC)
-low fibrinogen

-DIC: abnormal clotting & bleeding simultaneously

-If DIC is suspected:
1. full blood picture
2. coagulation screen
3. G & S need to be done

30
Q

what is the definition of eclampsia?

A

Eclampsia is the occurrence of one or more seizures in a woman with pre-eclampsia with the development of at least two of the following within 24 hours:
1. hypertension
2. proteinuria
3. thrombocytopenia
4. raised aspartate aminotransferase (AST).

Zero to finals obstetrics MARINA (37 decks)

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