pre-eclampsia

Question 1

what happens to uric acid

Answer 1

increases over 0.32

Question 2

what happens to calcium in urine

Answer 2

hypocalciuria

Question 3

BP in PE

Answer 3

over 140/90 where previously normal or increasing over pregnancy

Question 4

Protein in PE

Answer 4

dipstick unreliable

P:Cr over 30 or over 300mg in 24 hours

Question 5

platelets in PE

Answer 5

thrombocytopaenia

Question 6

LFT in PE

Answer 6

transaminases elevated

Question 7

role of calcium in PE prevention

Answer 7

In high risk women, can give 500mg QID from week 25= reduces risk of any cause of hypertension

but can mask pre-eclampsia and does not improve fetal outcomes

Question 8

aspirin in PE prevention

Answer 8

Up to 75mg, start before 20 weeks
no increased bleeding
decreasedpre-eclampsia and preterm delivery rate in high risk pregnancies

Question 9

What is the normal pattern of BP in pregnancy

Answer 9

Decreases, especially diastolic, until 20-24 weeks then increases towards pre-pregnancy values.

Question 10

Define hypertension in pregnancy

Answer 10

Systolic over 140, diastolic over 90
of increase above booking readings of 30/15

Note you dont get pregnancy induced hypertension or pre-eclampsia before 20 weeks!

Question 11

How do you tell the difference between Cardiac tamponade and constrictive pericarditis?

Answer 11

In cardiac tamponade there is characteristically no Y descent on the JVP (limited RV filling), pulsus paradoxus is present, Kussmaul’s sign is rare (compared with pericarditis- present).

Also look for pericardial calcification on CXR in constrictive pericarditis.

Question 12

Poor prognosis in HOCM- markers (6)

Answer 12

Syncope
FH SCD
Young age at presentation
nonsustained VT on holter monitor
Abnormal BP changes on exercise
Increased septal wall thickness

Question 13

Cause of P/E?

Answer 13

Fetus produces antagonists of VEGF, TGF beta which lead to disruption of glomerulus and endothelial function

Question 14

Risk factors

Answer 14

Past PE
Nulliparous
Age under 15 or over 35
diabetes
obesity
antiphospholipid syndrome
multiple gestation
renal disease
chronic hypertension
UTI!!!
Mother or sister had it

Question 15

treatment?

Answer 15

If severe –>deliver - IOL improves maternal outcomes, dont necessarily need LSCS

Aggressive BP management to reduce stroke- IV labetalol or hydralazine or nifedipine (good acute), prazocin
Methyldopa or oral labetalol ok if not acute

Concern that if you over treat hypertension, risk reduced fetal growth

Mg sulphate (?NMPA receptors in CNS)
steroids for fetal lung maturation

Aim under 140/85 as per CHIPS study -

• no difference in fetal outcomes with tight vs less tight control ie growth restiction
• methyldopa superior to labetalol for PB control and PE- only subacute
• higher risk worse maternal outcomes in over 160/110
• lower risk severe maternal hypertension if target under 85 vs under 100

Question 16

What does P/E mean for mum later?

Answer 16

increase vascular complications first 5 years
IHD, VTE, DM, CVA, ESRD
NOT CANCER

Question 17

Risks with pregnancy if chronic essential hypertension?

Answer 17

increase risk P/E
increase risk IUGR
increase risk placental abruption
increase perinatal mortality

but no evidence that mild chronic hypertension treatment improves fetal outcomes

Question 18

What BP meds ok in preg?

Answer 18

methyldopa
nifedipine
labetalol

Question 19

What is gestational hypertension?

Answer 19

hypertension after 20 weeks that is NEW, without features to make it pre eclampsia

Question 20

Risk recurrence PE?

Answer 20

Severe- 25%

regular- 15%

Question 21

Do you get high BP in HELP?

Answer 21

NOT ALWAYS

Question 22

What is the strongest risk factor?

Answer 22

APL syndrome

Question 23

How can the uterine artery doppler study help?

Answer 23

In high risk women do at 20-24 weeks- if high resistance index, can suggest increase risk

Question 24

How many times readings in order to diagnose hypertension in pregnancy?

Answer 24

Three times

Question 25

At what point in BP are you risking ICH, severe maternal morbidity and mortality?

Answer 25

160/110

Question 26

When would you avoid nifedipine?

Answer 26

aortic stenosis

Question 27

what happens to renal bicarb handling in normal preg?

Answer 27

bicarbonaturia–>met acid

Question 28

What happens to plasma osmolality in normal preg?

Answer 28

might decrease 10 mosm/kg

Question 29

What happens to renin in preg?

Answer 29

increase,

also EPO and active vitamin D

Question 30

How much protein normal in preg?

Answer 30

300mg/24 hours ULN or spot U:Cr ration 0.03
There is increased glom permeability in T3 - baseline protein will double in pregnancy

LEVEL not that important once established

Question 31

Define PE

Answer 31

New onset hypertension after 20 weeks with one or more of the following signs - over 140/90 rise from prev 30/15
renal: pr:cr over 3 or raised creast over 90 or oliguria under 80 mL in 4 hours period. DIPSTICK INACCURATE
liver: raised transaminases or severe RUQ or epigastric discomfot
neuro: convulsions, hyper-reflexia with sustained clonus, persistent new headache, persistent visual disturbances (photopsia, PRES, scotoma)
Pulmonary oedema
FETAL GROWTH RESTRICTION!!

Question 32

What does PE mean for babies later in life?

Answer 32

Increase risk of metabolic syndrome

Question 33

What is FLT?

Answer 33

FLT can be membrane bound or soluble (anti VEGF and antiPlacGF if soluble (decoy from actual receptors)–>failing placenta

Question 34

What if hypertension comes on before 20 weeks?

Answer 34

Chronic hypertension

Question 35

What if have chronic or gestational and then get proteinuria?

Answer 35

Superimposed PET

Question 36

Future risk of PE?

Answer 36

16%
if severe and before 28 weeks; 55% recurrence risk
if severe and after 34 weeks; 25%

Question 37

Urate in pregnancy- part of PE?

Answer 37

Not a diagnostic feature

but tends to be raised

Question 38

Renal in PEE

Answer 38

Creatinine over 90
Proteinuria over 300mg/24 hours or P:Cr over 30
oliguria under 80ml/hr 4 hours

Question 39

white coat hypertension

Answer 39

less risk PE compared with non chronic hypertension patients, but still at higher risk than normal