Pre-eclampsia

Question 1

Define Pre-eclampsia

Answer 1

This is a multi-system disorder characterised by hypertension and involvement of one or more other organ systems and/or the fetus. Raised BP is commonly but not always the first manifestation. Proteinuria is also common but should not be considered mandatory to make the clinical diagnosis.

Question 2

How is pre-clampsia diagnosed?

Answer 2

1. hypertension arises after 20 weeks gestation
2. accompanied by one or more of the following signs of organ involvement:
   - Renal involvement
   -proteinuria
   -Serum or plasma creatinine
   - Oliguria < 80mL / 4 hours
   -
   Haematological involvement
   -Thrombocytopenia
   -Haemolysis
   
   • DIC
     Liver involvement
     - Raised transaminases
     -Severe epigastric or right upper quadrant pain

Neurological involvement

• Convulsions (Eclampsia)
• Persistent visual disturbances
• posterior reversible encephalopathy syndrome, retinal vasospasm)
• stroke

Pulmonary oedema

Fetal growth restriction (FGR)

Question 3

Define gestational hypertension

Answer 3

 New onset of hypertension arising after 20 weeks gestation
 No additional maternal or fetal features of preeclampsia
 Resolves within 3 months postpartum

Question 4

Define Chronic hypertension

Answer 4

BP greater than 140/90 mmHg preconception or prior to 20 weeks without an underlying cause
or
BP less than 140/90 entering pregnancy on antihypertensives

Question 5

What are the moderate Risk Factors for Pre Eclampsia?

Answer 5

Age 40 years or more
 First pregnancy
 Multiple pregnancy
 Interval since last pregnancy of more than 10 years
 Body mass index of 35 or more at presentation
 Family history of pre-eclampsia

Question 6

What are the high Risk Factors for Pre Eclampsia?

Answer 6

 Chronic hypertension
 Chronic kidney disease
 Hypertensive disease during a previous pregnancy
 Diabetes
 Autoimmune disease

Question 7

What are the ominous signs of pre-eclampsia?

Answer 7

severe hypertension, 
headache, 
epigastric pain, 
oliguria or 
nausea and vomiting

Question 8

Which investigations should be performed for pre-eclampsia?

Answer 8

 Spot urine PCR
 Full blood picture
 Urea, creatinine, electrolytes
 Liver function tests
 Ultrasound assessment of fetal growth, amniotic fluid volume and umbilical artery Doppler assessment

Question 9

If preeclampsia is present which further tests are needed?

Answer 9

Urinalysis for protein and urine microscopy

If thrombocytopaenia or reduced HB - bloods for DIC

Question 10

What is the t Specific Management of Eclamptic Seizures?

Answer 10

Provide high flow oxygen
 Manage patient in the left lateral position if possible to prevent aspiration and improve uterine blood flow
 Suction mouth and clear of any saliva, blood and/or vomitus
Start magnesium infusion (same as for management of severe pre-eclampsia) to prevent and treat subsequent seizures
Regular BP, HR, SpO2, RR, Urine output check post seizures, FHR CTG
Transfer to tertiary if premature, Eclamptic or HELLP syndrome

Question 11

What are the indications for delivery of a pre-eclamptic woman?

Answer 11

Maternal
Gestational Age >37weeks 
Inability to control hypertension 
Deteriorating platelet count
Deteriorating liver function
Deteriorating renal function
Placental abruption
Persistent neurological symptoms
Eclampsia
Persistent epigastric pain, 
nausea or vomiting with abnormal LFT

Fetal
Severe fetal growth restriction
Non-reassuring fetal status

Question 12

What is the management for a woman that presents with hypertension?

Answer 12

• Perform baseline laboratory evaluations (FBP, Serum creatinine, LDH, ALT, AST, Uric Acid and PCR)
• BP Profile
• CTG, Fetal surveillance by biophysical Profile
• Review by obstetric registrar/ Consultant
  if appropriate.
  Corticosteroid therapy in pregnancies between 23 and 36+6 weeks accelerates fetal lung maturity, decreases Respiratory Distress Syndrome (RDS),intraventricular haemorrhage (IVH) and the risk of fetal death

Question 13

What does HELLP stand for?

Answer 13

Haemolysis, Elevated Liver enzymes and Low Platelet