Pre-eclampsia Flashcards
Definition of pre-eclampsia
New onset hypertension and/or* proteinuria after week 20 of pregnancy that resolves after delivery
*If or: need other features
Clinical features of pre-eclampsia (12)
Severe headache (hydrocephalus) Visual disturbance (photopsia, photophobia) Papilloedema Epigastric pain Right upper quadrant pain Facial swelling Hands and feet swelling (leg swelling can be normal) Vomiting Hyperreflexia and clonus Elevated ALT/AST (raised ALP normal as produced by placenta) HELLP Raised urea and creatinine
Types of hypertensive disorders of pregnancy
<20 weeks is preexisting/chronic
>20 weeks is gestational/pre-eclampsia
Definition of eclampsia
Generalised convulsions during pregnancy, labour or within 7 days postpartum
Not caused by neurological disorder
Pathophysiology of pre-eclampsia
Trophoblast fails to invade maternal spiral arteries
Resulting in placenta not being a low pressure system
Definition of proteinuria in pregnancy
PCR at least 30mg/mmol
Or
At least 300mg in 24hr urine collection (gold standard but rarely done in practice)
Definition of hypertension in pregnancy
Diastolic BP >110
Or
>140/90 on 2 consecutive occasions >4 hours apart
Complications of pre-eclampsia
Haemorrhagic stroke Eclampsia HELLP syndrome Renal tubular necrosis Pulmonary oedema Hepatic haemorrhage within capsule DIC Placental infarction Fetal death/growth restriction/prematurity
How to asses fetal risk in pre-eclampsia
Fetal movements CTG Fetal size Liquor volume Umbilical artery Doppler
Criteria for hospital admission
BP >170/110 Or BP >140/90 with proteinuria Or Significant symptoms
What can be done to prolong pregnancy in pre-eclampsia
Steroids
Primary prevention of pre-eclampsia
Low dose aspirin BEFORE 24 weeks ~12
Calcium supplements
Secondary prevention of pre-eclampsia
Antihypertensive drugs for severe hypertension
NO DIURETICS
NO ACE INHIBITORS
Prevention and treatment of eclampsia seizures
What is its secondary benefit
Magnesium sulphate
Decreases risk of cerebral palsy in fetus
If ineffective, second line is lorazepam
Significance of urea and creatinine in pregnancy
Should be lower than normal range in pregnancy
If in normal range need more investigation!
Why can’t you give ACEi inhibitors for hypertension in pregnancy
Cause renal impairment in fetus
Problem with lowering blood pressure too quickly
Blood flow directed to maternal brain and kidneys
Therefore flow restricted to uterus
Drugs for emergency BP control in pregnancy
Nifedipine modified release SR
Labetalol IV
Hydralazine IV
Contraindications for labetalol
Asthma
Type 1 diabetics - masks palpitations with hypo
Side effects of labetalol
Scalp tingling
Headache
GI disturbance
Liver damage
When do you need to stop methyldopa for hypertension in pregnancy
Within 2 days of delivery as increased risk of post natal depression
Why do you need to treat hypertension in pregnancy
Increased risk of haemorrhagic stroke
Post natal monitoring of hypertension
For 5 days after delivery
Medical review 2 weeks after delivery at GP to see if medication needs continuing
What is HELLP syndrome
Activation of clotting cascade causing:
Haemolysis
Elevated liver enzymes
Low platelets <150
Management of HELLP syndrome
Treat by delivering baby once mother stable <48 hours
Give mother corticosteroids x2 24 hours apart
Can transfuse blood products as needed
Fetal risks of HELLP syndrome
Prematurity Stillbirth Neonatal death Placental abruption Placental failure
Dosage of labetalol
100mg BD starting dose
Can increase every 2 weeks by 200mg if needed
Maximum dose of 2400mg per day
Risk factors for preeclampsia
>40 years old Nulliparous >10 years since last pregnancy Multiple pregnancy FH or PH Chronic hypertension Chronic renal disease
Recurrence rate of eclampsia
10%
Management of chronic hypertension in pregnancy
Serial fetal growth charts to monitor
Continue BP medication except for ACEi and diuretics
Aim to deliver by 40 weeks
When to deliver in preeclampsia
Mild - >36 weeks
Severe - asap regardless of gestational age unless proteinuria >5g/24hrs only criteria fulfilled
When is IV MgSO4 given
IV intrapartum for severe preeclampsia continued for at least 24 hours post partum
Pathophysiology of eclampsia
Cerebral oedema
Hypertensive encephalopathy
What commonly used drugs in labour are contraindicated in preeclampsia
Ergometrin
Syntometrin
Indications for urgent delivery I.e severe preeclampsia
Worsening thrombocytopenia Worsening liver function Worsening kidney function Fetal distress Eclampsia HELLP syndrome
