Pre-eclampsia

Question 1

How does blood pressure change in pregnancy?

Answer 1

• BP falls in early pregnancy due to vasodilation
• lowest BP at 22-24 weeks and slowly rises till term
• BP falls after birth but rises on day 3/4 postnatally and should return to prepregnancy level at day 10

Question 2

What is pregnancy induced hypertension?

Answer 2

• high blood pressure usually in the 2nd half of pregnancy
• resolves within 6 weeks after birth
• no other features of pre-eclampsia
• small % can progress to pre-eclampsia

Question 3

What is the criteria to diagnose pre-eclampsia?

Answer 3

• high blood pressure (>140/90 on 2 occasions OR 160/110 on 1 occasion)
• proteinuria (>0.3g/l OR >0.3g/24h)
• oedema

Question 4

What are the classifications of pre-eclampsia?

Answer 4

Early Pre-eclampsia (<34 weeks)
-uncommon
-extensive villous and vascular lesions of the placenta
-higher risk of maternal and fetal complications than late pre-eclampsia
Late Pre-eclampsia (34 weeks ++)
-common
-minimal placental lesions
-most cases of eclampsia and maternal death occur in late disease

Question 5

What occurs in pre-eclampsia?

Answer 5

stage 1-abnormal placenta perfusion (placental ischemia)

stage 2-maternal syndrome( antiangiogenic state with endothelial dysfunction)

Question 6

Which systems does pre-eclampsia affect?

Answer 6

-CNS (Eclampsia, intracranial haemorrhage,cortical blindness)
CVS/Respi (pulmonary oedema –> ARDS, PE)
-Liver-Elevated liver enzymes due to microvascular injury & hepatic necrosis
-Blood-thrombocytopenia due to formation of thrombus, DIC,haemolysis,
-Placenta-IUGR, IUD, placental abruption
-Kidneys-proteinuria, decreased GFR, oliguria/anuria, acute renal failure

Question 7

What is HELLP SYNDROME?

Answer 7

• haemolysis (because RBC get trapped against thrombi)
• elevated liver enzymes
• low platelets

Question 8

what are the symptoms of pre-eclampsia?

Answer 8

• headache
• RUQ/epigastric pain
• nausea/vomiting
• visual disturbances
• progressive oedema

Question 9

What are the signs of pre-eclampsia?

Answer 9

MOTHER 
-hypertension
-proteinuria
-abdominal tenderness
-disorientation
-hyper-reflexia/ankle clonus 
FETUS 
-IUGR
-SGA
-IUD

Question 10

How is pre-eclampsia investigated?

Answer 10

• if hypertension <20 weeks look for secondary causes
• maternal uterine artery doppler
• CTG
• LFT
• U&E
• urine protein creatinine ratio
• USS (fetal biometry, AFI)

Question 11

Management of pre-eclampsia?

Answer 11

• Delivery

- Low dose aspirin (75mg)-may prevent severe early onset pre-eclampsia. commence <12 weeks

Question 12

What drugs can be used to manage pre-eclampsia?

Answer 12

-100mg b.d-600mg q.i.d Labetolol (1st line)
-10mg b.d.-40mg b.d. nifedipine sustained release
-250mg b.d.-1g t.d.s. methyldopa (contraindicated in depression)
25mg t.d.s.-75mg q.i.d. Hydralazine (vasodilator)

Question 13

When should baby be delivered?

Answer 13

• term gestation
• uncontrollable BP
• rapidly deteriorating biochem/heamatology
• eclampsia
• fetal compromise (REDF, abnormal CTG)
• mother is stabilised
• consider expectant management if pre term (2x dexa 12mg 12 h apart)
• most women deliver within 2 weeks of diagnosis

Question 14

What crises can arise from pre-eclampsia?

Answer 14

• eclampsia
• HELLP syndrome
• cerebral haemorrhage
• placenta abruption
• cortical blindness
• DIC
• hepatic rupture
• acute renal failure
• pulmonary oedema

Question 15

What is the management for eclampsia?

Answer 15

• BP control (IV labetolol/IV hydralazine)-be aware to not cause hypotension
• fluid balance (be aware to not cause pulmonary oedema)
• delivery (epidural causes vasodilation. aim for SVD)
• stop seizure (MgSO4 4g IV over 5 min and then 1g/h IV infusion)
• if seizure persistent, consider diazepam 10mg IV