Pre-eclampsia And Eclampsia

Question 1

What is pre-eclampsia?

Answer 1

It is a multi-system disorder originating from the placenta.

It is characterised by proteinuria and hypertension.

Question 2

What is thought to be the pathophysiology of pre-eclampsia?

Answer 2

Thought to be due to a problem with trophoblastic invasion of the spiral arteries leaving them vasoactive.
This means they are reactive to vasoconstrictors which then compromises placental blood flow.
A high blood pressure partially compensates for this.
It effects hepatic, renal and coagulation systems.
Develops after 20 weeks and resolves within 6 weeks of delivery.

Question 3

How does pre-eclampsia cause maternal morbidity and mortality?

Answer 3

Multi-organ failure
Adult respiratory distress syndrome
Cerebral haemorrhage

Question 4

Why does pre-eclampsia increase the chance of prematurity?

Answer 4

Iatrogenic

Delivery is the only cure

Question 5

What are the high risk factors of pre-eclampsia?

Answer 5

Previous severe/early-onset (<20 weeks) pre-eclampsia
Chronic hypertension/hypertension in a previous pregnancy
Autoimmune disease e.g. SLE, antiphospholipid syndrome
CKD
Diabetes Mellitus

Question 6

What are the moderate risk factors of pre-eclampsia?

Answer 6

First pregnancy
Multiple pregnancy
FH of pre-eclampsia
Age 40+
BMI 30+
Pregnancy interval over 10 years
Low PAPP-A
Uterine artery notching on USS at 22-24 weeks

Question 7

When should aspirin be taken to prevent pre-eclampsia?

Answer 7

If 1 high risk factor is present or 2 moderate risk factors

75-150mg of aspirin should be taken everyday PO from 12 weeks to delivery

Question 8

What are the foetal risk factors of pre-eclampsia?

Answer 8

Hydatiform mole
Multiple pregnancy
Foetal hydrops

Question 9

What are the effects of pre-eclampsia?

Answer 9

Decreased plasma volume
Increased peripheral resistance 
Placental ischaemia
Microaneurysms
DIC
Oedema
HELLP syndrome
Placental infarcts

Question 10

What are the serious complications of pre-eclampsia?

Answer 10

Eclampsia
HELLP syndrome
Cerebral haemorrhage
Placental abruption
IUGR
Renal failure

Question 11

What are the symptoms of pre-eclampsia?

Answer 11

May be asymptomatic if mild
Headaches
Flashing lights
Epigastric/RUQ pain
NV
Swelling of the face/fingers/lower limbs

Question 12

What are the signs of pre-eclampsia?

Answer 12

Hypertension (pregnancy-induced)
Proteinuria
RUQ/epigastric tenderness
Brisk reflexes
Clonus (over 2 beats)
Confusion
Fits
IUGR
Stillbirth
Placental abruption

Question 13

What are the investigations for pre-eclampsia?

Answer 13

Urine dipstick for proteinuria and then a 24 hour collection to quantify it
FBC - low platelets, low Hb (if haemolysis)
U&Es - high urea, creatinine and urate, low urine output - increased PCR
LFTs - raised transaminases
Prolonged PT and APTT
Foetal growth restriction and oligohydramnios on USS
Uterine artery notching/abnormality on doppler

Question 14

What is mild pre-eclampsia and what is the treatment for it?

Answer 14

140-149/90-99 BP
4 hourly BP
2 weekly bloods - U&Es, LFTs, FBC
2 weekly growth scans 
IOL at over 37 weeks
Don’t give antihypertensives until over 150/100

Question 15

What is moderate pre-eclampsia and what is the treatment for it?

Answer 15

BP 150-159/100-109
Admit to hospital for monitoring until delivery if clinical concerns
4 hourly BP
Bloods (FBC, LFTs, U&Es) 3 times a week
Twice daily CTG
Antihypertensives - aim 135/85
Foetal growth scans twice a week
IOL at 37 weeks

Question 16

What is severe pre-eclampsia and how is it managed?

Answer 16

BP > 160/110, symptoms/signs e.g. Clonus, end-organ damage
Get senior obstetrician
Control BP with hypertensives e.g. nifedipine PO
If this doesnt work, IV hypertensives e.g. labetalol, hydralazine
Strict fluid balance and catheterise
Bloods every 12-24 hours
Magnesium sulphate prophylaxis 4g loading dose and then 1g IV/hour
Steroids for foetal lung maturity
Deliver if over 34 weeks
If under - timing decided by senior obstetrician, but usually once woman is stable

Question 17

What is eclampsia?

Answer 17

It is an obstetric emergency characterised by pre-eclampsia + tonic-clonic seizure
- can have the seizure during the antenatal, intrapartum or postpartum period
It occurs in 1% of pregnancies with pre-eclampsia

Question 18

What is the cause of death in eclampsia?

Answer 18

Cerebral haemorrhage
HELLP syndrome
Organ failure

Question 19

What is the management for eclampsia?

Answer 19

ABCDE
Call senior help
Catheterise and fluid restrict
- monitor urine output hourly 
Magnesium sulphate
If repeated seizures give diazepam 
Keep calcium gluconate ready for magnesium sulphate overdose and respiratory depression
Continuous CTG monitoring 
Deliver when stable

Question 20

What is HELLP syndrome?

Answer 20

Elevated liver enzymes are the first sign and then low platelets and then haemolysis
A severe variant of pre-eclampsia
Cure is with delivery of the foetus

Question 21

What are the symptoms of HELLP syndrome?

Answer 21

Raised BP
RUQ/epigastric pain and tenderness
NV
Dark urine due to haemolysis

Question 22

What is the treatment for HELLP syndrome?

Answer 22

Same as eclampsia
Delivery is the definitive diagnosis
Regional anaesthesia is contraindicated if platelets under 80
If platelets under 50 and surgery required - cover with platelet transfusion

Question 23

Why should syntometrine/ergometrine not be used in the 3rd stage of labour with eclampsia?

Answer 23

Can cause intracranial haemorrhage with severe hypertension leading to a stroke
Just use oxytocin