pre-eclampsia and eclampsia - GM Flashcards
define pre-eclampsia
multisystem syndrome developing after 20 weeks
de novo hypertension which co-exsits with one or more of the following:
- renal involvement
- haematological involvment
- liver innvolvement
- neurological involvemnt
- pulmonary oedema
- FGR
renal involvement in pre eclmapsia
significant proteinuria
serum or plasma creatinine >90
oliguria <80ml/4 hours
haematological involvement in pre eclampsia
thrombocytopaenia
haemolysis pattern on blood film
DIC
neurological involvement
convulsions
persistent visual disturbances
persistent new headache
stroke
liver innvolvement in pre eclampsia
raised transmaminases
severe epigastric or right upper quadrant pain
how common is pre-eclampsia
2-8% pregnancies
0.5% develop severe life threatening pre eclampsia
1 in 4000 pregnancies develop to eclampsia (maternal seizures)
aetiology of pre eclampsia
due to poor perfusion of the placenta resulting in release of pro inflammatory cytokines, causing peripheral endothelial dysfunction
is oedema a sign of pre eclampsia
no longer included in the definition because it occurs equally in women with and without pre eclampsia
rapid development of oedema should still alert the clinician to screen for pre eclampsia
high risk factors for pre-eclampsia
chronic hypertension
hypertensive disease in a previous pregnancy
type 1 or type 2 diabetes mellitus
chronic kidney disease
autoimmune disease
- anti-phospholipid syndrome
- systemic lupus erythematosus
moderate risk factors for pre-eclampsia
aged 40 and over
first pregnancy
pregnancy interval >10 years
multiple pregnancy
pre-pregnancy obesity (BMI >35kg/m2)
family history of pre eclampsia
symptoms of pre eclampsia may include
pateints often have no symtpoms
- headache
- visual disturbance such as blurring or flashing lights
- swelling or arms, legs and face
- nausea and vomiting
- abdominal pain
- reduced urine output
clinical signs of pre-eclampsia
hypertension
oedema: typically in the peripheries and face
epigastric/right upper quadrant tenderness
hyper reflexia and clonus (indicates an increased risk of eclamptic seizure)
papilloedema
ddx of pre eclampsia
chronic hypertension: occurs before 20 weeks gestations. or persists after 12 weeks post partum
gestational hypertension: occurs after 20 weeks gestation that develops without any co-existing complications
pre-eclampsia superimposed on chronic hypertension: hypertension that already exists but worsens after 20 weeks gestation alongside the development of coexisting complications
chronic hypertension is
hypertension occuring before 20 weeks and persisting after 12 weeks post partum
gestational hypertension is
hypertension occuring after 20 weeks gestation that develops without any complications
resolves within 3 months post partum
how does antenatal screening detect pre-eclampsia
antenatal appointments include assessment of blood pressure, a urine dipstick test to identify proteinuria and fetal heart auscultation
lab investigations for pre-eclampsia
FBCs: low platelet count may suggest HELLP syndrome
U&Es: raised urea, raised creatinine and low eGFR indicate renal impairment
LFTs: raised ALT or AST indicate liver dysfunction
clotting profile: clotting may be deranged in the context of disseminated intravascular coagulation (DIC)
placental growth factor (PIGF)
supports trophoblastic growth and placental angiogenesis
a blood test measuring PIGF levels can be used to aid diagnosis in pre-eclampsia
elevated levels of PIGF indictae that pre-eclampsia is unlikely
diagnostic criteria for pre-eclampsia
hypertension > 140mmHg systolic or >90 mmHg diastolic
proteinuria >300mg protein in a 24 hour urine collection
maternal organ dysfunction: liver involvement, renal insufficiency, haematological complications and neurological involvement eg. visual disturbance
uteroplacental dysfunction: IUGR/stillbirth
monitoring of patient with pre eclampsia involves
regular blood pressure assessment
regular screening for proteinuria
regular blood tests including FBC, U&Es and LFTs
regular fetal monitoring for patient with pre eclampsia
CTG: assessment of fetal heart beat
US: assessment of fetal growth and amniotic fluids
umbilical artery doppler velocimetry: assessment of placental and fetaal circulation
medical management of pre-eclampsia
aspirin
antihypertensives: PO nifedipine is first line, IV labetolol is second line and methyldopa is first line
venous thromboembolism prophylaxis: due to increased VTE risk
when to prescribe aspirin for pre-eclampsia
should be prescribed from 12 weeks gestation until delivery for patients with one high risk factor or two moderate risk factors
which VTE prophylaxis should be used
low molecular weight heparin
physical measures eg. anti-embolism stockings
severe pre-eclampsia
BP > 160mmHg systolic or >110mmHg diastolic
requires hospital admission
maternal complications of pre-eclampsia
multi-organ dysfunction: with progressive worsening to multi-organ failure
cardiovascular complications: MI or stroke
placental abruption
eclampsia
HELLP syndrome
eclampsia
seizures occuring in pregnancy or within 10 days of delivery as well as two of the following within 24 hours of the seizure
- hypertension
- proteinuria
- thrombocytopaenia
- raised AST
mortality of eclampsia
high mortality rate: 1 in 50 women, 1 in 14 unborn babies
treatment of eclampsia
obstetric emergency requiring hospital admission
IV magnesium sulphate and early delivery
corticosteroids to accelerate fetal lung maturation if less than 34 weeks
HELLP syndrome
endothelial damage and consequent thrombi formation associated with pre-eclampsia
develops in 10-20% of women with pre-eclampsia
what does HELLP stand for
Haemolysis: red blood cells become damaged by the abnormal endothelium, resulting in. microangiopathic. haemolytic anaemia
Elevated Liver enzymes: raised ALT and/or AST can occur due to hepatic sinusoid obstruction by fibrin
Low Platelets: platelet levels drop below 150 x 10^9 due to platelet consumption as a result of thrombi formation
why does HELLP syndrome cause thrmbocytopaenia
due to platelet consumption during multiple thrombi formation
what might a blood film from a patient with HELLP syndrome look like
it would contain schistocytes (fragmented red blood cells)
what causes Haemolysis in HELLP syndrome
red blood cells become damaged by the abnormal endothelium, resulting in microangiopathic haemolytic anaemia
management of HELLP
IV magnesium sulphate
antihypertensives
blood products
timely delivery
pre eclamptic angina
epigastric RUQ pain in a woman with pre-eclampsia
often represents hepatic involvement
which anticonvulsant medication to use
MgSO4 - indictaed for women with severe pre-eclampsia to prevent seizures and reduce maternal mortallity
corticosteroid therapy
corticcoteroids are indicated for women with severe pre-eclapmsia to enhance foetal lung maturity and reduce neomatal RDS
benefit does not last beyond 7 days
post partum management of pre-eclampsia
clinical annd lab derangements recover within several days
HTN can persist for up to 3 months
monitor patient
continue MgO4 until BP stabilisation and adequate diuresis achieved
acute hypertensive therapy should be commenced if BP > 150/110 in the first 4 days post partum
advise follow up with GP
consider secondary causes of hypertension in pregnaancy
what is gestational hyprtension
new onset of hypertension arising after 20 weeks gestation
no additional maternal or fetal features of preeclampsia
resolves within 3 months post partum
patients with pre-existing chronic hypertension
strong risk factor for the development of pre-eclampsia and requires close clinical surveillance
essential hypertnsion
BP >140/90 preconception or developing prior to 20 weeks without an underlying cause
or normal BP controlled with antihyprtnsives
secondary hypertsion
hypertnsion due to
- chronic kidney disease
- renal artery stenosis
- systemic disease with renal involvement eg. diabetes, SLE
- endocrine disorders
- coarctation of the aorta
in acute severe pre-eclampsia, ddelivery must always be preceeded by
control of severe hypertension
attention to fluid status
correction of coagulopathy (usually thrombocytopaenia)
control of eclampsia, or prophylaxis
agent of choice for the acute treatment of acute severe hyprtension
oral nifedipine 10mg
repeat dose after 30 minutes if there is inadequate response
intravenous agent of choice for the acute treatment of acute severe hyprtension
IV labetolol
20-80mg bolus over 2 minutes
repeat every ten minutes prn
third line for severe acute hypertension
hydralazine 5-10mg
first dose 5mg if fetal compromise
IV or IM administration
principles of management of eclampsia
- resuscitation: IV access, oxygen by mask, MgSO4, midazolam may be given if the seizure is long
- prevention of further seizures: continue MgSO4
- control of hypertension
- delivery: close fetal monitoring, arrange delivery, there is no role for continued pregnancy after eclampsia
strategies to prevent pre eclampsia
cacium supplimentation
low dose aspirin
medication for high blood pressure during pregnancy
methydopa, labetolol, hydralazine, nifedipine
HELLP syndrome
hemolysis, elevated liver enzymes and low platelet count
maternal mortality is 1-2%
presentation of HELLP syndrome
thrombocytopaecia (common)
haemolysis (rare)
elevated liver enzymes ALT, LDH
epigastric or right upper quadrant pain (pre-eclamptic angina)
management of HELLP syndrome
if the platelet count is sufficiently low to present. hazard for operative delivery, a platelet transfusion should be considered
