Pre-eclampsia (Complete) Flashcards
Define pre-clampsia
Emergence of high blood pressure during pregnancy that may be a precursor to a woman developing eclampsia
What is the pathophysiology of pre-eclampsia?
Abnormal placentation → endothelial dysfunction → systemic vasospasm → hypertension, organ damage, and seizures.
What is the triad of pre-eclampsia?
New onset hypertension
Proteinuria
Oedema
What criteria must be met to be diagnosed with pre-eclampsia?
New onset hypertension ( > 140/90 mmHg) after 20 weeks of pregnancy with one or more of the following:
Proteinuria
Organ involvement
What is eclampsia?
Development of seizures in association pre-eclampsia
What are the main risk factors for pre-eclampsia?
Obsteric:
Pre-existing hypertension or pre-eclampsia in previous pregnancy
Nullparity or multiparity
Maternal:
Obesity
Old maternal age (>40)
Young maternal age (<18)
Chronic conditions
* Diabetes
* Kidney disease
* Autoimmune conditions
Genetics:
Family history of pre-eclampsia
What are the main clinical features of pre-eclampsia
May be diagnosed asymptomatically at routine checkup with:
- New-onset hypertension (_>_140/90 mmHg)
- Proteinuria
Symptoms/Signs:
Oedema
Headaches
* Frontal
Visual disturbance
* Photophobia
* Scotoma (blind spot)
* Photopsia (percieved flashing lights)
* Blurred vision
Hyper-reflexia with sustained clonus
Abdominal pain
* Epigastric
* RUQ
Nausea and vomitting
Oliguria
What are features of severe pre-eclampsia?
Hypertension >160/110 mmHg
proteinuria: dipstick ++/+++
Frontal headache
Visual disturbance
Papilloedema
RUQ/epigastric pain
Hyperreflexia
Platelet count < 100 * 106/l
Abnormal liver enzymes or HELLP syndrome
Which presentation is associated with HELLP syndrome? (subtype of pre-eclampsia)
Epigastric/RUQ abdominal pain
What additional presentation occurs in patients with eclampsia
Generalised tonic-clonic seizures
What complications can occur due to pre-eclampsia?
Eclampsia (Generalised tonic-clonic seizures)
Foetal complications
- Intrauterine growth restriction
- Prematurity
Liver involvement (elevated transaminases)
Haemorrhage
- Placental abruption
- Intracerebral haemorrhage
- Intra-abdominal
Heart failure
What investigations should be done for patients with suspected pre-eclampsia?
Bedside:
Basic obs: Measure hypertension
Urine dipstick: Check for proteinuria
Bloods:
FBC: Check for thrombocytopenia (HELLP syndrome)
Blood film: Haemolysis (schistocytes)
LDH: Elevated in HELLP due to haemolysis
Coagulation profile: Check liver function or DIC
U&Es: Check renal involvement
LFTs: Check for elevated enzymes (HELLP syndrome)
Imaging:
Obsteric ultrasound: Check foetal growth and amniotic fluid status
Doppler studies: Check ureteroplacental blood flow
CT/MRI: If suspected intracranial bleed
What lab findings are indicative of HELLP syndrome?
Thrombocytopenia
Elevated liver enzymes
Haemolysis (Schizocytes + LDH)
What can be seen in blood film in patients with HELLP?
Schistocytes
Microangiopathic haemolytic anaemia (MAHA) – mechanical RBC destruction (forced through fibrin/platelet mesh in damaged vessels which shears RBCs) → schistocytes
What is the management plan for patients with pre-clampsia/eclampsia?
Conservative/supportive:
ICU or HDU monitoring.
Fluid balance management (to prevent pulmonary oedema).
Foetal monitoring: continuous cardiotocography (CTG) [Especially during labour]
Medicine:
Seizure control: IV magensium sulfate
BP control:
* Labetalol (IV/oral)
OR
* Nifedipine (oral)
OR
* Hydralazine (IV)
Interventional:
Delivery of foetus and placenta (Definitive management)
What is given for acute seizure control in patients with eclampsia?
First-line: Magnesium sulphate (loading dose 4 g IV, maintenance 1 g/hour)
Second-line: Lorzepam or diazepam
How much magnesium is given as loading dose?
4g
How much magnesium is given as maintenance dose?
1g/hour
What is given if magnesium sulfate still ineffective in management of seizures?
Lorazepam or diazepam
How is hypertension managed in patients with pre-eclampsia/eclampsia?
Either of the following:
Labetalol (IV or oral): Typically first-line
Hydralazine (IV)
Nifedipine (oral)
Labetalol is contraindicted in which individuals?
Pregnant women who are asthamtic
Give nifedipine or hydralazine instead
What is the definitive management plan for patients with pre-eclampsia/eclampsia?
Delivery of the placenta and foetus
Will get rid of placental endothelial dysfunction
What preventative measures are taken for pregnant women at risk of pre-eclampsia?
For women with 1 high-risk factor or 2 moderate risk factors:
Aspirin 75-150 mg daily from 12 weeks gestation until the birth
What maternal complications can occur in patients with pre-eclampsia?
Intracerebral haemorrhage/stroke
Pulmonary oedema
HELLP syndrome
DIC
AKI
What foetal complications can occur due to pre-eclampsia
Preterm delivery
Intrauterine growth restriction (IUGR)
Hypoxia or stillbirth
What differentials should be considered alongside pre-eclampsia/eclampsia?
Chronic hypertension
Gestational hypertension
Antiphospholipid syndrome
Epilepsy
How can chronic hypertension be distinguished from pre-eclampsia?
Pre-existing before pregnancy
Absence of new-onset proteinuria
How can gestational hypertension be distinguished from pre-eclampsia?
Can present similarly but will have absence of proteinuria
How can antiphospholipid syndrome be distinguished from pre-eclampsia?
History of repeated early pregnancy loss.
History of venous thrombosis, stroke, or transient ischaemic attack.
Lupus anticoagulant: positive.
Anticardiolipin antibodies: medium or high titre.
Anti-beta-2-glycoprotein I: titre >99th percentile.
How can epilepsy be distinguished from eclampsia?
History of seizures preceding pregnancy
