Pre-eclampsia/Eclampsia Flashcards
A 27-year-old primigravida 1+0 presents at 35 weeks gestation with a blood pressure of 165/120mmHg, and 3+ of proteinuria on dipstick testing. Prior to becoming pregnant, her blood pressure was stable at around 115/75mmHg and her only past medical history is well-controlled asthma. With regards to her management, which of these is true? 1. IV magnesium sulfate is the only curative treatment for her condition 2. Same-day delivery should not be considered, as she is not past 36 weeks gestation 3. Following Tx with Nifedipine into the post-natal period, the patient should not be advised to breastfeed 4. In induced labour, epidural anaesthesia should help to reduce BP 5. Antenatal hypertensive treatment should be discontinued in labour
In induced labour, epidural anaesthesia should help to reduce BP
A 45-year-old woman presents at 10 weeks gestation for a routine check. She has a previous history of severe pre-eclampsia. Her BMI is 38 kg/m^2. Her blood pressure was 145/94 mmHg. What treatment would you advise to reduce the risk of pre-eclampsia? 1. Aspirin 2. Bendroflumethiazide 3. Ramipril 4. Magnesium supplements 5. Labetalol
Aspirin
A 32-year-old women para 1+0 is 37+1 weeks pregnant and is being monitored and treated for pre-eclampsia. Her current treatment is with labetalol and her blood pressure has been well controlled. She attends the antenatal clinic complaining of a severe headache, one episode of vomiting, and blurred vision. Her blood pressure is currently 156/100 mmHg. On examination she has papilloedema. She is admitted to hospital. What is the appropriate management? 1. Start IV hydralazine 2. Give IV MgSO4 and plan immediate delivery 3. Give IV MgSO4 and IM beclomethasone 4. IV calcium gluconate 5. Plan immediate delivery
Give IV MgSO4 and plan immediate delivery
What is the definition of pre-eclampsia?
New onset of hypertension (>140 mmHg systolic or >90 mmHg diastolic) after 20 weeks of pregnancy and the coexistence of 1 or more of the following new-onset conditions:
proteinuria OR
other maternal organ dysfunction:
- renal insufficiency
- liver involvement with or without right upper quadrant or epigastric abdominal pain)
- neurological complications i.e eclampsia, altered mental status, blindness, stroke, clonus, severe headaches or persistent visual scotomata
- haematological complications such as thrombocytopenia (platelet count below 150,000/microlitre), DIC or haemolysis
uteroplacental dysfunction –> fetal growth restriction, abnormal umbilical artery doppler waveform analysis, or stillbirth
Give 5 SSx of pre-eclampsia
Neuro:
- Headaches
- Blurred vision/Flashing lights
- Brisk reflexes (plantar/patella)
Abdo:
- Abdominal pain
- Vomiting
- Oedema
Give 7 risk factors for pre-eclampsia
Mnemonic: NOPEFAT
Nulliparity
Obesity (BMI > 35)
Previous pre-eclampsia/hypertension history
Extremes of age (> 40)
Family history of pre-eclampsia (1st degree = 8-fold risk)
Associated maternal conditions: autoimmune disease, CKD
Twin pregnancy
What is the pathophysiology of pre-eclampsia (give 2 points)
- Impaired spiral artery remodelling
- Failure of trophoblastic invasion
What are the two components of the trophoblast? Which one secretes B-hCG?
Cytotrophoblast
Syncytiotrophoblast - secretes B-hCG
2 impt complications of pre-eclampsia
HELLP syndrome
DIC
IUGR
Eclampsia
2 investigations to predict risk of pre-eclampsia?
USS of the uterine arteries
Pregnancy-associated plasma proteins (PAPP-A)
Urine dipstick showed +1 for protein, what is the next investigation to do?
Protein: creatinine ratio
What are the high risk factors for pre-eclampsia?
Previous history of hypertensive disease during pregnancy
Chronic Kidney Disease
Autoimmune disease
Type 1 or Type 2 Diabetes
Chronic hypertension
What are the moderate risk factors for pre-eclampsia?
- First pregnancy
- Aged 40 years or older
- Pregnancy interval of more than 10 years
- BMI of 35 kg/m2 or greater at the first visit
- Family history of pre-eclampsia
- Multiple pregnancy
What is given to prevent pre-eclampsia? When is it indicated?
Aspirin 75-150mg PO OD
When either presence of 1 high risk factor or 2 moderate risk factors
What bedside investigations for pre-eclampsia?
Vital signs
Blood Pressure
Urine dipstick
Protein creatinine ratio/Urine creatinine ratio
What blood tests for pre-eclampsia and why?
FBC: look for signs of HELLP syndrome
LFT: look for signs of HELLP syndrome
Serum creatinine: look for signs of AKI
Clotting screen: look for signs of coagulopathy
What fetal investigations to do once pre-eclampsia is confirmed?
Cardiotocography
Ultrasound sound scan
- Umbilical artery doppler
- Assess fetal growth
- Amniotic fluid volume
What are the indications for a repeat CTG?
- Change in fetal movements
- Vaginal bleeding
- Abdominal pain
- Deterioration in maternal condition
Definitive treatment for pre-eclampsia?
Delivery of the baby
Women at 34 weeks gestation, biochemistry not resolving and she is deteriorating. What 3 treatments would you give her?
Delivery via C-section
IV MgSO4
Beclomethasone
What are the treatments for the different types of pre-eclampsia?
Degree of HTN
HTN:
BP of 140/90 – 159/109
Severe HTN:
BP of 160/110 or more
Admission to hospital
Admit if
- any clinical concerns for the wellbeing of the woman or baby
- or if high risk of adverse events suggested by the fullPIERS or PREP‑S risk prediction models
Admit if
- BP falls below 160/110mmHg then manage as for hypertension
Anti-HTN
Offer pharmacological treatment if BP remains above 140/90 mmHg i.e Labetalol (1st line) PO or IV
Offer pharmacological treatment for all women i.e Labetalol (1st line) PO or IV
Target BP
Target BP: 135/85 or less
Blood pressure measurement
At least every 48 hours or more frequently if woman is admitted to hospital
Every 15–30 minutes until BP is less than 160/110 mmHg, then at least 4 times daily while the woman is an inpatient, depending on clinical circumstances
Dipstick proteinuria testing
Only repeat if clinically indicated
Only repeat if clinically indicated
Blood tests
FBC
LFT
Renal function
At least 2x a week
FBC
LFT
Renal function
At least 3x a week
Fetal assessment
- Offer fetal heart auscultation at every antenatal appointment
- Carry out ultrasound assessment of the fetus at diagnosis and, if normal, repeat every 2 weeks
- Carry out a CTG at diagnosis and then only if clinically indicated
What are the considerations to give IV MgSO4 to prevent seizures in woman with severe pre-eclampsia?
ongoing or recurring severe headaches
visual scotomata
nausea or vomiting
epigastric pain
oliguria and severe hypertension
progressive deterioration in laboratory blood tests (such as rising creatinine or liver transaminases, or falling platelet count). → HELLP syndrome
