Pre-eclampsia, Eclampsia, and HELLP Syndrome

Question 1

What is dx for pre-eclampsia?

Answer 1

• BP >/= 140/90 after 20w GA x2, at least 4h apart
• AND! proteinuria
• OR! thrombocytopenia, renal insufficiency, impaired liver function, pulmonary edema, cerebral/visual changes

Question 2

What is dx for severe pre-eclampsia?

Answer 2

BP >/= 160/110

Question 3

What is dx for eclampsia?

Answer 3

inclusive of pre-eclampsia dx PLUS new onset seizures

Question 4

What is HELLP?

Answer 4

Hemolysis
Elevated Liver enzymes
Low Platelets

severe form of pre-eclampsia
can present w/ or w/out HTN or proteinuria

Question 5

What is included in the physical assessment of pts w/ PEC?

Answer 5

• q1h BP
• lung sounds, pulse ox, work of breathing = pulmonary edema
• epigastric pain
• headache
• visual changes
• dorsiflex foot to check for + clonus: rapid involuntary rhythmic muscle contractions
• I/Os (O at least > 30mL/h)
• deep tendon reflexes

Question 6

Describe scoring of deep tendon reflexes and what is indicated

Answer 6

0 = absent --> mag toxicity
1+ = diminished --> mag toxicity 
2+ = normal 
3+ = brisk --> +/- seizure
4+ = hyperactive --> +/- seizure

Question 7

What lab work is included in PEC workup?

Answer 7

1) creatinine (>1.1 = renal insufficiency)
2) CBC
- platelets < 100K = thrombocytopenia
- increased H/H
3) LFTs
- liver enzymes elevated to 2x normal value
- AST: 3rd tri = 4-32; term = 5-103
- ALT: 3rd tri = 2-32; term = 5-115
4) protein:creatinine or 24h urine collection

Question 8

What is dx of proteinuria?

Answer 8

• at least 300mg protine in 24h urine collection
• protein:creatine >/= 0.3
• urine dipstick protein 1+

Question 9

magnesium sulfate (prevention)

Answer 9

preventionof seizures

4-6g IV loading dose, then 1-2g/h infusion

• if creatinine elevated, 1g/h
• keep serum levels at 4-7 mEq/L
• check for mag toxicity (DTRs, respiratory status)

Question 10

calcium gluconate

Answer 10

antidote to mag toxicity

1g IV over 3min

Question 11

hydralazine (Apresoline)

Answer 11

antiHTN

5-10mg IV over 2min q20min

• max dose 20mg in first h
• contraindication: tachycardia

Question 12

labetalol (Normodyne, Trandate)

Answer 12

antiHTN

20mg IV over 2min

• no effect in 10 min –> 40mg IV
• no effect in another 10 min –> 80mg IV
• max dose - 300mg in first h
• contraindications: asthma, CHF

Question 13

nifidepine (Procardia)

Answer 13

antiHTN

10-20mg PO q30min

• max dose 50mg in first h
• contraindications: tachycardia

Question 14

Describe emergency management of a pt having an eclamptic seizure

Answer 14

• put up padded side rails
• place pt in lateral decubitus position
• suction ready if vomit

Airway: 8-10L via face mask
Blood pressure: hydralazine, labetalol, or nifedipine to maintain under 160/110
Convulsions: give mag sulfate
Delivery: do not rush for c/s! Monitor for placental abruption

Question 15

magnesium sulfate (tx)

Answer 15

treatment of active seizure

6g IV loading dose –> 2-3g/h infusion

give 2g IV bolus if seizure persists/recurs

Question 16

What can be given if mag sulfate does not treat an active eclamptic seizure?

Answer 16

lorazepam (Ativan) 1-2mg IV

Question 17

What labs indicate hemolysis in HELLP?

Answer 17

at least two of following:

• abnormal peripheral smear
• bilirubin > 1.2mg/dL
• haptoglobin = 1.2mg/dL

Question 18

What labs indicate elevated liver enzymes in HELLP?

Answer 18

• AST/ALT >2x normal (>70 IU/L)

- lactate dehydrogenase > 2x normal (>600 IU/L)

Question 19

What labs indicate low platelets in HELLP?

Answer 19

platelets < 100,000/mm3

Question 20

HELLP s/sx

Answer 20

nonspecific; similar to PEC

• RUQ/epigastric pain
• N/V
• HA/photophobia
• malaise
• +/- HTN or proteinuria

Question 21

When is immediate delivery indicated in HELLP?

Answer 21

1) DIC
2) liver infarction or hemorrhage
3) renal failure
4) pulmonary edema
5) placental abruption
6) non-reassuring fetal status