Pre-Eclampsia/PIH Flashcards
Define Pre-Eclampsia
The onset of HTN (140/90) in pregnancy with end-organ dysfunction + proteinuria after 20 weeks gestation.
How does pregnancy induced HTN differ to pre-eclampsia?
PIH is HTN without proteinuria
What is chronic/essential HTN in pregnancy?
HTN occurs <20 weeks gestation in a woman that was previously normotensive. (BP normally drops in pregnancy).
What is HELP Syndrome
Hemolysis, Elevated Liver Enzymes + Low platelets that occurs as an atypical presentation of pre-eclampsia. Associated with increased rates of mortality/morbidity.
What is DIC?
Clot lysis + simultaneous clot activation
Risk factors for Pre-eclampsia
Think ‘‘A to H’’
PMH:
APS
BMI >30
CKD
Diabetes
slE,
Fertility Rx
Gynae issues like PCOS
HTN / Hx of Pre-eclampsia / Hx in family
Clinical Features of Pre-eclampsia from Head to Toe
Headache
Vision disturbance
Periorbital edema, face swelling, peripheral edema
Epigastric pain
Breathlessness
RFM
SFDs
Brisk Reflexes
Clonus
Signs on Ax of Pre-eclampsia
Hyper-reflexia
Clonus
Pitting edema
Tachypnea
RUQ pain
RFM
What investigations would you do for Pre-eclampsia and why?
Bloods:
1. FBC (low Hb & platelets = HELLP syndrome),
2. LFTs (elevated transaminases, ALT, AST),
3. U&Es (raised urea and creatinine)
4. Lactate (elevated in HELLP)
5. Coag studies (elevated D-Dimer + PT/PTT, reduced fibrinogen
6. Urate - Raised in PET
7. Urinanalysis - ACR and 24 hr urine collection, proteinuria
8. Fetal US + doppler
What would one look for on Fetal US?
HC, BPD, OFD, AC, FL and amniotic fluid index
How would you approach monitoring pre-eclampsia?
Mild - Weekly
Mod - Biweekly
Severe - Admit + daily monitoring of BP every 4 hours, daily CTG, US scans, plan for delivery.
DDx for Pre-eclampsia
Chronic HTN
Eclampsia
HELP
Epilepsy
Encephalitis
AFLP?
When would you induce induce labour in someone with pre-eclampsia?
Mild pre-eclampsia = 37 weeks via induction or C section
Minimum 34 weeks (give steroids), ideally 37 weeks
What medications can be given to treat hypertension/Pre-Eclampsia?
Luke M Hates Neonates
Labetolol
Methyldopa
Hydralazine
Nifedipine
All should be on aspirin from 12 weeks
How would you both treat and prevent seizures?
Mg (4g LOAD + 1g/hr IV INFUSION)
What is important in post-partum period?
Magnesium infusion for 24 hours post partum (when seizures are at their greatest)
Monitor BP, urine output and signs of overload.
Change methyldopa to labetalol
Use syntocinon (not syntometrine)
Maternal complications in Pre-eclampsia?
- Intracranial haemorrhage
- Multiorgan failure - Liver / renal failure
- HELLP Syndrome
- DIC
- Increased risk of HTN, heart disease and stroke later in life
Fetal complications in Pre-eclampsia?
Hubert Og & Fionn = Paw Patrol
- FGR
- Oligohydramnios
- Hypoxemia, IUFD
- Prematurity
- Placental abruption
When is a C-Section indicated in pre-eclampsia?
- BP uncontrolled
- Fetal distress via unprovoked decelerations
- Worsening of bloods - thrombocytopenia
- Symptom progression (hyperreflexia or clonus)
- IUGR
- Doppler shows absent or reversed ratios
- Breech, transverse lie or <34 weeks
How does Eclampsia differ from Pre-Eclampsia
Eclampsia is the onset of seizures in a patient with pre-eclampsia that cannot be explained by other causes.
What anti-hypertensive drugs are teratogenic and contraindicated in pregnancy?
ACEi or ARBs
Should be given Labetalol, Nifedipine, Methyldopa
How would you manage Gestational Hypertsion?
Target BP <135/85
Every 2 weeks - Antenatal appointment to monitor BP
Every 4 weeks from week 28 - Assess fetal growth, amniotic fluid, doppler
If HTN >160/110 - Admit for 4 hourly obs
What anti-hypertensive is contraindicatedin asthma?
Labetalol.
Give nifedipine instead
What tests would indicate signs of severe pre-eclampsia?
Oliguria (<500ml in 24 hours)
Proteinuria >5g in 24 hours
Thrombocytopenia
Hemolysis
What US findings would indicate signs of severe pre-eclampsia?
FGR
Oligohydramnios
Abnormal fetal doppler
Outline your management of severe preeclampsia?
Clinical Exam - ABCDE approach, take Hx, perform abdominal exam, vitals, bloods, CTG + US
Admit for 1:1 monitoring
Monitor: BP + HR every 15 minutes until stable, fluid balance monitoring, CTG monitoring
IV access - X2 wide bore IV cannulas (to treat with IV anti-hypertensives)
When would you give magnesium sulphate and why?
During labour and immediately postpartum to reduce the risk of pre-eclampsia.
How is Mag sulphate given?
4g loading dose IV followed by 1g/hr maintenance
What are signs of Magnesium toxicity?
Resp depression
Loss of DTRs
Confusion
Heart block on ECG
Decreased urine output
Give calcium gluconate IV as an antidote
Indications for delivery in pre-eclampsia?
Term gestation
Refractory HTN
Thrombocytopenia
Liver dysfunction
Symptom worsening
Fetal compromise
Complications - Abruption, HELLP, renal failure, eclampsia
What to do in the postnatal period in pre-eclampsia?
Monitor in HDU - Seizures highest in the first 48 hours
Stepdown when BP stable
Bloods - Monitor for HELLP
Consider LMWH + thromboprophylaxis
Consider anti-hypertension change (e.g. amlodipine)
What would you do if eclampsia occurs?
ABCDE approach
Magnesium sulphate load + maintenance
Stabilise BP
Deliver when stable
