Pre_eclampsia_Flashcards

Question 1

What is pre-eclampsia?

Answer 1

Pre-eclampsia describes the emergence of high blood pressure during pregnancy that may be a precursor to eclampsia and other complications. It is classically a triad of new-onset hypertension, proteinuria, and oedema.

Question 2

What is the current formal definition of pre-eclampsia?

Answer 2

New-onset blood pressure ≥ 140/90 mmHg after 20 weeks of pregnancy, AND 1 or more of the following: proteinuria, or other organ involvement (e.g. renal insufficiency, liver, neurological, haematological, uteroplacental dysfunction).

Question 3

What are the potential consequences of pre-eclampsia?

Answer 3

Eclampsia, other neurological complications (altered mental status, blindness, stroke, clonus, severe headaches or persistent visual scotomata), fetal complications (intrauterine growth retardation, prematurity), liver involvement (elevated transaminases), haemorrhage (placental abruption, intra-abdominal, intra-cerebral), cardiac failure.

Question 4

What are the features of severe pre-eclampsia?

Answer 4

Hypertension (> 160/110 mmHg and proteinuria), headache, visual disturbance, papilloedema, RUQ/epigastric pain, hyperreflexia, platelet count < 100 * 106/l, abnormal liver enzymes, or HELLP syndrome.

Question 5

What are the high-risk factors for pre-eclampsia?

Answer 5

Hypertensive disease in a previous pregnancy, chronic kidney disease, autoimmune disease (e.g., systemic lupus erythematosus or antiphospholipid syndrome), type 1 or type 2 diabetes, chronic hypertension.

Question 6

What are the moderate-risk factors for pre-eclampsia?

Answer 6

First pregnancy, age 40 years or older, pregnancy interval of more than 10 years, BMI of 35 kg/m² or more at first visit, family history of pre-eclampsia, multiple pregnancy.

Question 7

How can the risk of hypertensive disorders in pregnancy be reduced?

Answer 7

Women with ≥ 1 high risk factors or ≥ 2 moderate factors should take aspirin 75-150mg daily from 12 weeks gestation until birth.

Question 8

What is the initial assessment for suspected pre-eclampsia?

Answer 8

NICE recommend arranging emergency secondary care assessment for any woman in whom pre-eclampsia is suspected. Women with blood pressure ≥ 160/110 mmHg are likely to be admitted and observed.

Question 9

What is the further management for pre-eclampsia?

Answer 9

Oral labetalol is first-line following the 2010 NICE guidelines. Nifedipine (e.g., if asthmatic) and hydralazine may also be used. Delivery of the baby is the most important and definitive management step; timing depends on the individual clinical scenario.

Question 10

summarise

Answer 10

Pre-eclampsia

Pre-eclampsia describes the emergence of high blood pressure during pregnancy that may be a precursor to a woman developing eclampsia and other complications. It is classically a triad of 3 things:
new-onset hypertension
proteinuria
oedema

Definition

The current formal definition is as follows
new-onset blood pressure ≥ 140/90 mmHg after 20 weeks of pregnancy, AND 1 or more of the following:
proteinuria
other organ involvement (see list below for examples): e.g. renal insufficiency (creatinine ≥ 90 umol/L), liver, neurological, haematological, uteroplacental dysfunction

Features

Potential consequences of pre-eclampsia
eclampsia
other neurological complications include altered mental status, blindness, stroke, clonus, severe headaches or persistent visual scotomata
fetal complications
intrauterine growth retardation
prematurity
liver involvement (elevated transaminases)
haemorrhage: placental abruption, intra-abdominal, intra-cerebral
cardiac failure

Features of severe pre-eclampsia
hypertension: typically > 160/110 mmHg and proteinuria as above
proteinuria: dipstick ++/+++
headache
visual disturbance
papilloedema
RUQ/epigastric pain
hyperreflexia
platelet count < 100 * 106/l, abnormal liver enzymes or HELLP syndrome

Prevention

NICE divide risk factors into high and moderate risk:

High risk factors Moderate risk factors
hypertensive disease in a previous pregnancy
chronic kidney disease
autoimmune disease, such as systemic lupus erythematosus or antiphospholipid syndrome
type 1 or type 2 diabetes
chronic hypertension
first pregnancy
age 40 years or older
pregnancy interval of more than 10 years
body mass index (BMI) of 35 kg/m² or more at first visit
family history of pre-eclampsia
multiple pregnancy

Reducing the risk of hypertensive disorders in pregnancy
women with the following should take aspirin 75-150mg daily from 12 weeks gestation until the birth
≥ 1 high risk factors
≥ 2 moderate factors

Management

Initial assessment
NICE recommend arranging emergency secondary care assessment for any woman in whom pre-eclampsia is suspected
women with blood pressure ≥ 160/110 mmHg are likely to be admitted and observed

Further management
oral labetalol is now first-line following the 2010 NICE guidelines. Nifedipine (e.g. if asthmatic) and hydralazine may also be used
delivery of the baby is the most important and definitive management step. The timing depends on the individual clinical scenario

Question 11

A 33-year-old woman presents to her general practitioner for a routine antenatal visit. She is 22 weeks pregnant. It is her first pregnancy and it has been uncomplicated thus far. She does not have any significant past medical history and does not take any regular prescribed medications. She does not smoke cigarettes or drink alcohol.

Her blood pressure is 148/92 mmHg. This is confirmed on repeat assessment and was previously within normal limits in early pregnancy.

On examination, there is no oedema and her reflexes are normal.

Urinalysis is as follows:

Protein negative
Blood negative
Leucocytes negative
Glucose negative
Nitrites negative

What is the most appropriate management?

Amlodipine
Labetalol
Methyldopa
Nifedipine
Ramipril

Answer 11

Labetalol

Labetalol is first-line for pregnancy-induced hypertension
Important for meLess important
Labetalol is the correct answer. This woman has gestational hypertension as evidenced by the development of new-onset stage I hypertension after 20 weeks gestation. There is no proteinuria to suggest pre-eclampsia. NICE guidelines in 2019 suggest medical treatment if the blood pressure remains elevated >140/90 mmHg.

Nifedipine is incorrect. This is a second-line treatment for pregnancy-induced hypertension if labetalol is contraindicated or not tolerated.

Methyldopa is incorrect. This is a suitable option if labetalol or nifedipine are contraindicated or not tolerated.

Amlodipine is incorrect. There is not enough data available to suggest this is safe in pregnancy.

Ramipril is incorrect. This medication should be avoided in pregnancy unless absolutely essential as it may adversely affect fetal and neonatal blood pressure control and renal function. Skull defects and oligohydramnios have also been reported.

Question 12

A woman who is 34 weeks pregnant is admitted to the obstetric ward. She has been monitored for the past few weeks due to pregnancy-induced hypertension but has now developed proteinuria. Her blood pressure is 162/94 mmHg. Which one of the following antihypertensives is it most appropriate to commence?

Nifedipine
Atenolol
Labetalol
Losartan
Methyldopa

Answer 12

Labetalol

Labetalol is first-line for pregnancy-induced hypertension

Question 13

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?

Start IV hydralazine
IV magnesium sulphate and plan immediate delivery
IV magnesium sulphate and intramuscular beclometasone
IV calcium gluconate
Plan immediate delivery

Answer 13

IV magnesium sulphate and plan immediate delivery

This woman has severe pre-eclampsia as she has presented with moderate hypertension and also has symptoms of headache and vomiting. NICE guidelines recommend delivery within 24-48 hours in those women who has pre-eclampsia with mild or moderate hypertension after 37 weeks. Magnesium sulphate is used to treat women with severe hypertension or severe pre-eclampsia that have already had a seizure. IV magnesium sulphate should also be considered if birth is planned within 24 hours or if there is concern that a woman may develop eclampsia.

IV hydralazine may lower her blood pressure but this woman requires immediate delivery and protection against eclampsia due to her presenting symptoms and signs. Intramuscular (IM) beclometasone is not required as the woman is past 36 weeks. IV calcium gluconate is used to treat magnesium toxicity and is not indicated. While delivery should be planned, this woman also requires protection against development of eclampsia and seizures.

Reference: BNF and NICE guideline https://www.nice.org.uk/guidance/cg107

Question 14

A 34-year woman attends the emergency room complaining of a severe headache and some visual changes. She is 36 weeks pregnant. This is her third pregnancy and there have been no complications so far. She has a past medical history of asthma which is well-managed with inhalers.

On examination, her blood pressure is 147/101 mmHg and she has some mild peripheral oedema.

What is the most appropriate medication to start this patient on?

Furosemide
Labetalol
Losartan
Nifedipine
Ramipril

Answer 14

Nifedipine

Nifedipine is the first line anti-hypertensive for pre-eclampsia in women with severe asthma

Nifedipine is the correct answer. Nifedipine is the correct choice for women with a past medical history of asthma, where beta-blockers (labetalol) would be contraindicated.

Furosemide is not the correct answer as it is not a medication used for pregnancy-induced hypertension.

Labetalol is not the correct answer as it is contraindicated in asthma. It would normally be the first line for pregnancy-induced hypertension if the patient did not have asthma.

Losartan is not the correct answer. It is not a medication used for pregnancy-induced hypertension as it is contraindicated due to potential fetal toxicity.

Ramipril is not the correct answer. It is not a medication used for pregnancy-induced hypertension as it is contraindicated due to potential fetal toxicity.

Question 15

buzz words

Answer 15

hypertension
proteinuria
labetalol
severe headache
vomiting
blurred vision/visual changes.
papilloedema
IV magnesium sulfate
3rd trimester
peripheral oedema.

Question 16

A 41-year-old nulliparous pregnant woman presents to the antenatal clinic. She has a history of type 1 diabetes which is well-controlled with an automated insulin pump. The pregnancy was unexpected but so far it has gone very well without any nausea or vomiting. She is a non-smoker and has no allergies.

Observations:
Heart rate 86 /min
Blood pressure 124/83 mmHg
Oxygen saturation 99%
Temperature 36.9ºC

A physical examination is normal. Her BMI is 23 kg/m2.

Routine screening and antenatal blood results are normal. An ultrasound scan reveals a singleton pregnancy of 12 weeks gestational age.

What is the next step?

Commence daily aspirin
Commence daily labetalol
No intervention is required
Perform a 2-hour oral glucose tolerance test
Refer for a detailed anatomy scan

Answer 16

Commence daily aspirin

A woman at moderate or high risk of pre-eclampsia should take aspirin 75-150mg daily from 12 weeks gestation until the birth
Important for meLess important
The correct answer is commence daily aspirin, because this woman has risk factors for pre-eclampsia, and aspirin is used as a preventative measure in these cases. Pre-eclampsia is a precursor to eclampsia, a severe and life-threatening condition that occurs in the later stages of pregnancy and can also cause significant complications in foetal development. Type 1 diabetes mellitus is classified by NICE as a high-risk factor for pre-eclampsia, and this woman also has two moderate risk factors including a maternal age greater than 40 years and nulliparity. If a woman has one or more high-risk factors (or ≥2 moderate risk factors), she should be prescribed 75-150mg of aspirin daily from 12 weeks gestation until birth to help prevent pre-eclampsia.

Commence daily labetalol is incorrect because although she is at high risk of developing pre-eclampsia compared to a younger and non-diabetic patient, she is not hypertensive and therefore does not need blood pressure-lowering medication. Labetalol is a beta blocker which is recommended as the first-line pharmacological therapy for lowering blood pressure in women with pre-eclampsia, which is defined as the onset of hypertension (≥140/90 mmHg) after 20 weeks of pregnancy with either proteinuria or evidence of end-organ dysfunction. The patient should be closely monitored with regular blood pressure readings in case this develops, but at this stage, she should be given daily 75-150mg aspirin as a preventative measure.

No intervention is required is incorrect because this patient has one high-risk factor for pre-eclampsia and two moderate-risk factors. This means that she should be prescribed a daily dose of 75-150mg aspirin to help prevent this from developing. Pre-eclampsia (and eclampsia) can be very dangerous and life-threatening to both the mother and foetus, so every attempt should be made to prevent this and mitigate the risk. Her ultrasound scan has dated the pregnancy at 12 weeks, and NICE recommends starting aspirin at this time for women at risk of pre-eclampsia so not intervening at this stage would be inappropriate.

Perform a 2-hour oral glucose tolerance test (OGTT) is incorrect because this test is used to screen for gestational diabetes in women who do not already have a known diagnosis of diabetes. For women with known type 1 diabetes mellitus, an HbA1c is a better test of glucose control, which is useful for risk stratifying the pregnancy. Fortunately, this patient has well-controlled diabetes using an insulin pump, but she is still at high risk of pregnancy complications including pre-eclampsia. Therefore, as she has now reached 12 weeks gestation she should start taking daily aspirin to prevent pre-eclampsia.

Refer for a detailed anatomy scan is incorrect because this scan is performed ideally between 18+0 weeks and 20+6 weeks gestation for all pregnancies. This foetus has only reached 12 weeks so an anatomy scan is not yet indicated. Instead, the woman should be prescribed daily aspirin from 12 weeks to reduce her risk of pre-eclampsia, as she is at higher risk due to her type 1 diabetes, age and nulliparity. A detailed anatomy scan can be organised later in the pregnancy but it is not the priority at this stage. The ultrasound that is performed ideally between 11+2 weeks and 14+1 weeks aims to determine gestational age, detect if multiple pregnancy is present and screen for some foetal anomalies.

Question 17

A 33-year-old woman who is 34 weeks pregnant sees her midwife for a routine review. She feels well in herself apart from reporting some constipation, for which she has been taking lactulose.

The midwife’s checks reveal:

Fundal height: 35cm
Blood pressure: 142/92 mmHg
Urine dip: protein 1+

What is the most appropriate next step in her management?

Arrange a growth scan
Arrange home blood pressure monitoring
Repeat in 24 hours
Start labetalol
Urgent obstetrics referral

Answer 17

Urgent obstetrics referral

NICE recommend arranging emergency secondary care assessment for any woman in whom pre-eclampsia is suspected

This patient has features of pre-eclampsia (blood pressure >=140/90 mmHg and proteinuria >= +1). Although pre-eclampsia may present with symptoms such as headache or swelling, it is often asymptomatic and detected initially through routine monitoring of urine and blood pressure. It is potentially life-threatening and she should therefore be referred to secondary care for further investigation and management.

A growth scan is likely to take place as part of her overall management but is not the priority now. Pre-eclampsia can cause intrauterine growth restriction, so growth scans are used to monitor this.

Home BP monitoring may be helpful going forward but is not indicated now. She needs further assessment first and therefore this is not the most appropriate option.

Repeating in 24 hours is incorrect as emergency secondary care assessment is indicated.

Labetalol may be indicated for the management of her blood pressure but it would not be initiated before obstetric specialist investigation and input.

Question 18

A 24-year-old primigravida attends her booking visit at 12 weeks. She is concerned because her mother had a condition in pregnancy that resulted in a seizure. She has no past medical history and her BP is 125/85 mmHg at this appointment. No abnormalities are detected on her urine dipstick. Her BMI is 38 kg/m².

What is the most appropriate management?

Aspirin
Hydralazine
Labetalol
Magnesium
No treatment required

Answer 18

Aspirin

A woman at moderate or high risk of pre-eclampsia should take aspirin 75-150mg daily from 12 weeks gestation until the birth

This patient has three moderate risk factors for pre-eclampsia (first pregnancy, BMI >35 kg/m² and family history of eclampsia) so she should be advised to take low-dose aspirin daily for the duration of her pregnancy.

Hydralazine is an antihypertensive that can be used as an alternative to labetalol in pregnancy. This patient is not hypertensive so this is not necessary at this stage.

Labetalol is the first line antihypertensive in pregnancy.

Magnesium is indicated in severe pre-eclampsia to prevent seizures or to treat seizures in patients with eclampsia. This patient does not have signs of eclampsia, which is the development of seizures in a patient with pre-eclampsia.

No treatment required is incorrect as this patient has ≥ 2 moderate risk factors for pre-eclampsia.