Preeclampsia

Question 1

Abdominal pain mx (pre-viable 23/40) on bkg of PET in the setting of Renal Tx

Answer 1

DDx
- HELLP/liver capsule hematoma (RUQ)
- Abruption/TPL (central)
- UTI (suprapubic)

Hx
- location/quality/quantity of pain
- FM, PV bleeding, HA, visual sx
- urinary/bowel sx
- anti-HTN regimen

Exam
- vitals, GCS, neuro (clonus/reflex), FWT
- abdo - RUQ vs central vs suprapubic
- speculum (blood/liquor/cervical dilation)
- RTS - FM, retroplacental clot

Mx
- TF to LW for stabilization +/- IV anti-HTN
- IV access - FBE/UEC/LFT/LDH (?HELLP)
- Kleihauer (abruption/FMH)
- PET -> HELLP = delivery via CS -> tertiary
- PRBC x-match + FFP + plt
- MDI - ano/paed/haematologist
- Post delivery - CCU

Question 2

Severe HTN or Hypertensive crisis mx

Scenario 1 - 24/40, un-booked

Scenario 2 - 26/40, 190/110 referred from GP, rural hospital

Answer 2

Resus
- Emergency - SBO>=170 or DBP=110mg
- M risk - CVA/abruption/eclampsia
- F risk - hypoxia/distress/FGR/PTB
- Call for help
- MDI - MFM/Obs Med/Paeds/Anesthetic
- Simultaneous resus/stabilization/ix
- DRABC - 100% O2 Hudson/IVC…
- PET/HELLP screen (end-org dysfunc)
- Stat dose of PO anti-HTN vs IV
- Admission in HDU
- Steroid + MgSo4 (mum and/or baby)
if Mg, monitor UEC/CMP/GCS/Reflex/Renal (UOP)
- VTE prophylaxis
- Fluid mx
- Delivery on mat or fetal ground
- Timing/MOD - individualized

PN
- BF/contraception/VTE prophylaxis
- BP mx/GP/PET education
- Preventative strategies future preg
(LDA+Ca+cFTS - UtA/PAPP-A/PIGF/sFLT…)

Question 3

What are triggers for delivery in context of PET

Answer 3

Fetal
- IUGR
- abnormal dopplers
- NRCTG

Maternal
- HELLP
- max anti-HTN therapy
- eclampsia
- evolving thrombocytopenia

MOD
- multi-factorial
- quickest way
- depends on cervix/fetal position/fetal wellbeing…

Question 4

Mx of PET related complications

Scenario 1 - APO 2nd to suspected heart failure on bkg 26/40, severe PET BP suboptimal control, FHR80, rural center

Answer 4

APO rx
- Stabilize
- MDI
- O2 - NIPV
- IV Fruse
- IV Anti-HTN
- HDU or ICU
- Transfer to Tertiary unit
- +/- delivery

If no improvement -> condition would only improve following delivery

Options (most desired to least)
1. Transfer to Tert
2. CS
3. Miso

Failed Miso -> need to reconsider CS to remove pregnancy

When both mum/baby are in danger, mum’s condition must be mx & stabilized first.

Question 5

Mx of eclamptic seizure

Answer 5

• risk M - recurrent seizure/arrest/death
• risk F - hypoxia/distress/SB
• Emergency
• Call for help
• MDI - simul resus/stabilization/Ix
• DRABC - Left lateral/O2/IVC
• Bloods/IVT
• IV benzo +/- IV phenytoin
• BP control
• Tocolytic if hypertonus
• NRCTG not recovered within 5 or recurrent seizures -> expedite del
• MgSo4 (loading/maintenance) for seizure prevention + BP control
• Mg monitor (UOP/renal function)
• BP control/mx
• Aim delivery once stabilized
• MOD individualized
• Avoid ergot
• PN - HDU/Debrief/Document…