PreEclampsia Flashcards
Etiology of PreE
still unclear
Diagnosis of PreE, proteinuria necessary?
Proteinuria no longer necessary
Diagnosis of PreE
Beyond 20 wks, 140/90 2 BPs 4 hours apart, pt at rest + Proteinuria
Without proteinuria: will need
1. thrombocytopenia (
Proteinuria Definition
300mg prot in 24 hr urine = Pr/Cr ratio 0.3mg/dL
1+ protein on dip (but not preferred method of eval)
Severe features
- 160/110 4 hours apart, while on bed rest or if antihypertensives started
- cerebral/visual disturbance new onset
- epig/ruq pain persistent/severe, or transaminitis (double)
- thrombocytopenia (
Can we predict pre-e?
Tests promising findings, but not ready for routine use
ASA regimen to help prevent PreE
Slightly reduces incidence of PreE in very high risk and perinatal morbidity
60-80mg/day starting late 1st trimester
Other methods proposed to prevent PreE? But do not work and are not routinely recommended
Vitamin E &C
Calcium (maybe in populations with low calcium intake)
Bed rest
Reduced sodium
Does proteinuria effect maternal/fetal outcome?
Nope
Postpartum NSAIDS: when to avoid, effect on BP
Avoid if elevated BPs persistent for greater than 1 day PP
When do we deliver GHTN or PrE without severe features?
37w0d
Can we expectantly manage severe PreE dx less than 34 wks? What about for superimposed severe PreE?
Continue pregnancy only if materno/fetal status is stable and at institution with adequate maternal and NICU resources
Delivery time of previable severe pre-e?
Deliver as soon as maternal status is stable, expectant management NOT recommended
Is it ok to delay delivery for 48 hours to administer corticosteroids in severe PreE?
Yes, before 34 wks, if conditions stable. Even with IUGR and reversed end diastolic flow, oligo, new onset/increasing renal dysfunction
Conditions with severe Pre E when you should not delay delivery, no matter what the gestational age…should you still give steroids?
Yes, give steroids but don’t necessarily need to wait for 48 hr benefit
- Eclampsia
- Pulmonary Edema
- Placental abruption
- Uncontrollable severe HTN
- Fetal demise
- DIC
- Nonreassuring fetal status
Should we cont Mag during C/S
YES!!
Severe PreE/HELLP Syndrome when should we deliver?
- If 34 wks or more, whenever stable
- From viability to 33w6d, delay delivery for 24-48 hrs to get steroids on board if stable, then deliver.
- Materno/fetal status is unstable–NO MATTER WHAT GESTATIONAL AGE, stabilize as much as possible, then deliver
Monitoring schedule for GHTN or PreE without severe features before 37 wks?
- Twice weekly BPs (one in office, one at home), monitoring symptoms
- Weekly labs
- Daily kick counts
- Serial IGS (q 3 wks)
- If GHTN, once weekly proteinuria check
- Weekly NSTs in GHTN; Twice weekly NST in PreE without severe features –> BPPs if nonreactive NST
Bed rest?
Not recommended, but task force recognizes that this decision may be individualized.
Do steroids always improve materno/fetal outcome? What else can steroids improve?
Not consistently shown to improve outcomes
May improve platelet counts, so if you need to improve platelet levels, steroids may be justifiable
How long should you monitor BPs after delivery for GHTN, PreE, Superimposed PreE? When should they f/u outpatient?
72 hours (either inpatient or outpatient equivalent) F/u 7-10 days, or earlier in women with symptoms
What if there is new onset PreE sx PP with severe features?
iv Mag, but quality of evidence is low, recommendation is qualified
What BP ranges should we give antihypertensive therapy PP?
150/100 at least 2 occasions, 4-6 hours apart
160/110 should be treated within 1 hour
Who should be offered ASA in next pregnancy to prevent PreE?
Preterm birth for PreE
PreE in multiple pregnancies
Are more frequent visits warranted in next preg in someone who has had pre-e?
YEs, more frequent earlier visits. You should tailor to outcome of previous pregnancy
What is considered low sodium diet?
Less than 100 mEq/day
What BP ranges should we give antihypertensives in CHTN?
> /= 160/105 persistent or presence of end organ damage
Ideal range of BP management in CHTN?
120/80 to
Preferred antihypertensives for CHTN?
Labetolol
Nifedipine
Methyldopa
Childbearing age nonpregnant HTN pt should only use ARBs, ACEI, Renin inhibitors, and mineralcorticoid receptor antagonists in what situation?
renal proteinuric diesease
Start ASA in CHTN who has what other great risk factors for PreE?
PreE early onset and DELIVERY before 34 wks prev preg
Multiple preg with PreE
When to deliver if superimposed PreE without severe features?
37w0d
Annual screening for women with h/o PreE Severe with delivery preterm or recurrent PreE in pregs?
Yearly lipids, BMI, BP, fasting glucose
Symptoms that may occur prior to Eclampsia/sz?
Severe headache
Hyperreflexia
No si/sx at all
Late postpartum HTN
2wks-6mo pp
BP Can remain labile for months, usually normalize by the end of the first year.
How can you classify HELLP from TTP?
order LDH
Increased alert for PreE?
New onset proteinuria after 20 wks
IUGR
Increase BP from baseline 30 SBP/15 DBP (usually normal but warrant close obs)
Uric acid levels (impending preE warrants increase obs?…but no well defined plans for action)
Rapid wt gain/edema
What abnormal lab value can predict poorer outcomes in PreE pts?
Uric acid levels elevation
How do you know when there is superimposed Pre E on CHTN?
- New onset proteinuria after 20 wks
- Proteinuria already present, but…
- –sudden exacerbation of BPs
- –increase in antihypertensive doses required
- –other lab abnormalities not before present
Describe eclamptic seizure
Grand mal: tonic clonic; facial twitching starts, then entire body rigid with generalized muscular contractions
TONIC ctxns: impair respiration, cyanosis, foam at mouth lasting 10-20 sec
CLONIC: rapidly alternating ctxns/relaxation
Most eclamptic sz last 60-75 sec
POSTICTAL: can be confused/combative. does not remember
Manage eclamptic sz?
Lateral decubitus O2 face mask Tongue blade Physical restraints Check ABG Status eclmpticus: anesthesia for intubation
What are alternative diagnoses for seizures in peripartum period?
Ruptured aneurysm
Idiopathic sz disorder
Bleeding AVM
When would alternative dx besides eclampsia be considered?
New onset sz after 48-72 hrs pp
sz occur even with antiepileptic therapy with mag sulfate
Increased risk for PreE?
2-4 fold if 1st deg fam member had it 7 fold if in prev pregnancy Multiple gestation triplet >twin >40yo Pregestational Diabetes obese CHTN/chronic renal disease or both SLE In vitro H/o thrombophilia Primiparity
Most cases of preE occur in whom?
healthy nulliparous women with no other known risk
Methods to predict pre-E and their effectiveness
- Uterine arter doppler velocimetry: low predictive value
- Biomarkers: urine PIGF (if combined with ut. art, dopps); sFLt-1 and PIGF ratio in serum;
- PAPPA
- Placental protein 13 LOW
* *do not use these because evidence of benefit to maternal fetal outcomes is lacking**
* *all require further investigation**
In which pt are biomarkers or methods used to predict adverse outcomes or progression to PreE useful?
GHTN
Pathogenesis hypothesis of PreE
- altered prostacyclin/thromboxane balance
- increased inflammation
- vitamin D deficiency
Why would ASA help prevent PreE
antiinflammatory
blocks thromboxane production
Any increased risk for bleeding or placental abruption with ASA use?
Nope
When should women with PreE be hospitalized and delivered?
- 37 wks or more
- Placental abruption suspected
- 34 wks or more PLUS
- -IUGR (
When does severe features develop in GHTN vs PreE without severe features?
GHTN: 1-3 wks
PreE w/o severe features: days
Should we give antihypertensive therapy to mild PreE or GHTN to prevent severe preE? Why would we consider giving antihypertensive therapy?
Task Force says Nope
National Institute for Health and Clinical Excellence rec if 150/100 bps persistent
to prevent severe disease/maternal hemorrhagic stroke (rare)/congestive heart failure (rare)
How can antihypertensives be potentially harmful in GHTN or mild PreE
may cause IUGR (compromise fetoplacental blood flow)
Does antenatal testing improve outcomes in these pts?
Unclear
What pts are candidates for ASA to prevent PreE?
Previous pregnancy with early onset PrE and delivery before 34 wks or PrE in more than one prior preg
Should we deliver Mild PreE or GHTN before 37 wks?
Not without another indication
What situation should we deliver no matter what gestational age/contraindications to expectant management?
PreE with severe features +
- pulmonary edema
- DIC
- renal failure (not really)
- placental abruption
- Severe thrombocytopenia
- persistent cerebral sx
- nonreassuring fetal testing (BPP 4/10 on at least 2 occasions, 6 hrs apart or FHTs)
- fetal demise
- uncontrollable severe htn
- Eclampsia
- NONVIABLE fetus
What complications are ok to delay delivery for 48 hours to get steroids on board?
- HELLP or partial HELLP (thrombocytopenia, liver enz)
- progressive renal insufficiency
- Reverse end diastolic flow
- persistent sx
- labor or PPROM
- severe oligohydramnios
- Less than or equal to 33w6d
- IUGR less than 5%
How can we expectantly manage PreE with severe features?
- in hospital, adequate maternal and NICU
- viability to 33w6d
- stop magnesium sulfate
- daily maternal/fetal tests (kick counts/nst)
- vitals/sx (also ctxns/lof/vb)/uop/fluid intake q8hrs
- oral antihypertensive drugs
- blood tests daily (spaced out to every other day if remain stable)
- BPP twice weekly
- serial fetal growth q2 wks and umb artery dopplers q 2 wks if IUGR is suspected
Magnesium sz prophylaxis dosage
4-6g loading dose, then 1-2g/hr for at least 24 hrs
1/2 life magnesium?
5 hrs
Level of thrombocytopenia safe for spinal/removing catheter?
Many studies not yet determined. On case series showed 80,000.
BP trend for PreE pt or superimposed pts PP?
falls in 48 hrs
rises again 3-6d PP
What is the latest PrE or Eclampsia can develop PP?
4 wks
What PP analgesic can cause elevation in BP, when should you use alternative analgesics?
NSAIDs, use alternative if BP persistently elevated 1 d PP
Signs pt should watch out for possible PreE
- n/v
- ruq/epig pain
- headache that will not go away
- sudden wt gain
- swelling face/hands
- difficulty breathing
Can GHTN/PreE develop before 20 wks??
YEs, if 1st trimester normal Bps, then sudden increase in BP before 20 wks, you can consider GHTN
Findings suggestive of secondary HTN
- Resistant severe HTN
- Cr greater than 1.1
- fam h/o kidney disease
- hypokalemia
- palpitations (maybe)
- no fam h/o HTN (maybe)
7.
When should you perform Echo or EKG in women with CHTN? Why?
Persistent prolonged severe BPs, to assess Left ventricular function
What is the most common genetic type of kidney disease?
Polycystic kidney disease
When should you do a renal ultrasound in CHTN pts?
Extensive fam h/o renal disease,
Causes of secondary HTN that may cause poorer maternofetal outcomes
pheochromocytoma, renovascular HTN
White coat HTN incidence
10-15%
What is extremely low sodium diet
When to initiate/change antihypertensive therapy in CHTN?
Goal of BP range?
persistent 160/105, evidence of end organ damage
120/80-less than 160/105
Can you combine nifedipine and mag sulfate?
Yes, but careful monitoring. These both block Ca channels. Theoretical risk of hypotension, but studies have shown that this risk is low
Methyldopa (type of drug), how long does it take to work?
alpha 2 agonist
BP control gradual, over 6-8 hrs
First line agent for lowering BP urgently? What kind of drug? Dose?
Labetolol: beta blocker with vascular alpha blocking
10-20mg iv, then 20-80mg q20-30 min, max dose 300mg or cont iv infusion 1-2mg/min
Labetolol is contraindicated in:
asthma
heart disease
CHF
Hydralazine dosing
Higher/more frequent dosages associated with…
5mg iv or IM, then 5-10 mg q20-40 min or constant infusion iv 0.5-1mg/hr
Fetal distress, headaches, maternal hypotension…more than other agents
Nifedipine urgent medication dosing
Side effects
10-20mg orally, repeat 30mg if needed then 10-20mg q2-6 hrs
Reflex tachy/headaches
Labetolol oral antihypertensive dosing
Side effects:
200-2400mg/day in 2-3 daily divided doses
Potential bronchoconstriction
Nifedipine oral dosing
Is it ok to use sublingual?
30-120mg/day extended release
Do not use sublingual
Methyldopa dosing
Disadvantage?
Childhood safety data
0.5-3g/day in 2-3 divided doses
May not be as effective for severe HTN
Childhood safety up to 7 years
Are thiazide diuretics ok in pregnancy?
Yes
Antihypertensives contraindicated in which trimesters? Why?
ACEI/ARBs cause fetal anomalies 2nd/3rd 1. fetal renal failure 2. oligo 3. pulmonary hypoplasia 4. calvarial abnormalities 5. IUGR 1st TRIMESTER ACEI: Cardiac, CNS abnormalities
Compelling reason to use ACEI/ARBs/Mineralcorticoid inhibitors/renin inhibitors in reproductive age women?
proteinuric renal disease
CHTN uncomplicated, when to deliver?
38-39 wks
Should we mag pts with superimposed Pre E without severe features?
NO
When should superimposed PreE without severe features be delivered? What about with severe?
37 wks
with severe: 34 wks
Breastfeeding OK with what antihypertensives?
Methyldopa
labetolol/propanolol low concentrations
atenolol and metoprolol high concentrations
Captopril/enalopril in low doses, low concentration
Little evidence for ca channel blockers, but risk prob low
Diuretics prob ok, but may reduce breast milk
Theory of pathogenesis of preE
- Poor placentation: inadequate remodeling of maternal vasculature and filling of intervillous space, abnormal trophoblast invasion
- Endothelial activation/dysfunction
- Placental Ischemia/hypoxia: VEGF and PIGF-1
