Preeclampsia Flashcards
1
Q
What is preeclampsia?
A
- new onset of HTN and proteinuria after 20 wks gestation in a previously normotensive ot
2
Q
What is HELLP?
A
- hemolysis, elevated liver enzymes, and low platelets
- may be part of severe preclampsia or may occur w/o preeclampsia
3
Q
What is eclampsia?
A
- preeclampsia has progressed and the pt now has seizures or coma
4
Q
Pathogenesis of preeclampsia?
A
- underlying problem is endothelial dysfxn which leads to: HTN activation of platelets CNS changes edema renal dysfxn resulting in proteinuria hemolysis hepatic ischemia
5
Q
What causes the endothelial dysfxn?
A
- mechanism is not clearly understood
- many maternal, placental, and fetal factors coem into play:
underperfusion of the placenta
immunologic factors
increased sensitivity to angiotensin II
genetic
inflammation
6
Q
What can preeclampsia lead to?
A
- maternal death (10-15% of maternal deaths)
- placental abruption
- acute kidney injury
- cerebral hemorrhage
- hepatic failure or rupture
- pulmonaray edema
- DIC
- eclampsia (seizures)
7
Q
Dx preeclampsia?
A
- essentials of dx:
HTN
proteinuria
if they have HTN but no proteinuria will meet criteria for preeclampsia if:
-low platelets (less than 100K)
-elevated serum creatinine (over 1.1 or doubling of creatinine)
-elevated liver enzymes (3x the ULN) - pulmonary edema (SOB, cough)
- cerebral or visual sxs: HA, visual changes
8
Q
When does preeclampsia-eclampsia occur? Cure? MC affected?
A
- can occur anytime after 20 wks of gestation and up to 6 wks postpartum
- sxs not evident until 3rd trimester but process begins as early as 2nd trimester
- only cure is delivery of fetus and placenta
- primiparas are most frequently affected
- extremes of maternal age: younger than 20 or older than 35
- multiple gestation: twins or triplets
9
Q
What is preeclampsia/eclampsia assoc with?
A
- chronic HTN, diabetes, renal disease, collagen vascular and autoimmune disorders and hydatidiform mole
- also assoc with:
new paternity, previous preeclampsia or eclampsia or a family hx
10
Q
Cause of preeclampsia/eclampsia?
A
- unknown for sure
- imbalance in placental prostacyclin and thromboxane production
- prostacyclin: potent vasodilator and inhibitor of platelet aggregation
- thromboxane: potent vasoconstrictor and stimulates platelet aggregation
- in normal pregnancy - thromboxane is increased so it equals prostacycline levels
- in preclampsia: placenta produces 7x more thromboxane than prostacycline and this results in vasoconstriction, platelet aggregation, and reduced uteroplacental blood flow
11
Q
- Primary goal of management of preeclampsia?
A
- delivery is only cure
- primary goal of management is to allow pregnancy to progress as far as possible w/o jeopardizing maternal or fetal well-being
- impt if possible to allow fetal lung maturity to develop while preventing progression to severe disease and eclampsia
- critical factors:
gestational age of fetus
maturity of fetal lungs
severity of maternal disease
12
Q
Management of preeclampsia depending on gestational age?
A
- at 36 wks or more managed by delivery regardless of how mild disease is judged
- prior to 36 wks - severe preeclampsia-eclampsia reqrs delivery except in unusual circumstances assoc with extreme fetal prematurity, in which case prolongation of pregnancy may be attempted
13
Q
What are strong indicators for delivery?
A
- epigastric pain, thrombocytopenia, and visual disturbances
14
Q
Management of mild preeclampsia? Also recommended in what high risk groups?
A
- home management with bedrest may be attempted with mild preeclampsia and stable home situation
- low dose ASA 60-80 mg/day
- no increased maternal or fetal risk
- recommmended in high risk groups:
women with chronic HTN
hx of placental abruption
PIH in previous pregnancy
systemic lupus - antiHTN therapy: decrease BP enough to protect maternal organs w/o causing hypotension and threatening fetal O2 supply -
Hydralazine
methyldopa
15
Q
Tx of moderate to severe preeclampsia?
A
- hospitalization for those w/ moderate or severe preeclampsia
- if pt is far enough along in her pregnancy that the fetus can be delivered safely - then deliver
- if not - pt needs to be hospitalized and started on Mg sulfate drip to prevent seizures
- fetal eval, daily fetal kick counts, consider amniocentesis to eval lung maturity if hospitalization occurs at 30-37 wks
- steroids: betamethasone, dexamethasone, can be given 12-24 hrs apart to mom, especially if fetus b/t 26-30 wks of gestation
16
Q
Moderate to severe preeclampsia needs regular assessment of what?
A
- BP
- reflexes
- urine protein
- FHT and activity
- CBC, platelet count, and electrolytes plus liver enzymes q 1-2 days
- 24 hr urine collection for CrCl and protein
17
Q
What is considered severe preeclampsia?
A
- BP: over 160 syst, or over 110 diastolic
- proteinuria: over 500mg/24 hrs or 4+ on dipstick
- oliguria of less than 500 ml/24 hrs
- thrombocytopenia
- HELLP: hemolysis, elevated liver enzymes, low platelets
- fetal growth restriction
18
Q
Systemic assoc with HELLP?
A
- renal insufficiency
- placenta abruption
- pulmonary edema and pulmonary HTN due to decreased CO
- CNS: multifocal petechial hemorrhages of grey matter/white matter jxn
19
Q
How common is HELLP?
A
- affects approx 12% of pts with preeclampsia
20
Q
Signs and sxs of HELLP?
A
- signs: BP mildly elevated proteinuria +/- edema - sxs: malaise almost 100% epigastric pain nausea w/ or w/o vomiting RUQ tenderness
21
Q
Dx HELLP?
A
- hemolysis: abnormal peripheral smear (burr cells and schistocytes), elevated bilirubin (greater than 1.2 mg/dl), increased lactic dehydrogenase (over 600 U/L) - elevated liver enzymes: SGOT: over 70 U/L LDH: over 600 U/L - low platelets: less than 100,000
22
Q
Complications of HELLP?
A
- placental abruption: 7-20%
- acute renal failure
- hepatic hematoma
- liver rupture
- ascites
- hemorrhage
- fetal death
- maternal death
- management: delivery
23
Q
When does preeclampsia become eclampsia?
A
- when seizures are present
- in addition other signs of severe preeclampsia are observed with eclampsia
24
Q
Emergenecy care for eclampsia?
A
- if convulsing- supportive care
- Mg sulfate: DOC to control seizures, given as bolus and followed with continuous IV infusion, blood levels checked q 4-6 hrs to maintain therapeutic level (4-6 mEq/L)
urine output checked q hr
watch for signs of Mg toxicity: loss of DTRs, decrease in RR and depth, can be reversed with Ca gluconate - readily crosses placenta: newborn suffers sedative properties of drug, effects subside as newborn excretes drug over following 3-4 days
25
Q
Tx of eclampsia?
A
- deliver baby
- postpartum - continue Mg sulfate infusion until postpartum resolution
may take 1-7 days, in any case, continue drip for 24 hrs - most reliable indicator of resolution is onset of diuresis - w/ this drip can be D/C
- majority return to normotensive state
- incidence of preeclampsia in next pregnancy isn’t definite but there is an increased risk with multiple pregnancies
- some women have chronic, manageable HTN afterwards
