Preeclampsia

Question 1

What is preeclampsia?

Answer 1

• new onset of HTN and proteinuria after 20 wks gestation in a previously normotensive ot

Question 2

What is HELLP?

Answer 2

• hemolysis, elevated liver enzymes, and low platelets

- may be part of severe preclampsia or may occur w/o preeclampsia

Question 3

What is eclampsia?

Answer 3

• preeclampsia has progressed and the pt now has seizures or coma

Question 4

Pathogenesis of preeclampsia?

Answer 4

- underlying problem is endothelial dysfxn which leads to:
HTN
activation of platelets
CNS changes
edema
renal dysfxn resulting in proteinuria
hemolysis
hepatic ischemia

Question 5

What causes the endothelial dysfxn?

Answer 5

• 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

Question 6

What can preeclampsia lead to?

Answer 6

• maternal death (10-15% of maternal deaths)
• placental abruption
• acute kidney injury
• cerebral hemorrhage
• hepatic failure or rupture
• pulmonaray edema
• DIC
• eclampsia (seizures)

Question 7

Dx preeclampsia?

Answer 7

• 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

Question 8

When does preeclampsia-eclampsia occur? Cure? MC affected?

Answer 8

• 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

Question 9

What is preeclampsia/eclampsia assoc with?

Answer 9

• 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

Question 10

Cause of preeclampsia/eclampsia?

Answer 10

• 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

Question 11

• Primary goal of management of preeclampsia?

Answer 11

• 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

Question 12

Management of preeclampsia depending on gestational age?

Answer 12

• 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

Question 13

What are strong indicators for delivery?

Answer 13

• epigastric pain, thrombocytopenia, and visual disturbances

Question 14

Management of mild preeclampsia? Also recommended in what high risk groups?

Answer 14

• 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

Question 15

Tx of moderate to severe preeclampsia?

Answer 15

• 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

Question 16

Moderate to severe preeclampsia needs regular assessment of what?

Answer 16

• 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

Question 17

What is considered severe preeclampsia?

Answer 17

• 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

Question 18

Systemic assoc with HELLP?

Answer 18

• renal insufficiency
• placenta abruption
• pulmonary edema and pulmonary HTN due to decreased CO
• CNS: multifocal petechial hemorrhages of grey matter/white matter jxn

Question 19

How common is HELLP?

Answer 19

• affects approx 12% of pts with preeclampsia

Question 20

Signs and sxs of HELLP?

Answer 20

- signs:
BP mildly elevated
proteinuria +/-
edema
- sxs:
malaise almost 100%
epigastric pain
nausea w/ or w/o vomiting
RUQ tenderness

Question 21

Dx HELLP?

Answer 21

- 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

Question 22

Complications of HELLP?

Answer 22

• placental abruption: 7-20%
• acute renal failure
• hepatic hematoma
• liver rupture
• ascites
• hemorrhage
• fetal death
• maternal death
• management: delivery

Question 23

When does preeclampsia become eclampsia?

Answer 23

• when seizures are present

- in addition other signs of severe preeclampsia are observed with eclampsia

Question 24

Emergenecy care for eclampsia?

Answer 24

• 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

Question 25

Tx of eclampsia?

Answer 25

• 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