Preeclampsia

Question 1

Cx of pre eclampsia

Answer 1

Neuro - Eclampsia (hyperreflexia with clonus), visual disturbance, stroke, severe headache with hyperreflexia.
Haem - PLT activation and aggregation, vasospasm (macroangiopathic hemolysis), hemolysis and DIC = thrombocytopenia.
Oedema of lungs, face, peripherals
Fetal growth restriction
Renal insufficiency - protein urea with PCP >30, Creatine >80.
Liver dysfunction - Nercorsis, ischemia and oedema = severe epigastric/RUQ pain.
HELLP syndrome
Placental abruption = DIC for mum.
Acute renal failure
Hepatic failure

Question 2

Risk reduction in future pregnancies in women with a hx of pre eclampsia. What and when.

Answer 2

Indication - previous early onset pre eclampsia, underlying material disease e.g. APLS, D, Renal or autoimmune disease
Tx - Aspirn for moderate - high risk. 100mg daily starting prior to 16 wks - > 37 wks or stop at birth.

Question 3

Symptoms of pre eclampsia

Answer 3

Severe HTN, Problems with vision e.g. blurring or flashing lights, RUQ pain, Vomiting, Swelling of face, hands or feet, headaches

Question 4

Risk factors for pre eclampsia

Answer 4

Previous Hx of preeclampsia
Fmhx of pre eclampsia
Inter pregnancy interval >10yr
Null parity
Pre existing med condition eg APLS, DM, Renal disease, Chronic HTN, Chronic autoimmune disease
Age >40yr
BMI>35
Multiple pregnancy
Increase BP at booking
Gestational trophoblastic disease
Fetal triploidy

Question 5

Pathogenesis of Pre eclampsia

Answer 5

Impaired 2rd invasion of spiral arteries by trophoblasts in the late 1st trimester = high resistance vessels = Impairment of placenta function = placenta hypoxia = ++ proliferation of cytotrophoblasts and thickening of trophoblastic basement membrane = deduced in secretion of vasodilator e.g. NO) from damaged endothelial cells. This leads to endothelial cells of placenta secrete less prostacyclin. PLT secrete increase thromboxane = generalised vasoconstriction + reduced aldosterone secretion. This result in HTN, 50% reduction in placenta perfusion + reduced blood vessels over time. Vasospasm = trophoblast fragments -> lungs = they’re destroyed = releasing thromboplastin = intravascular coagulation + deposit in kidneys = reduced GFR = Increased vasoconstriction. Deposit in vessels in CNS = Convulsion

Question 6

Discharge requirements for pre eclampsia

Answer 6

Contraception
Risk reduction for future pregnancies
CV screening with GP
Lifestyle advice - avoid smoking - maintain healthy wt exercise regularly and healthy eating
Summary to GP
Follow up at 6 wks

Question 7

Postpartum Mx of a women with pre eclampsia

Answer 7

Close clinical surveillance - 4 hourly BP, HR, RR and O2 sats
Ask about severe headache and epigastric pain
VTE prophylaxis
Drug therapy - continue until HTN resolves avoid abrupt withdrawal to avoid rebound HTN. If on methydepa need to stop postpartum and commence alternative
Breast feeding - safe - Nifedipine, enalapril, captopril
Psychological support
Consider timing of discharge
Arrange follow up
Maternal screening
Contraception advise
Normal post natal care

Question 8

Indications of birth in pre eclampsia women

Answer 8

Non reassuring fetal status
Severe fetal growth restriction
>= 37 week
Eclampsia
Placental abruption
Acute pulmonary oedema
Uncontrolled HTN
Decrease in PLT
Deteriorating liver and or renal function
Persistent neurological symptoms
Persistent epigastric pain, nausea or vomiting

Question 9

Location of birth in pre eclampsia

Answer 9

High dependency or birth suite

Question 10

Recommended mode of birth in pre eclampsia

Answer 10

Vaginal unless CS is required for other indications

Question 11

What needs to be done prior to birth for pre eclampsia

Answer 11

Stabilise HTN
Correct coagulation issues
Consider eclampsia prophylaxis
Attention to fluid balance

Question 12

Timing of birth in pre eclampsia

Answer 12

> 37+0 wk

34-36.6 with caution

Question 13

Intrapartum Mx of Pre eclampsia

Answer 13

Monitoring - continuous CTG, BP every 1/2 hr and IV access. Epidural may be helpful for BP
2rd stage - assist if BP poorly controlled, progress is inadequate or signs of eclampsia
3rd stage - Active Mx indicated due to risk of PPH. Ergometrine or syntometrine are contraindicated due to increase BP effect.
Consider MgSO4 if eclampsia or severe pre eclampsia or preeclampsia with CNS irritability
Strict fluid MX
Ix - FBC, eLFTs, LDH, Coagulation, Urinalnalysis and PCR

Question 14

Antenatal care of pre eclampsia

Answer 14

Strict Control of BP
Medication- must if >/= 160/100 and consider if >/=140/90. Methlydopa, labetaolol, Nifedipine, oxprenolol, hydralaxine, prazosin
VTE prophylaxis
Fluid balance
Regular assessment 2 weekly at ANDAC
Mode of care - out Pt if HTN without preeclampsia
Admit if fetal concerns or symptomatic

Question 15

Ix for pre eclampsia

Answer 15

Maternal - BP, PCR >30g/mol, INR, Urine dipstick for proteinuria +2
FBC, U&E, LFT +LDH, Bilirubin, Albumin
Fetal - CTG, USS

Question 16

DDX for HTN in pregnancy

Answer 16

Chronic HTN
HELLP syndrome
Gestational HTN
Chronic HTN with superimposed pre eclampsia
Pre eclampsia

Question 17

Clinical problems in preeclampsia

Answer 17

Neurological problems - Convulsion (eclampsia), hyperreflexia with clonus, severe headaches with hyperflexia, persistent visual disturbances, Stroke,
Haematological disturbance - thrombocytopenia probably is caused by platelet activation and aggregation as well as microangiopathic hemolysis induced by severe vasospasm, haemolysis (severe disease). DIC
Fetal growth restriction
Oedema - lungs, facial and peripheral
Proteinuria >300mg in 24 hr urine collection or spot protein/creatinine ratio >30
Renal insufficiency - creatinine >80
Liver dysfunction - elevated AST/ALT, severe epigastric/RUQ pain which is thought to result from hepatocellular necrosis, ischemia and oedema that stretches the Glisson capsule - sub capsular haemotoma

Question 18

Define chronic HTN in pregnancy

Answer 18

Chronic hypertension - 140/90 or greater before pregnancy or before 20 wk gestation. Cause may be essential (90%) or secondary to renal, endocrine or other disease

Question 19

Define gestational HTN

Answer 19

Gestational hypertension - 140/90 or greater without proteinuria. New onset of HTN arising after 20 wks gestation
Prognosis - very good if only hypertension. Though at risk of developing pre-eclampsia (40%) if hypertensive before 30wks.
Management - needs Ix and close monitoring. usually normalises by 12 weeks post part.

Question 20

Work up of chronic HTN in pregnancy

Answer 20

Why we care: at twice the risk of developing pre-eclampsia
high risk pregnancy
possible underlying cause
Chronic kidney disease (e.g. glomerulonephritis, reflux nephropathy and adult polycystic kidney disease)
Renal artery stenosis
Systemic disease with renal involvement (e.g. diabetes mellitus, systemic lupus erythematosus)
Endocrine disorders (e.g. phaeochromocytoma, Cushing’s syndrome and primary hyperaldosteronism, hyper or hypothryroidism, hyperparathyroidism, acromegaly)
Coarctation of the aorta
Medications or supplements (e.g. sympathomimetics in decongestants, steroids, liquorice, cocaine, methamphetamines)
end organ damage from chronic hypertension

Question 21

Tx of Chronic HTN

Answer 21

antihypertensives might be more useful in this group
Severe - Nifedipine, labetalol, Hydralazine, Diazoxide
MDT
High dependency unit or birth suite
Strict control of BP is required
Monitor BP 15-30 mins until stable and then at a minimum 4 holy
Perform a through assessment of maternal and fetal condition
CTG

Question 22

HELLP syndrome

Answer 22

Defined - a severe variant of pre-eclampsia
Haemolysis
Elevated liver enzymes
Low Platelets
Variant of severe preeclampsia (Haemolysis, Elevated Liver enzymes and Low Platelet count). Elements include:
Thrombocytopenia (common)
Haemolysis (rare) and
Elevated liver enzymes (common)
In a woman with preeclampsia, the presence of any of the following is an indicator of severe disease
Maternal platelet count of less than 100 x 10 /L
Elevated transaminases
Microangiopathic haemolytic anaemia with fragments/schistocytes on blood film
Tx
MDT - obstetrician, haematologist or anaesthetist
> 34 wk and or condition deteriorating, birth plan
MgSO4 infusion
Consider PLT transfusion if low PLT present a hazard to operative birth or significant bleeding postpartum attributable to preeclamptic thrombocytopenia

Question 23

Eclampsia

Answer 23

Preeclampsia complicated by generalized tonic-clonic convulsions is termed eclampsia
Major complications included placental abruption (10 percent), neurological deficits (7 percent), aspiration pneumonia (7 percent), pulmonary edema (5 percent), cardiopulmonary arrest (4 percent), acute renal failure (4 percent), and maternal death (1 percent)
Majority Antepartum and in labour but 45% can occur post-partum usually upto 48 ours but rarely even a week later!
DDX - epilepsy, intoxications, hypoglycaemia.

Question 24

Mx of eclampsia

Answer 24

Preeclampsia complicated by generalized tonic-clonic convulsions is termed eclampsia
Major complications included placental abruption (10 percent), neurological deficits (7 percent), aspiration pneumonia (7 percent), pulmonary edema (5 percent), cardiopulmonary arrest (4 percent), acute renal failure (4 percent), and maternal death (1 percent)
Majority Antepartum and in labour but 45% can occur post-partum usually upto 48 ours but rarely even a week later!
DDX - epilepsy, intoxications, hypoglycaemia.

Question 25

Mx of Hypertensive mother delivering

Answer 25

> 160/>110 give acute treatment to lower - oral hyphen…
Antihypertensives acute vs longer term
Delivery - timing and mode
consult NICO
Anaesthetics - need to know PLT.
MgSO4 - reduces seizures and reduces hypertension.
Fluid management - fluid restriction to 80-100ml an hour
VTE prophylaxis