Preeclampsia Flashcards
What hypertensive drugs are contraindicated in pregnancy?
ACEi and diuretics
Management of PET and delivery plan?
***delaying delivery is not warranted byond 38 weeks
Between 34-37 monitoring as elective delivery is associated with poorer fetal outcomes
<34 conservative management +corticosteroids
What drugs can be given prediagnosis to reduce the risk (in a high risk woman)
- Low dose aspirin i.e 100mg daily early in pregnancy can reduce the risk of preeclampsia by around 15%.
- Women with low calcium intake should be offered calcium supplements ,this reduces the risk of preeclampsia by about 60%
- Low dose multivitamin/folic acid may help reduce preeclampsia occurance
What is HELLP syndrome
Haemolysis, elevated liver functions, low platelets
- Serious complicaion of PET
- Can present mildly such as abdominal pain, nausea , vomiting malaise, headaches, oedema , visual disturbances
- The diagnosis of HELLP syndrome should be considered in any pregnant patient with new-onset epigastric/upper abdominal pain until proven otherwise
Diagnostic criteria for HELLP
- ELevated AST/ALT <70
- LDH serum lactate >600IU/L
- Platlet count <100x109
__% of eclamptic seizures occur after delivery
40%
Pathophysiology of PET
- When the trophoblastic cells dont growth properly into the placenta, leading to a maladaption of some of the spiral arteries supplying the placenta to dilate.
- This causes suboptimal placental perfusion which can cause the placenta to release pro-inflammatory substrate
- This can cause vasocontriction
- Poor kidney perfusion, liver swelling
- And endothelial dysfunction
- oedema, HTN, cerebral oedema/neuro symptoms
- As plasma volume falls due to fluid leakage the coagulation system is activat, and DIC
This is thought to be due to a combination of genetic and environmental influences as well as the maternal response
Clinical Feature of PET
- Occuring >20 weeks gestation
- Hypertension >140/90
- in previously normotensive woman, 4 hours apart
- Headache (frontal) (40%)
- Visual disturbance
- Oedema
- Epigastric or RUQ pain (?HELLP)
- Reduced fetal movements
- Reduced fetal growth
Risk factors for developing PET
- Nulliparity
- Multiple pregnancy
- Maternal age >35 or <20
- Family history
- Previous PET
- Obesity
- Renal Disease
- Diabetes
- AI disease (antiphospholipid)
- Chronic HTN
What would you see with PET renal involvement?
- significant proteinuria (+1)
- Confirmed by
- Spot urine preotein/Creatinine ration >30mg/mmol OR
- Plasma Creatinine >90micromol/l
- Confirmed by
- Oliguria <80ml/four hours
What would you see with PET haemoatological involvement
- Thrombocytopenia
- haemolysis
- DIC
What would you see with PET liver involvement
- Raised serum transaminases
- Severe epigastric or RUQ pain
What could you see with PET neurological invovlement?
- Eclampsia/convulsions
- Hypereflexia with sustained clonus
- severe frontal headache
- Persistant visual disturbances
- Stroke
General involvement as a result of PET
- Pulmonary oedema
- Fetal growth restriction
- Placental abruption
What investigations would you want to determine/rule out potenital PET
- Repeat BP after 4 hours
- Urine tests:
- MSU
- Dipstick screening + PCR
- Also need a 24hr collection >0.3g/24hr
- Blood tests to order
- FBC: platelets
- LFT: albumin, AST, ALT (****NORMAL RANGE LOWER IN PREGNANCY)
- G+H
- Fetal wellbeing assessment:
- Fetal USS + measurements + liquor
- CTG
- Umbilical artery doppler
What could be your differential diagnosis outside of PET?
- Chronic HTN
- GEstational HTN
- Epilepsy
- Antiphospholipid Syndrome
- Renal disease
- Liver disease
- …….
Why would you admit
- If they were symptomatic for PET (headaches, visual change, epigastric or RUQ pain)
- proteinuria + HTN >160/100
- Change in blood tests
- APH
- Reduced fetal movements
- Uterine activity
What does inpatient maternal monitoring of a PET patient include?
- Clincial assessment of symptoms
- 4-6hourly BP (overnight 8hrs acceptable) and compare to <20week readings
- Daily urinalysis
- MSU (at least once)
- 2/week FBC, LFT, CR
- Coags should be done if platelets are falling (<100), abnormal LFTs or ?placental abruption
- Uterine +liver tenderness, oedema, hyperreflexia,and fundal height
- Serial fetal GROW scans
Increase investigation frequency if there are any concerns
What can be given therapeutically in high risk women?
- Aspirin has show to reduce risk by 15%
- 100mg OD start ideally 12-16weeks
- Calcium in low intake women can reduce risk by 60%
- 1-1.5g OD
- Low dose multivitamin/folic acid may help
Anti-hypertensives: considerif BP consistently above 140/90-160/100
- Nifedipine
- Labetalol
- Metoprolol
- Methyldopa
- Mg S
Sudden onset HTN >170/110.
What antihypertensive do we use?
SA Nifedipine or iv labetalol
Methyldopa or labetalol can be used for >160/100
Women with eclampsia, what antihypertensive can we use?
MgS as a loading dose (4g / 20 mins) followed by maintenence infusion (1-2g/hr) for 24-48hrs
If seizure continues you can give a IV benzodiazepine (not reccomended in pregnancy usually)
Do we need to continue management after delivery, what the main risk to mother
yes and the main risk is fluid overload
Gestational HTN vs Chronic HTN vs Pre-eclampsia
Gestational HTN:
- New onset HTN after 20 weeks gestation
- No PET features
- 25% develop PET later
Chronic HTN:
- HTN prior to pregnancy or <20weeks gestation
Pre-eclampsia:
- Multisystem progressive disorder
- Dx >20 weeks
- Involvement of more then one organ system and/or the fetus
- ***can be superimposed on chronic HTN
When should
