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PREECLAMPSIA / ECLAMPSIA Flashcards

1
Q

WHAT IS PREECLAMPSIA

A

New onset of HTN and proteinuria or end organ dysfunction after 20 weeks gestation in a previously normotensive patient

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2
Q

WHAT IS ECLAMPSIA

A

Preeclampsia has progressed and the patient now has seizures or coma

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3
Q

WHAT IS HELLP SYNDROME

A

Hemolysis, elevated liver enzymes, low platelets

May be part of severe preeclampsia
May occur without preeclampsia

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4
Q

PATHOGENESIS OF PREECLAMPSIA / ECLAMPSIA

A
  • the underlying problem is endothelial dysfunction that leads to abnormalities such as:

⦁ HTN
⦁ activation of platelets (micro-thrombi)
⦁ CNS changes
⦁ edema
⦁ renal dysfunction resulting in proteinuria
⦁ hemolysis
⦁ hepatic ischemia

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5
Q

WHAT CAUSES THE ENDOTHELIAL DYSFUNCTION?

A
  • mechanism not clearly understood
  • many maternal, placental & fetal factors come into play
    ⦁ Under-perfusion of the placenta
    ⦁ Immunologic factors
    ⦁ Increased sensitivity to angiotensin II
    ⦁ Genetic
    ⦁ Inflammation
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6
Q

risk factors for preeclampsia

A
  • first pregnancy
  • multiple gestations (twins +)
  • mothers > 35
  • HTN
  • DM
  • Obesity
  • family hx of preeclampsia
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7
Q

PREECLAMPSIA MAY LEAD TO

A 
⦁	Maternal death (10-15% of maternal deaths)
⦁	Placental abruption (from HTN)
⦁	Acute kidney injury
⦁	Cerebral hemorrhage
⦁	Hepatic failure or rupture
⦁	Pulmonary edema
⦁	DIC
⦁	Eclampsia (Seizures)
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8
Q

essentials for the diagnosis of preeclampsia

A

HTN
proteinuria

  • SBP > or = 140mmHg or DBP > or = 90mmHg on 2 occasions at least 4 hrs apart after 20 weeks of gestation in a previously normotensive pt
  • If SBP is > or = 160 mmHg or DBP is > or = 110 mmHg, confirmation within minutes will suffice

AND

Proteinuria > or = 0.3g in a 24hr urine specimen, or protein:creatinine ratio > or = 0.3

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9
Q

can she still have preeclampsia if she only has new onset HTN, but no proteinuria?

A

YES!

if she also has:

⦁ Low platelets (< 100k)
⦁ Elevated serum creatinine (not getting through damaged kidneys) = > 1.1 or doubling of creatinine in the absence of other renal dz
⦁ Elevated Liver enzymes (at least 2x normal lvls)
⦁ Pulmonary Edema
⦁ Cerebral or Visual symptoms (ie Headache, visual changes)

***so basically this puts them in the category of severe preeclampsia (end organ damage) - so no longer need proteinuria to prove preeclampsia

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10
Q

when can preeclampsia - eclampsia occur?

A

Preeclampsia-Eclampsia can occur anytime after 20 weeks of gestation and up to 6 weeks postpartum

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11
Q

only cure of preeclampsia - eclampsia

A

Only cure is delivery of the fetus and placenta

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12
Q

____________ are most frequently affected with preeclampsia-eclampsia

A

Primiparas (first child)

Extremes of maternal age (< 20 or > 35)

Multiple gestation (twins, triplets, etc.)

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13
Q

PREECLAMPSIA / ECLAMPSIA IS ASSOCIATED WITH

A 
Chronic HTN
diabetes
renal disease
collagen vascular and autoimmune disorders
Hydatidiform mole

OTHERS

  • New paternity (new baby daddy)
  • Previous preeclampsia or eclampsia or a family history
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14
Q

Symptoms not evident until ___________ but process begins as early as ________

A

3rd trimester

2nd trimester

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15
Q

cause of pre/eclampsia:

A

Unknown for sure

Imbalance in placental prostacyclin and thromboxane production (proteins released from placenta that act on maternal endothelial cells in vessels)

normally in balance (both increase in pregnancy)
- with Pre/eclampsia = have an imbalance = more Thromboxane than Prostacyclin

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16
Q

PROSTACYCLIN

A

potent vasodilator & inhibits platelet aggregation

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17
Q

THROMBOXANE

A

potent vasoconstrictor & stimulates platelet aggregation

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18
Q

with pre/eclampsia, have an imbalance between placental protein production (that maybe occurs with decreased placental perfusion?)

A

have more thromboxane than prostacyclin

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19
Q

In a normal pregnancy, Prostacycline levels = thromboxane levels

In preeclampsia/eclampsia, the Placenta produces _______________________

A

7x more thromboxane than prostacycline

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20
Q

The imbalance (much higher thromboxane) results in:

A

Vasoconstriction
Platelet aggregation
Reduced uteroplacental blood flow

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21
Q

only cure

A

delivery of fetus & placenta

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22
Q

Primary goal of management is

A

to allow pregnancy to progress as far as possible without jeopardizing maternal or fetal well-being

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23
Q

critical factors that affect delivery (3)

A

⦁ gestational age of fetus
⦁ maturity of fetal lungs
⦁ severity of maternal disease

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24
Q

Preeclampsia at 36 weeks or more is managed by

A

delivery, regardless of how mild the disease is judged

25
Q

Prior to 36 weeks, severe preeclampsia-eclampsia

A

requires delivery…

UNLESS

unusual circumstances associated with extreme fetal prematurity, in which case prolongation of pregnancy may attempted

26
Q

strong indications for delivery***

A

⦁ epigastric pain
⦁ thrombocytopenia
⦁ visual disturbances

27
Q

management of mild preeclampsia

A

home management with bedrest may be attempted with mild preeclampsia & a stable home situation

Aspirin (low dose: 60-80mg/day)
is recommended in high risk groups
⦁	women with chronic HTN
⦁	Hx of placental abruption
⦁	PIH (pregnancy induced HTN) in previous pregnancy
⦁	systemic lupus
  • ASA = no increased maternal or fetal risk
Antihypertensive therapy (to decrease BP enough to protect maternal organs without causing hypotension &amp; then threatening fetal oxygen supply
⦁	Hydralazine (vasodilator)
⦁	Methyldopa (alpha-agonist)
28
Q

aspirin is recommended as tx for mild preeclampsia in addition to home rest in high risk women:

A
  • women with chronic HTN
  • hx of placental abruption
  • PIH (previous pregnancy induced HTN)
  • SLE

giving ASA = no increased maternal or fetal risk

29
Q

antihypertensive therapy for mild preeclampsia

A

⦁ Hydralazine (vasodilator)

⦁ Methyldopa (alpha-agonist)

30
Q

summary of management for mild preeclampsia

A
  • home management - bedrest
  • ASA for high risk - low dose
  • Antihypertensives (hydralazine or methyldopa)
31
Q

management for mod to severe preeclampsia

A
  • hospitalization
  • if the patient is far enough along in her pregnancy for the fetus to be delivered safely, then deliver the baby!
  • if pt is not far along enough = hospitalize the pt, start on Magnesium Sulfate drip to prevent seizures
32
Q

if pt is not far along enough = hospitalize the pt, start on _________________________

A

Magnesium Sulfate drip to prevent seizures

33
Q

⦁ need to monitor Mag Sulfate closely: toxicity can cause

A

toxicity can cause respiratory depression

34
Q

WITH MOD/SEVERE PREECLAMPSIA = REGULAR ASSESSMENT OF:

A 
⦁	BP
⦁	Reflexes (DTRs are decreased with too much magnesium sulfate levels)
⦁	Urine protein
⦁	FHT &amp; activity (fetal heart tone)
⦁	CBC - platelet count
⦁	Electrolytes
⦁	Liver enzymes
⦁	24 hr urine collection for CrCl &amp; protein
  • fetal evaluation
  • daily fetal kick counts
  • consider amniocentesis to evaluate fetal lung maturity if hospitalization occurs at 30-36 weeks

⦁ give steroids: Betamethasone (Diprolene), Dexamethasone (Decadron) - can be given 12-24 hrs apart to mom to help mature fetal lungs - especially if fetus is 26-30 weeks

35
Q

why do you check reflexes with magnesium sulfate

A

DTRs are decreased with too much magnesium sulfate levels)

36
Q

with mod to severe preeclampsia, in addition to regular assessments, consider amniocentesis in order to:

A

evaluate fetal lung maturity if hospitalization occurs at 30-36 weeks

⦁ give steroids: Betamethasone (Diprolene), Dexamethasone (Decadron) - can be given 12-24 hrs apart to mom to help mature fetal lungs - especially if fetus is 26-30 weeks

37
Q

what steroids to give to help mature fetal lungs

A

Betamethasone (Diprolene)

Dexamethasone (Decadron)

38
Q

Severe preeclampsia BP

A

B/P: ≥ 160 systolic or ≥ 110 diastolic

39
Q

severe preeclampsia =

A

Any of the following

B/P: ≥ 160 systolic or ≥ 110 diastolic
Thrombocytopenia < 100K
Impaired liver function
RUQ pain, epigastric pain, LFTs 2X normal
Progressive renal insufficiency (creat > 1.1 or a doubling)
Pulmonary edema
New onset cerebral or visual disturbances

40
Q

severe preeclampsia can be associated with

41
Q

HELLP consists of

A

hemolysis
elevated liver enzymes
Low platelets

42
Q

Severe preeclampsia can have systemic associations

A

⦁ renal insufficiency
⦁ placenta abruption (from HTN –> placenta being dettached)
⦁ pulmonary edema & pulmonary HTN –> due to decreased CO
⦁ CNS - multifocal petechial hemorrhages of the grey/white matter junction

43
Q

SIGNS/SYMPTOMS OF HELLP

A

o SIGNS
⦁ BP is mildly elevated
⦁ with or without proteinuria
⦁ edema

o SYMPTOMS
⦁	malaise = almost 100% of the time
⦁	epigastric pain (liver)
⦁	RUQ tenderness (liver)
⦁	Nausea with or without vomiting
44
Q

WHAT SYMPTOM DO YOU HAVE ALMOST 100% OF THE TIME WITH HELLP

A

MALAISE***

45
Q

DIAGNOSIS OF HELLP

A
  • Hemolysis
    ⦁ abnormal peripheral smear (burr cells, schistocytes, or both)
    ⦁ elevated bilirubin (> 1.2 mg/dl) - produced by the breakdown of RBCs
    ⦁ increased lactic dehydrogenase (> 600 U/L)
  • Elevated Liver Enzymes
    ⦁ SGOT (> 70)
    ⦁ LDH (> 600)
  • Low platelets
    ⦁ < 100 k
46
Q

COMPLICATIONS OF HELLP

A 
Placental abruption (7-20%)
Acute renal failure
Hepatic hematoma
Liver rupture
Ascites
Hemorrhage
Fetal death
Maternal death
47
Q

what complication of HELLP to worry most about

A

placental abruption (fairly common) - 7-20%

48
Q

MANAGEMENT OF HELLP

49
Q

ECLAMPSIA EMERGENCY CARE

A

IF PT IS CONVULSING, DRUG OF CHOICE = MAGNESIUM SULFATE

50
Q

WHAT IS THE DRUG OF CHOICE FOR ECLAMPSIA

A

MAGNESIUM SULFATE

51
Q

Magnesium toxicity = can be reversed with

A

CALCIUM GLUCONATE

52
Q

MAGNESIUM SULFATE FOR ECLAMPSIA - EMERGENCY CARE

A

⦁ Drug of choice to control seizure activity
⦁ given as a bolus, followed by continuous IV infusion
⦁ check blood levels q4-6 hrs to maintain therapeutic level (4-6 mEq/L)
⦁ check urine output hourly
⦁ watch for signs of magnesium toxicity
- loss of DTRs
- decrease in Respiratory rate & depth
- Magnesium toxicity = can be reversed with CALCIUM GLUCONATE

53
Q

therapeutic level for magnesium sulfate

54
Q

signs of magnesium toxicity

A

loss of DTRs

decrease in respiratory rate & depth

55
Q

does magnesium sulfate cross the placenta?

A

YES

Magnesium sulfate readily crosses the placenta; Newborn suffers sedative properties of the drug; the effects subsides as the newborn excretes the drug over the following 3-4 days

56
Q

ECLAMPSIA TREATMENT SUMMARY

A
  • magnesium sulfate
  • deliver the baby
  • post-partum - continue mag sulfate x next 1-7 days until resolution = diuresis (increased urine production)
57
Q

Most reliable indicator of resolution of eclampsia

A

onset of diuresis

can then discontinue the magnesium sulfate drip

58
Q

will women with preeclampsia have preeclampsia with subsequent pregnancies? will the HTN go away?

A

A good number of women return to normotensive state

The incidence of preeclampsia in the next pregnancy is not definite, but there is an increase risk with multiple pregnancies

Some women have chronic, manageable HTN afterwards

WOMEN'S HEALTH (13 decks)

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