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Gwen - Reproductive Medicine (Obs, Gyn, Breast) > Pregnancy complications - Pre-eclampsia and Eclampsia > Flashcards

Pregnancy complications - Pre-eclampsia and Eclampsia Flashcards

1
Q

What is pre-eclampsia?

A

A hypertensive syndrome that occurs in pregnant women after 20 weeks’ gestation, consisting of new-onset, persistent hypertension (defined as a BP of ≥140 mmHg systolic and/or ≥90 mmHg diastolic, based on at least 2 measurements taken at least 4 hours apart) with either proteinuria (defined as urinary excretion of ≥0.3 g protein/24 hours) or evidence of systemic involvement.

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2
Q

What is thought to be the main pathophysiological cause of pre-eclampsia?

A
  • Disorder of placentation, primary defect i sfailure of trophoblast invasion of spinal arteries which leads to uteroplacental ischaemia and wide spread endothelial dysfunction
  • HIGH RESISTANCE, LOW FLOW PLACENTA so suboptimal uroplacental perfusion

Failure of trophoblastic invasion of spiral arteries, leaving them vasoactive. This leaves them unable to clamp down in response to vasoconstrictors, and this protects placental flow. The dysfunctional placenta releases pro-inflammatory mediators, which increase BP (hypertension) and make vessels more leaky (oedema). They also affect the kidneys (proteinuria) and even the liver

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3
Q

When does pre-eclampsia manifest?

A

>20 weeks gestation

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4
Q

How long after delivery does pre-eclampsia resolve?

A

Roughy 6 weeks

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5
Q

What are risk factors for pre-eclampsia?

A
  • Previous pre-eclampsia/Early onset
  • Underlying PMH
    • Chronic hypertension - current or previous pregnancy
    • CKD
    • DM
  • Autoimmune disease - SLE, antiphospholipid, thrombophilia
  • 1st pregnancy
  • >40 yrs, <20
  • FH pre-eclampsia
  • Multiple pregnancy
  • Low PAPP-A
  • BMI >/= 30
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6
Q

What are complications fo pre-eclampsia?

A
  • Eclampsia
  • HELLP
  • Cerebral haemorrhage
  • IUGR
  • Renal Failure
  • Placental abruption
  • DIC
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7
Q

What cut off for blood pressure is used in defining pre-eclampsia?

A
  • SBP > 140
  • DBP > 90
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8
Q

What level of protein in the urine is used to define pre-eclampsia?

A

Urinary protein ≥0.3 g protein/24 hours

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9
Q

What are the physiological effects of pre-eclampsia?

A
  • Decreased plasma volume
  • Increased peripheral vascular resistance
  • Placental ischaemia
  • If BP > 180/140 - microaneurysms develop in arteries
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10
Q

What are symptoms of pre-eclampsia?

A

May be asymptomatic (often picked up on screening), or:

  • Headache, usually frontal
  • Blurred vision, flashing lights/floaters
  • Epigastric/RUQ pain
  • Nausea and vomiting
  • Swelling of face/fingers/lower limbs
    • ​Rapid onset
    • Esp face
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11
Q

What are signs of pre-eclampsia?

A
  • Tachycardia
  • Hypertension
  • Proteinura
  • Epigastric/RUQ tenderness
  • Reduced foetal movements
  • Hyperreflexia
  • >2 beats clonus
  • Confusion
  • Oliguria
  • Fits
  • Oedema
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12
Q

What signs are red flags?

A

Hyper-reflexia, clonus

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13
Q

What investigations would you consider doing in someone with suspected pre-eclampsia?

A
  • Bedside - Dipstick, Basic observations, foetal CTG, consider fundoscopy
  • Bloods - FBC, LFTs, U+E’s, Coag screening
  • Imaging - Foetal USS, Umbilical artery doppler velocimetry
  • Other - Amniotic fluid assessment, consider MSSU
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14
Q

Whats the gold standard investigation?

A

URINARLYSIS

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15
Q

What might you see on urinalysis in pre-eclampsia?

A

Proteinuria

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16
Q

What might the preotin:creatinine ratio be in someone with Pre-eclampsia?

A

>30 mg/mmol

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17
Q

Why might you do foetal ultrasound in someone with pre-eclampsia?

A

Due to reduced foetal movements - always requires and ultrasound

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18
Q

What might you see on FBC in someone with pre-eclampsia?

A
  • Thrombocytopenia
  • Anaemia (haemolysis)
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19
Q

What might you find on LFT in someone with pre-eclampsia?

A

May be elevated

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20
Q

What might coagulation tests show?

A

A raised PT - if severe or thrombocytopenia

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21
Q

What might you find on foetal CTG in someone with pre-eclampsia?

A

Signs of foetal distress

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22
Q

What might you find on investigation of coag screen in someone wtih pre-eclampsia?

A

May be normal, but PT or APTT may be prolonged in DIC

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23
Q

What might you find on foetal USS?

A
  • IUGR
  • Oligohydramnios
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24
Q

What might you find on doppler USS of umbilical arteries and uterus in someone with pre-eclampsia?

A
  • Notching of the uterine arteries
  • Abnormal umbilical artery
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25
Q

What might anaemia, elevated LFTs and low Platelets indicate?

A

HELLP syndrome

26
Q

What bloods usually derange first in HELLP syndrome; Haemoglobin, LFTs or PLatelets?

A

LFTs elevate first

27
Q

What is eclampsia?

A

OBSTETRIC EMERGENCY

  • Tonic-clonic seizures + pre-eclampsia
28
Q

What are the main causes of death in pre-eclampsia/eclampsia?

A
  • Cerebral haemorrhage
  • HELLP
  • Organ failure
29
Q

What is regarded as mild pre-eclampsia?

A

BP - 140-149/90-99 mmHg

30
Q

What is regarded as moderate pre-eclampsia?

A

150-159/100-109 mmHg

31
Q

What is regarded as severe pre-eclampsia?

A

>160/110 mmHg, or signs/symptoms, or end organ damage

32
Q

How would you manage someone with mild pre-eclampsia?

A
  • 4-hourly BP
  • Twice weekly bloods
  • Foetal growth scans every 2 weeks
  • Induce after 37 weeks
  • Only use antihypertensives if >150/100 mmHg
33
Q

How would you manage someone with moderate pre-eclampsia?

A

Admit until delivery

  • 4-hourly BP
  • Check bloods 3 times/week
  • Fortnightlly foetal growth scans
  • Twice daily CTG
  • Start antihypertensives
34
Q

How would you manage severe pre-eclampsia?

A

Call for senior help, anaesthetics and midwife:

  • Stabilise BP - Oral, then IV if not working (Labetalol, hydralazine - small bolus
  • Prophylactic IV Magnesium sulphate
  • Bloods every 12-24 hours
  • Strict fluid balance + catheter
  • Steroids - if indicated i.e. preterm
  • Deliver baby
35
Q

What is the main cure for pre-eclampsia?

A

Delivery of the baby

36
Q

What IV drugs would you consider for controlling BP in pre-eclampsia?

A
  • Labetalol
  • Hydralazine
37
Q

What oral anti-hypertensives would you consider giving someone to control BP in pre-eclampsia?

A

Nifedipine

38
Q

When would you consider giving IV anti-hypertensives in pre-eclampsia?

A

If BP > 160/110 mmHg

39
Q

What would you use in subsequent pregnancies as a prophylactic for pre-eclampsia?

A

Low dose aspirin

40
Q

If you were giving prophylactic magnesium sulphate in severe pre-eclampsia, what dose would you give?

A

4g IV loading dose, then 1g/hr

41
Q

If someone developed eclampsia, how would you manage them?

A

Call for help:

  • ABCDE - IV access, bloods, catheterise
  • Magnesium sulphate
  • Consider diazepam in repeated seizures
  • Restrict fluids - <80ml/h
  • Monitor CTG
  • Deliver once mother is stable
42
Q

What dose of magnesium sulphate would you give for eclampsia, and at what rate?

A
  • 4g over 5-10 minutes, then 1g/h for 24 hrs.
  • Treat further fits with 2g bolus
43
Q

What methods of delivery are options for managing eclampsia?

A
  • IOL
  • LSCS - quicker
44
Q

What medication would you want to have handy in case of magnesium sulphate toxicity?

A

Calcium gluconate

45
Q

What fluid restriction would you put someone on if they were pre-eclamptic/eclamptic?

A

80mls/hr - only if no haemorrhage

46
Q

How is pre-eclampsia prevented?

A
  • Regular BP checks
  • Regular urinalsysis
  • Magensium sulphate - by pump
  • Aspirin - from 12 weeks until birth of the baby
47
Q

What is HELLP syndrome?

A
  • Haemolysis
  • Elevated Liver Enzymes - ALT/AST >70
  • Low Platelet count
48
Q

What are features of HELLP syndrome?

A

This is a syndrome indicative of moderate - severe PET - not a separate disease

  • Epigastric pain/RUQ pain
  • Nausea + vomiting
  • Dark urine
  • Hypertension
49
Q

How would you manage HELLP syndrome?

A

Same as for eclampsia - deliver baby

50
Q

If you chose to induce someone with pre-eclampsia, what drug should you not use to induce them?

A

Syntometrine

51
Q

Does smoking increase risk of PET?

A

No

52
Q

If someone presents with normal BP, bloods and examination, but has + protein on urinalysis, what might be the most likely cause?

A

UTI

53
Q

What are the main signs which indicate someone has severe pre-eclampsia?

A
  • SOB/cynosis
  • Oliguria
  • BP - 160/110
  • Proteinuria - +++
  • Neurological symptoms - clonus, hyperreflexia
54
Q

If someone required induction of labour/C-section for PET and the baby was preterm, what would you consider doing?

A

Steroid injection for foetal lung maturity

55
Q

If you admitted someone with PET, what thromboprophlactic measure would you take whilst trying to arrange management of the problem?

A

TED stockings

56
Q

Why might it be important to check MSSU in a patient with severe pre-eclampsia?

A

Before putting in catheter - check what organisms are there

57
Q

What is the risk of doing an epidural in a woman with severe pre-eclampsia?

A

Spinal haematoma

58
Q

When do most seizures occur in pre-eclampsia?

A

Post natally, typically 4 days post partum

59
Q

What labour inducers would you NOT use in pre-eclampsia?

A

Ergomertine or synrometrine as they INCREASE BP

60
Q

Management of eclampsia?

A

Call for help

ABC

IV magnesium sulphate

IV labetlolol

Check RR and tendon reflexes

61
Q

Maternal complcaitions of pre-eclampsia?

A

SHAME

Stroke

HELLP syndrome

Abruption of placenta

Multi-organ failure

Eclampsia

+Renal, liver, cardiac failure and pulmonary oedema

62
Q

Foetal complications of pre-eclampsia

A

IUGR - impaired blood flow through placenta

Prematurity

RDS

Gwen - Reproductive Medicine (Obs, Gyn, Breast) (49 decks)

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