Pregnancy complications - Pre-eclampsia and Eclampsia Flashcards
What is pre-eclampsia?
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.
What is thought to be the main pathophysiological cause of pre-eclampsia?
- 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

When does pre-eclampsia manifest?
>20 weeks gestation
How long after delivery does pre-eclampsia resolve?
Roughy 6 weeks
What are risk factors for pre-eclampsia?
- 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
What are complications fo pre-eclampsia?
- Eclampsia
- HELLP
- Cerebral haemorrhage
- IUGR
- Renal Failure
- Placental abruption
- DIC
What cut off for blood pressure is used in defining pre-eclampsia?
- SBP > 140
- DBP > 90
What level of protein in the urine is used to define pre-eclampsia?
Urinary protein ≥0.3 g protein/24 hours
What are the physiological effects of pre-eclampsia?
- Decreased plasma volume
- Increased peripheral vascular resistance
- Placental ischaemia
- If BP > 180/140 - microaneurysms develop in arteries
What are symptoms of pre-eclampsia?
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
What are signs of pre-eclampsia?
- Tachycardia
- Hypertension
- Proteinura
- Epigastric/RUQ tenderness
- Reduced foetal movements
- Hyperreflexia
- >2 beats clonus
- Confusion
- Oliguria
- Fits
- Oedema
What signs are red flags?
Hyper-reflexia, clonus
What investigations would you consider doing in someone with suspected pre-eclampsia?
- 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
Whats the gold standard investigation?
URINARLYSIS
What might you see on urinalysis in pre-eclampsia?
Proteinuria
What might the preotin:creatinine ratio be in someone with Pre-eclampsia?
>30 mg/mmol
Why might you do foetal ultrasound in someone with pre-eclampsia?
Due to reduced foetal movements - always requires and ultrasound
What might you see on FBC in someone with pre-eclampsia?
- Thrombocytopenia
- Anaemia (haemolysis)
What might you find on LFT in someone with pre-eclampsia?
May be elevated
What might coagulation tests show?
A raised PT - if severe or thrombocytopenia
What might you find on foetal CTG in someone with pre-eclampsia?
Signs of foetal distress
What might you find on investigation of coag screen in someone wtih pre-eclampsia?
May be normal, but PT or APTT may be prolonged in DIC
What might you find on foetal USS?
- IUGR
- Oligohydramnios
What might you find on doppler USS of umbilical arteries and uterus in someone with pre-eclampsia?
- Notching of the uterine arteries
- Abnormal umbilical artery
What might anaemia, elevated LFTs and low Platelets indicate?
HELLP syndrome
What bloods usually derange first in HELLP syndrome; Haemoglobin, LFTs or PLatelets?
LFTs elevate first
What is eclampsia?
OBSTETRIC EMERGENCY
- Tonic-clonic seizures + pre-eclampsia
What are the main causes of death in pre-eclampsia/eclampsia?
- Cerebral haemorrhage
- HELLP
- Organ failure
What is regarded as mild pre-eclampsia?
BP - 140-149/90-99 mmHg
What is regarded as moderate pre-eclampsia?
150-159/100-109 mmHg
What is regarded as severe pre-eclampsia?
>160/110 mmHg, or signs/symptoms, or end organ damage
How would you manage someone with mild pre-eclampsia?
- 4-hourly BP
- Twice weekly bloods
- Foetal growth scans every 2 weeks
- Induce after 37 weeks
- Only use antihypertensives if >150/100 mmHg
How would you manage someone with moderate pre-eclampsia?
Admit until delivery
- 4-hourly BP
- Check bloods 3 times/week
- Fortnightlly foetal growth scans
- Twice daily CTG
- Start antihypertensives
How would you manage severe pre-eclampsia?
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
What is the main cure for pre-eclampsia?
Delivery of the baby
What IV drugs would you consider for controlling BP in pre-eclampsia?
- Labetalol
- Hydralazine
What oral anti-hypertensives would you consider giving someone to control BP in pre-eclampsia?
Nifedipine
When would you consider giving IV anti-hypertensives in pre-eclampsia?
If BP > 160/110 mmHg
What would you use in subsequent pregnancies as a prophylactic for pre-eclampsia?
Low dose aspirin
If you were giving prophylactic magnesium sulphate in severe pre-eclampsia, what dose would you give?
4g IV loading dose, then 1g/hr
If someone developed eclampsia, how would you manage them?
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
What dose of magnesium sulphate would you give for eclampsia, and at what rate?
- 4g over 5-10 minutes, then 1g/h for 24 hrs.
- Treat further fits with 2g bolus
What methods of delivery are options for managing eclampsia?
- IOL
- LSCS - quicker
What medication would you want to have handy in case of magnesium sulphate toxicity?
Calcium gluconate
What fluid restriction would you put someone on if they were pre-eclamptic/eclamptic?
80mls/hr - only if no haemorrhage
How is pre-eclampsia prevented?
- Regular BP checks
- Regular urinalsysis
- Magensium sulphate - by pump
- Aspirin - from 12 weeks until birth of the baby
What is HELLP syndrome?
- Haemolysis
- Elevated Liver Enzymes - ALT/AST >70
- Low Platelet count
What are features of HELLP syndrome?
This is a syndrome indicative of moderate - severe PET - not a separate disease
- Epigastric pain/RUQ pain
- Nausea + vomiting
- Dark urine
- Hypertension
How would you manage HELLP syndrome?
Same as for eclampsia - deliver baby
If you chose to induce someone with pre-eclampsia, what drug should you not use to induce them?
Syntometrine
Does smoking increase risk of PET?
No
If someone presents with normal BP, bloods and examination, but has + protein on urinalysis, what might be the most likely cause?
UTI
What are the main signs which indicate someone has severe pre-eclampsia?
- SOB/cynosis
- Oliguria
- BP - 160/110
- Proteinuria - +++
- Neurological symptoms - clonus, hyperreflexia
If someone required induction of labour/C-section for PET and the baby was preterm, what would you consider doing?
Steroid injection for foetal lung maturity
If you admitted someone with PET, what thromboprophlactic measure would you take whilst trying to arrange management of the problem?
TED stockings
Why might it be important to check MSSU in a patient with severe pre-eclampsia?
Before putting in catheter - check what organisms are there
What is the risk of doing an epidural in a woman with severe pre-eclampsia?
Spinal haematoma
When do most seizures occur in pre-eclampsia?
Post natally, typically 4 days post partum
What labour inducers would you NOT use in pre-eclampsia?
Ergomertine or synrometrine as they INCREASE BP
Management of eclampsia?
Call for help
ABC
IV magnesium sulphate
IV labetlolol
Check RR and tendon reflexes
Maternal complcaitions of pre-eclampsia?
SHAME
Stroke
HELLP syndrome
Abruption of placenta
Multi-organ failure
Eclampsia
+Renal, liver, cardiac failure and pulmonary oedema
Foetal complications of pre-eclampsia
IUGR - impaired blood flow through placenta
Prematurity
RDS