Pre-eclampsia Flashcards
(32 cards)
Why is PE important? (5)
- 6th leading cause of direct maternal deaths (6 deaths over 3 years)
- Commonest medical problem in pregnancy:
– Gestational hypertension = 10%
– PE = 2-5%
– Severe PE= 1%
– Eclampsia (2% death rate) - Leading cause of iatrogenic prematurity
- Immediate risks of eclampsia, stroke and heart failure
- Life-long risk of cvd
High risk factors (5)
Previous pre-eclampsia
Chronic hypertension
Autoimmune disease
Diabetes mellitus
Chronic kidney disease
Moderate risk factors (6)
Nulliparity
Age >40
Pregnancy interval >10yr
BMI >35
Family hx pre-eclampsia
Multiple pregnancy
Pathphys
Normal placentation (5)
- Trophoblasts invade maternal vessels
- Narrow spiral arteries remodelled
- Wide-bore low-resistance vessels
deliver large amounts of maternal blood - Nutrient and oxygen delivery to fetus
PE implantation (7)
- Deficient trophoblast invasion
- Spiral arteries not remodelled
- High-resistance placental bed
- Poorly perfused hypoxic placenta
- Deficient nutrient and oxygen delivery
- Release of inflammatory cytokines (IL, TNF etc)
- Maternal endothelial dysfunction:
– Increased vascular reactivity and vasospasm
– Increased capillary permeability + reduced intravascular volume
ALTERNATIVE HYPOTHESIS:
CARDIOVASCULAR DYSFUNCION
look over
Common end pathway (2)
- Endothelial injury
- Vasoconstriction
Maternal effects of PE (4)
– Cerebral oedema: eclampsia
– Vasospasm: hypertension, renal failure
– Endothelial injury: low
platelets, disseminated
intravascular coagulopathy (DIC)
– Albumin leakage: proteinuria,
pulmonary oedema
Fetal effects of PE
– Growth restriction
– Prematurity
– Placental abruption
– Fetal death
Prevention (3)
Indication for Aspirin: 1 high or >1 moderate
Aspirin dose: 75-150mg
Aspirin duration: from 12w - Daily until delivery
screening + prediction 1st trim: (6)
after initial risk factor checks
* Age: every 10 years above 30 y
* Weight: every 10 kg above 70 kg
* Racial origin: Afro-Caribbean, South Asian
* Obstetric history: 1st pregnancy
* Family history of PE
* Autoimmune : SLE / APS
NICE risk-factor screening= 40.8% (32.8 – 48.9)
Maternal factors (MF)= 41.5% (33.3 – 50.1)
MF + Mean arterial pressure (MAP)= 49.3% (40.8 – 57.8)
MF + MAP + PAPP-A= 52.8% (44.3 – 61.2)
MF + MAP + PAPP-A + UtA-PI= 76.1% (68.2 – 82.8)
MF + MAP + PlGF + UtA-PI= 81.7% (74.3 – 87.7)
Classification of hypertension in preg. (4)
No proteinuria:
- <20/40 = pre-existing HTN
->20/40: gestational HTN
Significant proteinuria:
- <20/40 = pre-existing HTN, secondary to renal disease
->20/40: PE
Diagnostic criteria (5)
1) Hypertension Threshold: >140/90 mmHg
2) Hypertension Baseline Normotensive: <20 weeks (BUT can have superimposed PE on
background of Chronic HTN)
3) Proteinuria: >300 mg/24 hrs OR Protein:Creatinine ratio (PCR) >30 mg/mmol
OR +2 urine dipstick
4)Proteinuria a prerequisite for diagnosis= No
5)Other clinical criteria for diagnosis: Yes
- Renal Creatinine >90 μmol/litre
- Liver Liver enzymes: ALT or AST >40 IU/L, +/- RUQ or epigastric pain
- Neurological Eclampsia, altered mental status, blindness, stroke, clonus, severe
headaches or persistent visual scotomata
- Haematological Platelets <150,000 x 10 9 /L, Disseminated Intravascular
Coagulopathy (DIC) or haemolysis
- Uteroplacental Fetal growth restriction, abnormal umbilical artery Doppler waveform analysis, or stillbirth
SIGNS AND SYMPTOMS (9)
- No symptoms
- Headaches
- Flashing lights
- Epigastric pain
- Nausea/vomiting
- Confusion
- Hypertension
– Use the right cuff size
– Disappearance of sounds - Proteinuria
- Brisk jerks
PE INVESTIGATIONS (7)
- 24-hr urinary protein OR spot protein:creatinine ratio
- Platelet count
- LFT - Liver enzymes(ALT)
- U&E - Creatinine
- Clotting tests
- sFlt-1:PlGF ratio
- Fetal assessment –Ultrasound for growth and Dopplers +/- CTG
sFlt-1:PlGF ratio explained
sFlt-1:PlGF for antenatal management
estimation of risks study (4)
- Aim to identify the risk of fatal or life-threatening complications w/ PE within 48hr of hospital admission for disorder
- Internally and externally validated
- Outcome of interest was maternal mortality or other serious complications of PE
- Predictors of adverse maternal outcome included gestational age, chest pain or
dyspnoea, oxygen saturation, platelet count, and creatinine and aspartate
transaminase concentrations. - AUC ROC 0·88, 95% CI 0·84–0·92
A threshold of ≥30% risk is suggested as a threshold to rule-in the outcome.
Bp management (5)
BP Target = (130 – 140)/
(80 – 90)
- 1st Line = Labetalol (CI Asthma, Ischemic Heart Disease), Max 2g/day (500mg qds)
- 2nd Line = Nifedipine (CI Aortic Stenosis), Max 80mg/day (20-30mg tds)
- Consider = MethylDopa (CI Depression), Max 3g/day (1000mg tds)
BP = CO x TVR
CO = HR x SV:
SV relatively constant in 2nd-3rd trimester so HR will be driver for changes in CO
Home BP monitoring benefits (3)
- Safe and cost effective
- Reduction in induction of labour, antenatal admissions and PE diagnosis
- No compromise of maternal and pregnancy outcomes
Why not deliver? (4)
- Complications of prematurity
- Possibility of failed induction needing C section
- Attempts to prolong pregnancy are justified for pre-term PE
- Severe uncontrolled PE needs delivery after stabilisation
Severe PE (3)
- Diastolic BP ≥ 110 mm X 2
- Systolic BP ≥ 160 mm X 2 and ≥ ++ proteinuria
Signs or symptoms of imminent eclampsia
– Hyper-reflexia (neuronal irritability)
– Frontal headache
– Blurred vision (cerebral vasospasm)
– Epigastric tenderness (tension on liver capsule)
Prevention of Seizures (4)
Mag. Sulfate w/ PE = red. risk of eclamptic risk
women allocated mag. sulfate has 58% lower risk
maternal mortailty rate lower in treatment group
reduced risk of placental abruption
