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Science of Repro > Pre-eclampsia > Flashcards

Pre-eclampsia Flashcards

1
Q

Why is PE important? (5)

A
  • 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
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2
Q

High risk factors (5)

A

Previous pre-eclampsia
Chronic hypertension
Autoimmune disease
Diabetes mellitus
Chronic kidney disease

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3
Q

Moderate risk factors (6)

A

Nulliparity
Age >40
Pregnancy interval >10yr
BMI >35
Family hx pre-eclampsia
Multiple pregnancy

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4
Q

Pathphys

A
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5
Q

Normal placentation (5)

A
  • 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
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6
Q

PE implantation (7)

A
  • 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
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7
Q

ALTERNATIVE HYPOTHESIS:
CARDIOVASCULAR DYSFUNCION

A

look over

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8
Q

Common end pathway (2)

A
  • Endothelial injury
  • Vasoconstriction
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9
Q

Maternal effects of PE (4)

A

– Cerebral oedema: eclampsia
– Vasospasm: hypertension, renal failure
– Endothelial injury: low
platelets, disseminated
intravascular coagulopathy (DIC)
– Albumin leakage: proteinuria,
pulmonary oedema

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10
Q

Fetal effects of PE

A

– Growth restriction
– Prematurity
– Placental abruption
– Fetal death

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11
Q

Prevention (3)

A

Indication for Aspirin: 1 high or >1 moderate

Aspirin dose: 75-150mg

Aspirin duration: from 12w - Daily until delivery

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12
Q

screening + prediction 1st trim: (6)

A

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)

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13
Q

Classification of hypertension in preg. (4)

A

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

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14
Q

Diagnostic criteria (5)

A

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

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15
Q

SIGNS AND SYMPTOMS (9)

A
  • No symptoms
  • Headaches
  • Flashing lights
  • Epigastric pain
  • Nausea/vomiting
  • Confusion
  • Hypertension
    – Use the right cuff size
    – Disappearance of sounds
  • Proteinuria
  • Brisk jerks
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16
Q

PE INVESTIGATIONS (7)

A
  • 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
17
Q

sFlt-1:PlGF ratio explained

A
18
Q

sFlt-1:PlGF for antenatal management

A
19
Q

estimation of risks study (4)

A
  • 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.

20
Q

Bp management (5)

A

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

21
Q

Home BP monitoring benefits (3)

A
  • Safe and cost effective
  • Reduction in induction of labour, antenatal admissions and PE diagnosis
  • No compromise of maternal and pregnancy outcomes
22
Q

Why not deliver? (4)

A
  • 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
23
Q

Severe PE (3)

A
  • 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)

24
Q

Prevention of Seizures (4)

A

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

25
Q

For controlled PE, should the pregnancy be prolonged after
36+6 weeks?

A

No- Authors concluded that induction of labour is recommended for women w/ mild PE or mild gestational hypertension at a gestational age beyond 37+0 weeks

26
Q

For PE between 34 – 37
weeks, should delivery be considered?

A

yes - Authors concluded that between 34-36+6
weeks induction of labour should be considered for women w/ mild/moderate PE to reduce maternal
complications vs expectant to 37+0
weeks, but with higher chance of NNU
admission (due to prematurity)

27
Q

But does earlier delivery cause harm?

A

yes + no - no stat. risk but slight variations and increases in neonatal Resp. distress + 2yr self-reports

28
Q

Postnatal management (5)

A
  • Carefully assess women with signs or symptoms of PE
  • Assess need to continue anti-hypertensives
  • Arrange appropriate follow-up
  • An assessment of BP and proteinuria by the gp at the 6 weeks postnatal check is recommended
  • If hypertension or proteinuria persists then further investigation is required.
29
Q

PE effected postnatal management 920

A
  • Women whose pregnancies have
    been complicated by severe PE or eclampsia should be offered a formal postnatal review to discuss the events of the pregnancy.
  • Pre-conceptional counseling should
    be offered where the events that occurred, any risk factors and any
    preventative therapies can be discussed.
30
Q

Pregnancy as stress test

A
31
Q

Long term complications of PE (4)

A

Ischaemic heart disease
Stroke/VTE
Risk of mortality
Impact on baby:
* Higher systolic/diastolic BP
* Increased BMI
* Higher rates of pe in future

32
Q

Summary (7)

A
  • Recognise the importance of
    (PE)
  • Understand the adverse maternal and fetal consequences
  • Debate the aetiology of PE
  • Define the risk factors and preventative strategies
  • Describe the clinical definition PE
  • Understand antenatal and postnatal management
  • Discuss long term complications after PE

Science of Repro (32 decks)

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