Pre-eclampsia

Question 1

Definition of pre-eclampsia

Answer 1

New onset hypertension and/or* proteinuria after week 20 of pregnancy that resolves after delivery

*If or: need other features

Question 2

Clinical features of pre-eclampsia (12)

Answer 2

Severe headache (hydrocephalus)
Visual disturbance (photopsia, photophobia) 
Papilloedema 
Epigastric pain
Right upper quadrant pain
Facial swelling
Hands and feet swelling (leg swelling can be normal) 
Vomiting 
Hyperreflexia and clonus 
Elevated ALT/AST (raised ALP normal as produced by placenta)
HELLP
Raised urea and creatinine

Question 3

Types of hypertensive disorders of pregnancy

Answer 3

<20 weeks is preexisting/chronic

>20 weeks is gestational/pre-eclampsia

Question 4

Definition of eclampsia

Answer 4

Generalised convulsions during pregnancy, labour or within 7 days postpartum
Not caused by neurological disorder

Question 5

Pathophysiology of pre-eclampsia

Answer 5

Trophoblast fails to invade maternal spiral arteries

Resulting in placenta not being a low pressure system

Question 6

Definition of proteinuria in pregnancy

Answer 6

PCR at least 30mg/mmol
Or
At least 300mg in 24hr urine collection (gold standard but rarely done in practice)

Question 7

Definition of hypertension in pregnancy

Answer 7

Diastolic BP >110
Or
>140/90 on 2 consecutive occasions >4 hours apart

Question 8

Complications of pre-eclampsia

Answer 8

Haemorrhagic stroke 
Eclampsia
HELLP syndrome 
Renal tubular necrosis
Pulmonary oedema
Hepatic haemorrhage within capsule
DIC
Placental infarction
Fetal death/growth restriction/prematurity

Question 9

How to asses fetal risk in pre-eclampsia

Answer 9

Fetal movements
CTG
Fetal size
Liquor volume
Umbilical artery Doppler

Question 10

Criteria for hospital admission

Answer 10

BP >170/110
Or
BP >140/90 with proteinuria
Or
Significant symptoms

Question 11

What can be done to prolong pregnancy in pre-eclampsia

Answer 11

Steroids

Question 12

Primary prevention of pre-eclampsia

Answer 12

Low dose aspirin BEFORE 24 weeks ~12

Calcium supplements

Question 13

Secondary prevention of pre-eclampsia

Answer 13

Antihypertensive drugs for severe hypertension
NO DIURETICS
NO ACE INHIBITORS

Question 14

Prevention and treatment of eclampsia seizures

What is its secondary benefit

Answer 14

Magnesium sulphate
Decreases risk of cerebral palsy in fetus

If ineffective, second line is lorazepam

Question 15

Significance of urea and creatinine in pregnancy

Answer 15

Should be lower than normal range in pregnancy

If in normal range need more investigation!

Question 16

Why can’t you give ACEi inhibitors for hypertension in pregnancy

Answer 16

Cause renal impairment in fetus

Question 17

Problem with lowering blood pressure too quickly

Answer 17

Blood flow directed to maternal brain and kidneys

Therefore flow restricted to uterus

Question 18

Drugs for emergency BP control in pregnancy

Answer 18

Nifedipine modified release SR
Labetalol IV
Hydralazine IV

Question 19

Contraindications for labetalol

Answer 19

Asthma

Type 1 diabetics - masks palpitations with hypo

Question 20

Side effects of labetalol

Answer 20

Scalp tingling
Headache
GI disturbance
Liver damage

Question 21

When do you need to stop methyldopa for hypertension in pregnancy

Answer 21

Within 2 days of delivery as increased risk of post natal depression

Question 22

Why do you need to treat hypertension in pregnancy

Answer 22

Increased risk of haemorrhagic stroke

Question 23

Post natal monitoring of hypertension

Answer 23

For 5 days after delivery

Medical review 2 weeks after delivery at GP to see if medication needs continuing

Question 24

What is HELLP syndrome

Answer 24

Activation of clotting cascade causing:
Haemolysis
Elevated liver enzymes
Low platelets <150

Question 25

Management of HELLP syndrome

Answer 25

Treat by delivering baby once mother stable <48 hours Give mother corticosteroids x2 24 hours apart Can transfuse blood products as needed

Question 26

Fetal risks of HELLP syndrome

Answer 26

``` Prematurity Stillbirth Neonatal death Placental abruption Placental failure ```

Question 27

Dosage of labetalol

Answer 27

100mg BD starting dose Can increase every 2 weeks by 200mg if needed Maximum dose of 2400mg per day

Question 28

Risk factors for preeclampsia

Answer 28

``` >40 years old Nulliparous >10 years since last pregnancy Multiple pregnancy FH or PH Chronic hypertension Chronic renal disease ```

Question 29

Recurrence rate of eclampsia

Answer 29

10%

Question 30

Management of chronic hypertension in pregnancy

Answer 30

Serial fetal growth charts to monitor Continue BP medication except for ACEi and diuretics Aim to deliver by 40 weeks

Question 31

When to deliver in preeclampsia

Answer 31

Mild - >36 weeks | Severe - asap regardless of gestational age unless proteinuria >5g/24hrs only criteria fulfilled

Question 32

When is IV MgSO4 given

Answer 32

IV intrapartum for severe preeclampsia continued for at least 24 hours post partum

Question 33

Pathophysiology of eclampsia

Answer 33

Cerebral oedema | Hypertensive encephalopathy

Question 34

What commonly used drugs in labour are contraindicated in preeclampsia

Answer 34

Ergometrin | Syntometrin

Question 35

Indications for urgent delivery I.e severe preeclampsia

Answer 35

``` Worsening thrombocytopenia Worsening liver function Worsening kidney function Fetal distress Eclampsia HELLP syndrome ```