Pre-eclampsia and eclampsia

Question 1

What is the difference between pregnancy-associated hypertension and pregnancy-induced hypertension? What is another name for pregnancy-induced hypertension?

Answer 1

Pregnancy-associated HT = HT that exists before and will exist after pregnancy
Pregnancy-induced HT (pre-eclampsia) = HT caused by pregnancy that will resolve after pregnancy

Question 2

What is the definition of pre-eclampsia (including values)?

Answer 2

Pregnancy induced hypertension (>140/90 or >30/15 above baseline), proteinuria (300mg/24 hrs), generalised oedema, and multi-system dysfunction

Question 3

At what BP must you start anti-hypertensive agents in a pregnant woman?

Answer 3

> 170/110

Question 4

Name 3 differentials for proteinuria in pregnancy

Answer 4

Normal (pregnancy induces proteinuria normally)
Contaminant (often from vaginal discharge released in pregnancy)
UTI
Pre-eclampsia

Question 5

How is the distribution of oedema different in pre-eclampsia than normal pregnancy?

Answer 5

Facial oedema more prominent

Question 6

What proportion of pregnancies in Australia will have mild and severe PE?

Answer 6

Mild - 5-10%

Severe - 1-2%

Question 7

What 6 organ systems are affected in PE and how?

Answer 7

Cardiovascular - HT, pulmonary oedema
Renal - oligouria, renal failure
Haematological - haemolysis, thrombocytopaenia, DIC
Neurological - eclampsia, cerebral oedema and haemorrhage
Hepatic - cellular dysfunction, rupture
Uteroplacental - abruption, IUGR, FDIU

Question 8

What are the 3 stages of pre-eclampsia? Outline the general management of each stage

Answer 8

Stage 1 - just HT. No need for admission, aim for delivery at term
Stage 2 - HT + proteinuria. Admit today for delivery 34-36 weeks
Stage 3 - HT + proteinuria + symptoms of end-organ dysfunction. Admit immediately for anticonvulsants and delivery after stabilisation

Question 9

Name 5 risk factors for pre-eclampsia

Answer 9

FHx
Age extremes
First pregnancy
New paternity
Assisted reproduction
Sexual cohabitation (higher risk if woman is pregnant from first sexual activity with new partner)
Co-morbid disease

Question 10

Name 3 medical conditions that predispose towards PE

Answer 10

Chronic HT (pregnancy-associated HT)
Renal disease
DM
Autoimmune diseases
Thrombophilias

Question 11

Name 3 pregnancy conditions that predispose towards PE. How come?

Answer 11

Multiple pregnancy
GDM
Gestational trophoblastic disease
Hydrops fetalis
Trisomy 13

All increase placental mass (except Trisomy 13)

Question 12

Name 5 indicators suggestive of severe PE (think of the systems affected)

Answer 12

Cardio - Extreme HT (refractory to anti-HTs), pul oedema
Neuro - Headache, papilloedema, seizures, hyperreflexia, visual disturbances
Renal - oliguria, generalised oedema, worsening proteinuria
Haematological - thrombocytopaenia
Liver - elevated enzymes, upper abdo pain

Question 13

What are the 10 stages of management for severe pre-eclampsia (sorry….)

Answer 13

Admission
Stabilisation
BP control
Seizure prophylaxis
Fluid balance
Fetal welfare surveillance
Delivery
Third stage active management
Post-partum observation
Follow-up

Question 14

What is the key treatment principle of severe pre-eclampsia? Why do they say this?

Answer 14

PE is cured by delivery, but not at delivery! Things can still go wrong after delivery (15-30% of eclampsia is postpartum)

Question 15

What usually occurs in the puerperium following severe pre-eclampsia?

Answer 15

Torrential diuresis to remove excess fluid

Question 16

Name 3 anti-HT agents used in PE. Which one can’t be used for rapid BP reduction?

Answer 16

Methyldopa - only oral and slow acting, not good for acute setting
Labetalol
Nifedipine
Hydralazine
Diazoxide

Question 17

Are anti-HTs disease-modifying agents in PE? If not, why do we use them?

Answer 17

Not disease-modifying, but they reduce the risk of stroke

Question 18

What medication do you give for neuronal stabilisation? Name 3 things to monitor for after giving this medication. What is the antidote to this medication?

Answer 18

MgSO4 IV. Monitor serum levels, reflexes (avoid areflexia!), respiration and urine output.

Give CaCl2 as antidote

Question 19

Name 5 factors that would help you determine whether to deliver vaginally or by C/S in pre-eclampsia

Answer 19

Vaginally - multiparous, stable BP and CNS, ripe cervix, mature foetus (> 1.5kg estimated weight), cephalic, good foetal surveillance

C/S - primip, unstable BP, cerebral irritability, unripe cervix, immature foetus, breech, abnormal foetal doppler or CTG

Question 20

Name 5 signs indicative of imminent eclampsia

Answer 20

Upper abdo pain, facial itchiness, visual disturbance, headache, rapidly increasing BP and proteinuria, increasing hyper-reflexia

Question 21

What is the most common cause of seizures in pregnancy?

Answer 21

Epilepsy! Not eclampsia

Question 22

Go through the 7 principles of management in eclampsia (sorry again…)

Answer 22

Protect patient
Protect airway
Control convulsion
Prevent further convulsions
Review maternal and foetal state
Stabilise maternal and foetal state
Deliver

Question 23

What does the HELLP syndrome stand for? How does it relate to pre-eclampsia?

Answer 23

Haemolysis
Elevated Liver enzymes
Low Platelets

Subtype of pre-eclampsia where liver and blood are most affected

Question 24

Name 3 Ddx for pre-eclampsia

Answer 24

Essential HT
Endocrine (Pheochromocytoma, Cushing’s)
Renal HT

Question 25

What is the main theory for why pre-eclampsia occurs?

Answer 25

Poor implantation of the placenta = reduced oxygenation of foetus in later pregnancy = release of vasoactive factors by placenta into maternal circulation to increase blood supply = systemic vasoconstriction = increased BP

Question 26

How does pre-eclampsia cause eclampsia?

Answer 26

Increased BP = cerebral oedema = cerebral dysfunction