pre-eclampsia and eclampsia - GM

Question 1

define pre-eclampsia

Answer 1

multisystem syndrome developing after 20 weeks
de novo hypertension which co-exsits with one or more of the following:
- proteinuria
- maternal dysfunction
- uteroplacental dysfunction

Question 2

how common is pre-eclampsia

Answer 2

2-8% pregnancies
0.5% develop severe life threatening pre eclampsia
1 in 4000 pregnancies develop to eclampsia (maternal seizures)

Question 3

aetiology of pre eclampsia

Answer 3

poorly understood
thought to be due to poor perfusion of the placenta resulting in release of pro inflammatory cytokines, causing peripheral endothelial dysfunction

Question 4

typical features of pre-eclampsia

Answer 4

oedema and proteinuria: due to increased capillary permeability and movement of fluid into interstitial spaces
hypertension and end organ damage (eg. kidneys, liver): systemic vasoconstriction occurs secondary to the release of vasoconstrictive factors

Question 5

high risk factors for pre-eclampsia

Answer 5

chronic hypertension
hypertensive disease in a previous pregnancy
type 1 or type 2 diabetes mellitus
chronic kidney disease
autoimmune disease
- anti-phospholipid syndrome
- systemic lupus erythematosus

Question 6

moderate risk factors for pre-eclampsia

Answer 6

aged 40 and over
first pregnancy
pregnancy interval >10 years
multiple pregnancy
pre-pregnancy obesity (BMI >35kg/m2)
family history of pre eclampsia

Question 7

symptoms of pre eclampsia may include

Answer 7

pateints often have no symtpoms
- headache
- visual disturbance such as blurring or flashing lights
- swelling or arms, legs and face
- nausea and vomiting
- abdominal pain
- reduced urine output

Question 8

clinical signs of pre-eclampsia

Answer 8

hypertension
oedema: typically in the peripheries and face
epigastric/right upper quadrant tenderness
hyper reflexia and clonus (indicates an increased risk of eclamptic seizure)
papilloedema

Question 9

ddx of pre eclampsia

Answer 9

chronic hypertension: occurs before 20 weeks gestations. or persists after 12 weeks post partum
gestational hypertension: occurs before 20 weeks gestation that develops without any co-existing complications
pre-eclampsia superimposed on chronic hypertension: hypertension that already exists but worsens after 20 weeks gestation alongside the development of coexisting complications

Question 10

chronic hypertension is

Answer 10

hypertension occuring before 20 weeks and persisting after 12 weeks post partum

Question 11

gestational hypertension is

Answer 11

hypertension occuring before 20 weeks gestation that develops without any complications

Question 12

how does antenatal screening detect pre-eclampsia

Answer 12

antenatal appointments include assessment of blood pressure, a urine dipstick test to identify proteinuria and fetal heart ausultation

Question 13

lab investigations for pre-eclampsia

Answer 13

FBCs: low platelet count may suggest HELLP syndrome
U&Es: raised urea, raised creatinine and low eGFR indicate renal impairment
LFTs: raised ALT or AST indicate liver dysfunction
clotting profile: clotting may be deranged in the context of disseminated intravascular coagulation (DIC)

Question 14

placental growth factor (PIGF)

Answer 14

supports trophoblastic growth and placental angiogenesis
a blood test measuring PIGF levels can be used to aid diagnosis in pre-eclampsia
elevated levels of PIGF indictae that pre-eclampsia is unlikely

Question 15

diagnostic criteria for pre-eclampsia

Answer 15

hypertension > 140mmHg systolic or >90 mmHg diastolic
proteinuria >300mg protein in a 24 hour urine collection
maternal organ dysfunction: liver involvement, renal insufficiency, haematological complications and neurological involvement eg. visual disturbance
uteroplacental dysfunction: IUGR/stillbirth

Question 16

monitoring of patient with pre eclampsia involves

Answer 16

regular blood pressure assessment
regular screening for proteinuria
regular blood tests including FBC, U&Es and LFTs

Question 17

regular fetal monitoring for patient with pre eclampsia

Answer 17

CTG: assessment of fetal heart beat
US: assessment of fetal growth and amniotic fluids
umbilical artery doppler velocimetry: assessment of placental and fetaal circulation

Question 18

medical management of pre-eclampsia

Answer 18

aspirin
antihypertensives: PO nifedipine is first line, IV labetolol is second line and methyldopa is first line
venous thromboembolism prophylaxis: due to increased VTE risk

Question 19

when to prescribe aspirin for pre-eclampsia

Answer 19

should be prescribed from 12 weeks gestation until delivery for patients with one high risk factor or two moderate risk factors

Question 20

which VTE prophylaxis should be used

Answer 20

low molecular weight heparin
physical measures eg. anti-embolism stockings

Question 21

severe pre-eclampsia

Answer 21

BP > 160mmHg systolic or >110mmHg diastolic
requires hospital admission

Question 22

maternal complications of pre-eclampsia

Answer 22

multi-organ dysfunction: with progressive worsening to multi-organ failure
cardiovascular complications: MI or stroke
placental abruption
eclampsia
HELLP syndrome

Question 23

eclampsia

Answer 23

seizures occuring in pregnancy or within 10 days of delivery as well as two of the following within 24 hours of the seizure
- hypertension
- proteinuria
- thrombocytopaenia
- raised AST

Question 24

mortality of eclampsia

Answer 24

high mortality rate: 1 in 50 women, 1 in 14 unborn babies

Question 25

treatment of eclampsia

Answer 25

obstetric emergency requiring hospital admission
IV magnesium sulphate and early delivery
corticosteroids to accelerate fetal lung maturation if less than 34 weeks

Question 26

HELLP syndrome

Answer 26

endothelial damage and consequent thumb formation associated with pre-eclampsia
develops in 10-20% of women with pre-eclampsia

Question 27

what does HELLP stand for

Answer 27

Haemolysis: red blood cells become damaged by the abnormal endothelium, resulting in. microangiopathic. haemolytic anaemia
Elevated Liver enzymes: raised ALT and/or AST can occur due to hepatic sinusoid obstruction by fibrin
Low Platelets: platelet levels drop below 150 x 10^9 due to platelet consumption as a result of thrombi formation

Question 28

why does HELLP syndrome cause thrmbocytopaenia

Answer 28

due to platelet consumption during multiple thrombi formation

Question 29

what might a blood film from a patient with HELLP syndrome look like

Answer 29

it would contain schistocytes (fragmented red blood cells)

Question 30

what causes Haemolysis in HELLP syndrome

Answer 30

red blood cells become damaged by the abnormal endothelium, resulting in microangiopathic haemolytic anaemia

Question 31

management of HELLP

Answer 31

IV magnesium sulphate
antihypertensives
blood products
timely delivery

Question 32

which anticonvulsant medication to use

Answer 32

MgSO4 - indictaed for women with severe pre-eclampsia to prevent seizures and reduce maternal mortallity

Question 33

corticosteroid therapy

Answer 33

corticcoteroids are indicated for women with severe pre-eclapmsia to enhance foetal lung maturity and reduce neomatal RDS
benefit does not last beyond 7 days

Question 34

post partum management of pre-eclampsia

Answer 34

clinical annd lab derangements recover within several days
HTN can persist for up to 3 months
monitor patient
continue MgO4 until BP stabilisation and adequate diuresis achieved
acute hypertensive therapy should be commenced if BP > 150/110 in the first 4 days post partum
advise follow up with GP
consider secondary causes of hypertension in pregnaancy