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:
- renal involvement
- haematological involvment
- liver innvolvement
- neurological involvemnt
- pulmonary oedema
- FGR

Question 2

renal involvement in pre eclmapsia

Answer 2

significant proteinuria
serum or plasma creatinine >90
oliguria <80ml/4 hours

Question 3

haematological involvement in pre eclampsia

Answer 3

thrombocytopaenia
haemolysis pattern on blood film
DIC

Question 4

neurological involvement

Answer 4

convulsions
persistent visual disturbances
persistent new headache
stroke

Question 5

liver innvolvement in pre eclampsia

Answer 5

raised transmaminases
severe epigastric or right upper quadrant pain

Question 6

how common is pre-eclampsia

Answer 6

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

Question 7

aetiology of pre eclampsia

Answer 7

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

Question 8

is oedema a sign of pre eclampsia

Answer 8

no longer included in the definition because it occurs equally in women with and without pre eclampsia
rapid development of oedema should still alert the clinician to screen for pre eclampsia

Question 9

high risk factors for pre-eclampsia

Answer 9

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 10

moderate risk factors for pre-eclampsia

Answer 10

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

Question 11

symptoms of pre eclampsia may include

Answer 11

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 12

clinical signs of pre-eclampsia

Answer 12

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 13

ddx of pre eclampsia

Answer 13

chronic hypertension: occurs before 20 weeks gestations. or persists after 12 weeks post partum
gestational hypertension: occurs after 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 14

chronic hypertension is

Answer 14

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

Question 15

gestational hypertension is

Answer 15

hypertension occuring after 20 weeks gestation that develops without any complications
resolves within 3 months post partum

Question 16

how does antenatal screening detect pre-eclampsia

Answer 16

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

Question 17

lab investigations for pre-eclampsia

Answer 17

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 18

placental growth factor (PIGF)

Answer 18

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 19

diagnostic criteria for pre-eclampsia

Answer 19

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 20

monitoring of patient with pre eclampsia involves

Answer 20

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

Question 21

regular fetal monitoring for patient with pre eclampsia

Answer 21

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 22

medical management of pre-eclampsia

Answer 22

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 23

when to prescribe aspirin for pre-eclampsia

Answer 23

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

Question 24

which VTE prophylaxis should be used

Answer 24

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

Question 25

severe pre-eclampsia

Answer 25

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

Question 26

maternal complications of pre-eclampsia

Answer 26

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

Question 27

eclampsia

Answer 27

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 28

mortality of eclampsia

Answer 28

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

Question 29

treatment of eclampsia

Answer 29

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

Question 30

HELLP syndrome

Answer 30

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

Question 31

what does HELLP stand for

Answer 31

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 32

why does HELLP syndrome cause thrmbocytopaenia

Answer 32

due to platelet consumption during multiple thrombi formation

Question 33

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

Answer 33

it would contain schistocytes (fragmented red blood cells)

Question 34

what causes Haemolysis in HELLP syndrome

Answer 34

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

Question 35

management of HELLP

Answer 35

IV magnesium sulphate antihypertensives blood products timely delivery

Question 36

pre eclamptic angina

Answer 36

epigastric RUQ pain in a woman with pre-eclampsia often represents hepatic involvement

Question 37

which anticonvulsant medication to use

Answer 37

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

Question 38

corticosteroid therapy

Answer 38

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 39

post partum management of pre-eclampsia

Answer 39

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

Question 41

what is gestational hyprtension

Answer 41

new onset of hypertension arising after 20 weeks gestation no additional maternal or fetal features of preeclampsia resolves within 3 months post partum

Question 42

patients with pre-existing chronic hypertension

Answer 42

strong risk factor for the development of pre-eclampsia and requires close clinical surveillance

Question 43

essential hypertnsion

Answer 43

BP >140/90 preconception or developing prior to 20 weeks without an underlying cause or normal BP controlled with antihyprtnsives

Question 44

secondary hypertsion

Answer 44

hypertnsion due to - chronic kidney disease - renal artery stenosis - systemic disease with renal involvement eg. diabetes, SLE - endocrine disorders - coarctation of the aorta

Question 45

in acute severe pre-eclampsia, ddelivery must always be preceeded by

Answer 45

control of severe hypertension attention to fluid status correction of coagulopathy (usually thrombocytopaenia) control of eclampsia, or prophylaxis

Question 46

agent of choice for the acute treatment of acute severe hyprtension

Answer 46

oral nifedipine 10mg repeat dose after 30 minutes if there is inadequate response

Question 47

intravenous agent of choice for the acute treatment of acute severe hyprtension

Answer 47

IV labetolol 20-80mg bolus over 2 minutes repeat every ten minutes prn

Question 48

third line for severe acute hypertension

Answer 48

hydralazine 5-10mg first dose 5mg if fetal compromise IV or IM administration

Question 49

principles of management of eclampsia

Answer 49

1. resuscitation: IV access, oxygen by mask, MgSO4, midazolam may be given if the seizure is long 2. prevention of further seizures: continue MgSO4 3. control of hypertension 4. delivery: close fetal monitoring, arrange delivery, there is no role for continued pregnancy after eclampsia

Question 50

strategies to prevent pre eclampsia

Answer 50

cacium supplimentation low dose aspirin

Question 51

medication for high blood pressure during pregnancy

Answer 51

methydopa, labetolol, hydralazine, nifedipine

Question 52

HELLP syndrome

Answer 52

hemolysis, elevated liver enzymes and low platelet count maternal mortality is 1-2%

Question 53

presentation of HELLP syndrome

Answer 53

thrombocytopaecia (common) haemolysis (rare) elevated liver enzymes ALT, LDH epigastric or right upper quadrant pain (pre-eclamptic angina)

Question 54

management of HELLP syndrome

Answer 54

if the platelet count is sufficiently low to present. hazard for operative delivery, a platelet transfusion should be considered