Pre-ecplamsia and Ecplamsia Flashcards
Define
Hypertension BP 140/90 to 159/109mmHg
Severe hypertension BP >160/110mmHg
Chronic hypertension: Hypertension present before 20 weeks (assumed to have been present before pregnancy)
Gestational hypertension: Hypertension (new) present after 20 weeks, without significant proteinuria
Pre-eclampsia
N.B. can be superimposed on one with chronic HTN after 20 weeks if S/S
N.B. you don’t have to have proteinuria
Hypertension (new) present after 20 weeks (BP >140/90mmHg) and ≥1 of:
- Proteinuria (>0.3g in 24 hours)
- AND/OR Any maternal organ dysfunction:
- Renal: Rising creatinine
- Liver: Rising AST/ALT ± epigastric/RUQ pain
- Neurological: Eclampsia, blind, stroke, clonus, severe headache, visual scotomata
- Haematological: Thrombocytopaenia, DIC, haemolysis
- Uteroplacental: IUGR, abnormal dopplers, stillbirth
HELLP syndrome “Haemolysis, Elevated Liver enzymes, and Low Platelets” [SEVERE FORM OF PRE-ECLAMPSIA]
Eclampsia ≥1 seizure in one with pre-eclampsia
Aetiology
Incr in progesterone –> vasodilation –> lower BP –> activates RAAS –> increase HR and incr Na and H2O retention –> Incr BP to maintain perfusion of placenta
In pre-eclampsia you are volume depleted –>
- vessels constrict to keep BP up
- Haemoconcentration –> poorly perfused placenta –> IUGR
- As harder to get glooopy blood through small arteries
Poorly perfused placenta causes endothelial damage to mom’s vessels:
1) Vasocontriction
- Kidneys: proteinuria
- Eye: scotoma, vision flashes
- Liver: RUQ, decreased clotting factors, DIC
2) Thrombus formation
- Haemolysis
- Stroke, VTE risk
3) Increased permeability
- Leaky vessels –> oedema and thrombocytopenia (as plts try to plug)
- Protein leaking out of kidneys –> proteinuria + less albumin and creatinine
- Lung inflam –> PO
- Liver inflam –> incr in ALT + epigastric pain + decr in clotting factors (so risk of DIC)
- Procoag state –> VTE risk and HELLP syndrome
Risk factors
Risk factors – used to stratify management -> “high-risk” treat with aspirin:
High-Risk Factors
- ≥1 = Aspirin
- Pre-eclampsia in previous pregnancy
- Chronic kidney disease
- Autoimmune disease (SLE, antiphospholipid syndrome)
- T1DM, T2DM
- Chronic hypertension
Moderate Risk Factors
≥2 = Aspirin
- Primigravid
- Age ≥40 years
- Pregnancy interval of >10 years
- BMI ≥35
- FHx of pre-eclampsia
- Multiple pregnancy
Symptoms and Signs
- Frontal headache
- Visual disturbance (blurred vision)
- Epigastric pain/ tenderness- suggests liver involvement
- Ask specifically if they have noticed swelling in hands, feet and face
- Rapidly progressing oedema of the face and hands (as well as feet)
Patients may also be ASYMPTOMATIC or complain of ‘FLU-LIKE’ symptoms
- INC RISK OF STROKE
- Check if they have had a seizure at home (e.g., LOC or fitting)
Signs O/E
- RUQ pain
- Reduced foetal movements
- Foetal growth restriction
- Hyperreflexia
- Check for stiffness in hands and feet
- Clonus
- Always do a neuro scan
DDx
- Gestational HTN
- Eclampsia
- HELLP
Investigations
- Preg abdo, cardio, peripheral and neuro exam
- Continuous BP monitioring
HTN- ≥ 140/90mmHg + previously normotensive
3. Urine dipstick- testing for PROTEINURIA
* Trace- insignificant
* 1+ - Possible significant proteinuria, warrants quantifying
* ≥2+ - Probable significant proteinuria, warrants quantifying
* PCR is needed to quantify amount of protein
4. FBC- want to know platelets and Hct
* Low plt you are worried about HELLP
5. Serum renal profile (including serum uric acid)
6. Dehydration, electrolyte imbalance
7. Serum liver profile
8. Coag screen
* As pt is at higher risk of DIC
9. Placental Growth Factor (PlGF) - test on one occasion between 20-35wks GA if pre-eclampsia suspected
* Levels would be low in pre-eclampsia
10. Check foetal size
11. Amniotic fluid volume
12. Maternal and foetal USS (transabdo) + Dopplers
13. Foetal auscultation, cardiotocography (CTG)
14. Umbilical artery Doppler velocimetry
If a women is < 40 and has chronic hypertension, need investigations for secondary causes:
- Renal USS
- Echo
- ECG
Management
Management (always: give healthy lifestyle advice; dip urine at every appointment):
High risk pre-eclampsia, Chronic Hypertension:
- Aspirin (75mg OD, from 12w until birth) N.B. no ACEi or ARB (teratogenic)
Pre-eclampsia pharmacological therapy:
- 1st line: Labetalol (100mg, BD) Contraindicated in asthma
- 2nd line: Nifedipine Causes tocolysis (use methyldopa at term)
- 3rd line: Methyldopa (250mg, BD or TDS)
Eclampsia -> IV magnesium sulphate (potent cerebral vasodilator)
PACES
ASK If THEY ARE asthmatic (BETA blockers)
risk factors has to be on aspirin
symptoms:
scotoma, headache, flu-like, RUQ pain
