8.15 Pre-eclampsia

Question 1

What features form the triad of pre-eclampsia?

Answer 1

• HTN (>140/>90)
• proteinuria (ie end organ dysfunction)
• oedema

Question 2

What can untreated pre-eclampsia lead to?

Answer 2

Maternal organ damage
FGR
Seizures (eclampsia)
Early labour
and rarely death

Question 3

At what gestation does pre-eclampsia occur?

Answer 3

after 20 weeks (when lacunae are formed)

Question 4

What part of the blastocyst form chorionic vili? (finger like projections into the endometrium)

Answer 4

the syncytiotrophoblast

Question 5

What does the invading syncytiotrophoblast cause in the endometrium?

Answer 5

Signals to the spiral arteries to decrease resistance and become for fragile
–> spiral arteries break down and form lacunae

Question 6

What pathophysiological happens if the spiral arteries don’t form lacunae properly?

Answer 6

This can lead to pre-eclampsia:
–> high vacular resistance in the spiral arteries and poor perfusion of the placenta
–> causes oxidative stress in the placenta and release of inflammatory chemicals
–> leads to systemic inflammation and impaired endothelial function

Question 7

What are some high-risk factors for pre-eclampsia?

Answer 7

• pre-existing HTN
• previous HTN in pregnancy
• autoimmune conditions eg SLE
• diabetes
• CKD

Question 8

What are some moderate-risk factors for pre-eclampsia?

Answer 8

• older than 40
• BMI >35
• more than 10 years since previous pregnancy
• multiple pregnancy
• first pregnancy
• FHx pre-eclampsia

Question 9

What can be given as pre-eclampsia prophylaxis?

Answer 9

aspirin

Question 10

Based on risk factors when is a woman offered aspirin prophylaxis for pre-eclampsia?

Answer 10

• one high-risk factor
• more than one moderate-risk factor
• start at 12 weeks

Question 11

What are the symptoms of pre-eclampsia?

Answer 11

• headache
• visual disturbance or bluriness
• nausea and vomiting
• upper abdo or epigastric pain (liver swelling)
• oedema
• reduced urine
• brisk reflexes

Question 12

What can be tested in a normal pregnancy to check there isn’t pre-eclampsia?

Answer 12

NICE 2019 say test PIGF between 20-30 weeks

PIGF = Placental Growth Factor

Question 13

What are the NICE diagnostic criteria for pre-eclampsia?

Answer 13

1. BP >140 or >90
2. PLUS any one of:
   - proteinuria (urine dipstick +)
   - organ dysfunction
   - placental dysfunction (FGR or doppler)

Question 14

What signs of organ dysfunction can there be in pre-eclampsia?

Answer 14

• raised creatinine
• elevated liver enzymes
• seizures
• thrombocytopenia
• haemolytic anaemia

Question 15

How can you quantify the proteinuria in pre-eclampsia?

Answer 15

• urine albumin:creatinine ratio above 30mg/mmol

- urine protein:creatinine ratio above 8mg/mmol

Question 16

Pre-eclampsia is pregnancy-induced HTN with organ dysfunction, what is gestational hypertension?

Answer 16

pregnancy-induced HTN occurring after 20 weeks gestation without proteinuria

Question 17

What is chronic HTN in pregnancy?

Answer 17

HTN occurring before 20 weeks (this is not caused bu placenta in anyway)

Question 18

What is eclampsia?

Answer 18

When seizures occur due to pre-eclampsia

Question 19

What is the management of gestational HTN?

Answer 19

• treat to aim BP below 135/85
• admit if BP 160/110
• minimum weekly urine dipstick
• weekly bloods (FBC, liver, renal)
• monitor fetal growth with serial scans
• PIGF testing once

Question 20

What is 1st line drug for pre-eclampsia?

Answer 20

labetalol (beta blocker antihypertensive)

Question 21

What is 2nd line drug for pre-eclampsia?

Answer 21

nifedipine (CCB modified release)

Question 22

What is 3rd line drug for pre-eclampsia?

Answer 22

methyldopa is 3rd line (stop within 2 days of birth)

Question 23

What 3 things can be used in severe pre-eclampsia?

Answer 23

• hydralazine IV, antihypertensive in critical care in severe pre-eclampsia or eclampsia
• magnesium sulphate IV during labour and 24 hrs after to prevent seizures
• fluid restrict during labour in severe pre-eclampsia or eclampsia, to avoid fluid overload

Question 24

Medical treatment choices of pre-eclampsia after delivery?

Answer 24

BP will return to normal over time. Meanwhile:

1. enalapril (1st)
2. nifedipine or amlodipine (1st in black)
3. labetalol or atenolol (3rd line)

Question 25

What drug is used to manage seizure in eclampsia?

Answer 25

magnesium sulphate IV (stabilises the CNS)

Question 26

What syndrome can occur as a complication of pre-eclampsia or eclampsia?

Answer 26

HELLP syndrome

Question 27

What is HELLP syndrome?

Answer 27

Haemolysis Elevated Liver enzymes Low Platelets (complication of pre-eclampsia or eclampsia)

Question 28

What complication can result from using magnesium sulphate to control pre eclampsia seizures? How do you manage the complication?

Answer 28

Respiratory depression Calcium gluconate can be used to manage magnesium sulphate induced resp depression