Eclampsia

Question 1

Name 2 main causes death in gestational hypertension

Answer 1

• Cerebral haemorrhage: control dangerous ht
• pulmonary edema:fluid overload

Question 2

Name 7 risk factors gestational hypertension

Answer 2

History
- Prior pre-eclampsia

Comorbidities
- chronic ht
- pre-gestational diabetes
- maternal BMI > 35
- anti-phospholipid syndrome /sle

Current Pregnancy
- multiple gestation
- assisted reproduction

Question 3

Treatment gestational hypertension (2)

Answer 3

• Calcium supplement 500g
• start aspirin at 12-14 weeks (up to 20/52)

Alpha methyldopa 500mg oral 8 hourly

Question 4

Define and manage gestational pre-ht

Answer 4

Bp 130 - 139 / 85 - 89

• repeat after 30 min - 2 hours
• if persistent review after 3-7 days
• if normal follow up as low risk

Question 5

Define hypertension in pregnancy

Answer 5

Systolic 140 or more
Or diastolic 90 or more
On >2 occasions at least 2 hours apart

Severe > 160 /110

Before 20 weeks

Question 6

Define gestational hypertension

Answer 6

Systolic 140 - 160
Or diastolic 90 - 110
Without proteinuria
On >2 occasions at least 2 hours apart

After 20 weeks

Question 7

Define pre-eclampsia (7)

Answer 7

Ht after 20 weeks with 1 or more:

• proteinuria!
• renal impair: creatinine > 100; doubling creatinine
• liver impair: transaminases x2 normal
• haematological impair: platelets <100
• neurological impair: cerebral /visual symptoms
• growth restriction
• Pulmonary oedema

Question 8

Management hypertension in pregnancy?

Answer 8

• Alpha methyldopa 500 mg TDS (aldomet)
• refer to District Hospital within 3 days to check bp, urine

Or nifedipine, labetolol, prazocin (third line)

Question 9

Management pre-eclampsia (9)

Answer 9

1. Stabilise mom then deliver fetus if needed; terminate pre-viable, call a CAB
   - cab, position, iv, big 5 forgotten 4 core 1
   - when stable, monitor fetus with 6 hourly ctg
2. treat and prevent fits (mgso4)
3. treat dangerously raised bp. Repeat in 20 min
4. attention to fluid balance
   - loading dose 200 ml NaCl
   - maintain ringers ml /h
   - if output <30 / h give 200 ml ringers bolus
   - still < 30 - continue iv at 80 ml /h without further boluses otherwise will cause cerebral + pulmonary oedema. No diuretics! (Capillary leak)
5. prevent complications; assess foetus. If prem, steroids. Admit to high care

Question 10

Define severe pre-eclampsia (5)

Answer 10

• Bp 160/110 or more, or
• proteinuria 3+ or
• symptomatic pre-eclampsia / imminent eclampsia (headache, visual disturbances, nausea vomiting, epigastric pain,jittery)
• HELLP syndrome
• AKI
• pulmonary oedema
• CNS dysfunction: cerebral/visual disturbance, severe headache, altered mental status

Question 11

Dose mgso4? (4)

Answer 11

Loading dose 14g
- 4g in 200 ml ns iv over 20 minutes
- 5g with 1 ml 2% lignocaine IM in each buttock

Maintenance
- 5g with 1 ml 2% lignocaine IM every 4 hours until 24 hours after birth or 24 hours after last convulsion

Recurrence
- additional 2g iv over 10-15 minutes

Question 12

When should maintenance dose of mgso4 not be given and what is given instead

Answer 12

• first sign toxicity: Absent knee jerk
• urine output < 25 ml /h or <100 ml in last 4 h
• Rr <16

If rr < 16, stop mg. Give calcium gluconate 10% 1g iv over 10 minutes

Question 13

Name 4 indications mgso4

Answer 13

• Severe pre-eclampsia
• imminent eclampsia
• Eclampsia
• concern when transferring

Question 14

How manage severe ht > 160/110 in pregnancy ( at risk cva) (2)

Answer 14

Oral nifedipine 10 mg po (ccb)
- repeat every 30 min
- max 4 doses or until bp < 160/110

And/or

Parental labetalol 20,40, 80, 80 and 80 mg (max 300 mg )
- bolus every 10 minutes until bp < 160/110

Question 15

Name 3 contraindications nifedipine

Answer 15

• Pulse > 120
• cardiac lesion
• unable to swallow (oral med)

Question 16

Name 2 contraindications labetolol

Answer 16

• Asthma
• IHD

Question 17

How do organ system evaluation when resuscitating? (10)

Answer 17

Big 5
- CNS: avpu
- CVS
- resp
- liver, git
- Renal

Forgotten 4
- haematological: hb, plt
- immunological: HIV, temp
- endocrine: glucose
- musculoskeletal: DvT

Core 1
- abdo

Core 2
- vaginal

Question 18

Name 5 indications to deliver in pre-eclampsia

Answer 18

Only once mom stable

• Imminent/ eclampsia after MgS04,
• can’t control bp,
• deteriorating organ function
• fetal compromise,
• known foetal maturity

Question 19

Define HELLP syndrome

Answer 19

• Haemolysis (ldh 600 or more, or bili 0,2 or more
• elevated liver enzymes (ast/alt 70 or more)
• low platelet count 100 or less

Treatment is always delivery

Question 20

Maternal biochemical testing in pre-eclampsia? (6)

Answer 20

• Urinalysis: protein to creatinine ratio
• Pulse oximetry
• hb, platelet count
• urea and creatinine
• AST or alt
• LDH (elevated = severe prognostic marker. Signal cellular death /haemolysis. )

Question 21

Foetal testing in pre-eclampsia? (3)

Answer 21

• Ctg if viable every 6 hours
• ultrasound for foetal growth
• Doppler of umbilical cord , middle cerebral arteries, ductus venosus

Question 22

Name complications pre-eclampsia/eclampsia during pregnancy (9)

Answer 22

• End organ damage
• abruptio placenta
• preterm labour
• still birth
• cerebro vascular accident
• convulsions
• HELLp syndrome
• occipital lobe blindness
• DVT

Question 23

Name complications pre-eclampsia/eclampsia after pregnancy (5)

Answer 23

• pph
• ht later in life
• ischaemic heart disease later in life
• DvT
• stroke

Question 24

Initial management eclampsia (6)

Answer 24

• Call for help
• call a cab
• position left lateral
• iv access
• mgso4
• big 5, forgotten 4, core 1