Pre-eclampsia

Question 1

What is the definition of pre-eclampsia?

Answer 1

• new hypertension in pregnancy with end-organ dysfunction
• it most notably presents with proteinuria

Question 2

When does pre-eclampsia typically present?

Answer 2

after 20 weeks gestation

Question 3

Why is it important to recognise and treat pre-eclampsia?

Answer 3

without treatment it can result in:

• seizures
• early labour
• intrauterine growth restriction
• maternal organ damage
• death

Question 3

Why is it important to recognise and treat pre-eclampsia?

Answer 3

without treatment it can result in:

• seizures
• early labour
• intrauterine growth restriction
• maternal organ damage
• death

Question 4

What is the classic triad of pre-eclampsia?

Answer 4

1. hypertension
2. proteinuria
3. oedema

(oedema is no longer used in diagnosis as this is a normal feature of pregnancy)

Question 5

What is the difference between pre-eclampsia and pregnancy-induced hypertension?

Answer 5

pregnancy-induced HTN:

• HTN occurring after 20 weeks gestation
• WITHOUT proteinuria

pre-eclampsia:

• HTN occurring after 20 weeks gestation
• this is associated with organ damage - most notably proteinuria

Question 6

What is the underlying cause of pre-eclampsia?

Answer 6

• there is high vascular resistance in the spiral arteries

AND

• there is poor perfusion of the placenta
• oxidative stress in the placenta releases inflammatory chemicals
• there is systemic inflammation + impaired endothelial function in blood vessels

Question 7

What are the high risk factors for pre-eclampsia?

Answer 7

• previous HTN in pregnancy
• pre-existing HTN
• diabetes
• chronic kidney disease
• existing autoimmune conditions (e.g. SLE)

Question 8

What are the moderate risk factors for pre-eclampsia?

Answer 8

• age > 40
• BMI > 35
• more than 10 years since last pregnancy
• multiple pregnancy
• first pregnancy
• FHx of pre-eclampsia

Question 9

Why is it important to identify the RFs for pre-eclampsia?

Answer 9

• they are used to determine who is offered prophylaxis with aspirin 150mg
• women are offered aspirin from 12 weeks gestation if they have 1 high RF or 2+ moderate RFs

it is better to take aspirin at night

Question 10

What are the symptoms of pre-eclampsia?

Answer 10

• visual disturbances / blurriness
• headache
• facial oedema
• reduced urine output
• brisk reflexes / clonus
• N&V
• upper abdominal / epigastric pain

pain is due to swelling of the liver

Question 11

How is pre-eclampsia diagnosed?

Answer 11

• systolic BP > 140 mmHg

AND

• diastolic BP > 90 mmHg

PLUS ANY OF:

1. proteinuria
2. organ dysfunction
3. placental dysfunction

Question 12

How can placental dysfunction be identified?

Answer 12

• foetal growth restriction
• abnormal Doppler studies

Question 13

How can organ dysfunction be identified?

Answer 13

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

Question 14

What test should be used on ONE occassion during pregnancy in suspected pre-eclampsia?

Answer 14

placental growth factor (PlGF)

• this is released by the placenta to stimulate development of new blood vessels
• levels will be LOW in pre-eclampsia

Question 15

When should PlGF testing be performed?

Answer 15

• it should be performed on one occasion
• between 20 and 35 weeks gestation
• to RULE OUT pre-eclampsia

Question 16

How can proteinuria be quantified?

Answer 16

urine protein:creatinine ratio:

• above 30mg/mmol is significant

urine albumin:creatinine ratio:

• above 8mg/mmol is significant

Question 17

How are women monitored for pre-eclampsia?

Answer 17

at every antenatal appointment, the following are performed:

• blood pressure
• assessment of symptoms
• urine dipstick for proteinuria

Question 18

What is the management for gestational HTN (without proteinuria)?

Answer 18

• urine dipstick at least weekly
• blood tests weekly (FBC, U&Es, LFTs)
• monitoring foetal growth with serial growth scans
• PlGF testing on one occasion

• the aim is for BP < 135/85 mmHg
• admission is needed when BP > 160/110 mmHg

Question 19

What is the difference in management when pre-eclampsia is diagnosed?

Answer 19

• BP monitored at least every 48 hours
• urine dipstick NOT required as diagnosis is made
• US of fetus, amniotic fluid & dopplers every 2 weeks

Question 20

What is used to help determine whether to admit someone with pre-eclampsia?

Answer 20

scoring systems - fullPIERS or PREP-S

Question 21

What are the 1st, 2nd and 3rd line treatments for pre-eclampsia?

Answer 21

• labetalol is first line
• nifedipine (MR) is second-line
• methyldopa is third-line

!! beta blockers are contraindicated in asthma !!

methyldopa MUST be stopped within 2 days of birth

Question 22

What may be used in severe pre-eclampsia?

Answer 22

IV hydralazine

• used in critical care in severe pre-eclampsia or eclampsia

Question 23

What is the additional management for pre-eclampsia during labour?

Answer 23

IV magnesium sulphate:

• given during labour and for 24 hours afterwards
• used to prevent seizures

fluid restriction:

• used in severe pre-eclampsia / eclampsia to avoid fluid overload

Question 24

If the blood pressure cannot be controlled with pre-eclampsia, what may be done?

Answer 24

* **planned early birth** may be necessary * **corticosteroids** should be given to help **mature the fetal lungs**

Question 25

Following delivery, how should pre-eclampsia be managed?

Answer 25

* **enalapril** is first line * **nifedipine / amlodipine** are first line in ***black African*** or ***Caribbean*** patients * **labetalol / atenolol** are third line ## Footnote the BP will return to normal over time once the placenta is removed

Question 26

What is eclampsia? | How is it treated?

Answer 26

* this refers to **seizures** associated with pre-eclampsia * **IV magnesium sulphate** is used to manage the seizures

Question 27

What syndrome can occur as a result of pre-eclampsia / eclampsia?

Answer 27

**HELLP syndrome:** * **H**aemolysis * **E**levated **L**iver enzymes * **L**ow **P**latelets ## Footnote monitored through regular blood tests - FBC, LFTs, coagulation

Question 28

When should labour be induced where there is HTN in pregnancy?

Answer 28

* induce labour at ***37 weeks*** in **pre-eclampsia** * induce labour at ***40 weeks*** in pregnancy-induced HTN (without proteinuria)