Pre-eclampsia

Question 1

What is pre-eclampsia?

Answer 1

• refers to new high blood pressure (hypertension) in pregnancy with end-organ dysfunction, notably with proteinuria (protein in the urine)
• occurs after 20 weeks gestation, when the spiral arteries of the placenta form abnormally, leading to a high vascular resistance in these vessels

Question 2

What can pre-eclampsia lead to without treatment?

Answer 2

• maternal organ damage
• fetal growth restriction
• seizures
• early labour
• in a small proportion, death

Question 3

What are the triad of features in pre-eclampsia?

Answer 3

• Hypertension
• Proteinuria
• Oedema

Question 4

What is eclampsia?

Answer 4

-when seizures occur as a result of pre-eclampsia

Question 5

What is the difference between gestational hypertension and pre-eclampsia?

Answer 5

• Pregnancy-induced hypertension or gestational hypertension is hypertension occurring after 20 weeks gestation, without proteinuria.
• while Pre-eclampsia is pregnancy-induced hypertension associated with organ damage, notably proteinuria.

Question 6

What are high-risk factors of pre-eclampsia?

Answer 6

• Pre-existing hypertension
• Previous hypertension in pregnancy
• Existing autoimmune conditions (e.g. SLE)
• Diabetes
• Chronic kidney disease

Question 7

What are moderate-risk factors of pre-eclampsia?

Answer 7

• Older than 40
• BMI > 35
• More than 10 years since previous pregnancy
• Multiple pregnancy
• First pregnancy
• Family history of pre-eclampsia

Question 8

What do the presence of these risk factors determine?

Answer 8

• used to determine which women are offered aspirin as prophylaxis against pre-eclampsia
• women are offered aspirin from 12 weeks gestation until birth if they have one high-risk factor or more than one moderate-risk factors

Question 9

What are the symptoms of pre-eclampsia?

Answer 9

• Headache
• Visual disturbance or blurriness
• Nausea and vomiting
• Upper abdominal or epigastric pain (this is due to liver swelling)
• Oedema
• Reduced urine output
• Brisk reflexes

Question 10

What is needed for a diagnosis of pre-eclampsia to be made?

Answer 10

diagnosis can be made with a:

• Systolic blood pressure above 140 mmHg
• Diastolic blood pressure above 90 mmHg

PLUS any of:

• Proteinuria (1+ or more on urine dipstick)
• Organ dysfunction (e.g. raised creatinine, elevated liver enzymes, seizures, thrombocytopenia or haemolytic anaemia)
• Placental dysfunction (e.g. fetal growth restriction or abnormal Doppler studies)

Question 11

How can proteinuria be quantified?

Answer 11

• Urine protein:creatinine ratio (above 30mg/mmol is significant)
• Urine albumin:creatinine ratio (above 8mg/mmol is significant)

Question 12

What is the placental growth factor (PlGF)?

Answer 12

Placental growth factor is a protein released by the placenta that functions to stimulate the development of new blood vessels

Question 13

What are the levels of PlGF in pre-eclampsia?

Answer 13

• the levels of PlGF are low

- NICE recommends using PlGF between 20 and 35 weeks gestation to rule-out pre-eclampsia

Question 14

What is the initial management for pts at risk of preeclampsia?

Answer 14

-Aspirin is used for prophylaxis from 12 weeks gestation until birth to women with 1 high risk factor or more than 1 moderate risk factors

All pregnant women are routinely monitored at every antenatal appointment for evidence of pre-eclampsia, with:

• Blood pressure
• Symptoms
• Urine dipstick for proteinuria

Question 15

When gestational hypertension (without proteinuria) is identified, what is the general management?

Answer 15

• Treating to aim for a blood pressure below 135/85 mmHg
• Admission for women with a blood pressure above 160/110 mmHg
• Urine dipstick testing at least weekly
• Monitoring of blood tests weekly (full blood count, liver enzymes and renal profile)
• Monitoring fetal growth by serial growth scans
• PlGF testing on one occasion

Question 16

When pre-eclampsia is diagnosed, what is the general management?

Answer 16

similar to gestational hypertension, except:

• Scoring systems are used to determine whether to admit the woman (fullPIERS or PREP‑S)
• Blood pressure is monitored closely (at least every 48 hours)
• Urine dipstick testing is not routinely necessary (the diagnosis is already made)
• Ultrasound monitoring of the fetus, amniotic fluid and dopplers is performed two weekly

Question 17

What is the medical management for pre-eclampsia?

Answer 17

• Labetolol is first-line as an antihypertensive
• Nifedipine (modified-release) is commonly used second-line
• Methyldopa is used third-line (needs to be stopped within two days of birth)
• Intravenous hydralazine may be used as an antihypertensive in critical care in severe pre-eclampsia or eclampsia
• IV magnesium sulphate is given during labour and in the 24 hours afterwards to prevent seizures
• Fluid restriction is used during labour in severe pre-eclampsia or eclampsia, to avoid fluid overload

Question 18

If blood pressure cannot be controlled or complications occur what may be necessary in pre-eclampsia?

Answer 18

• planned early birth

- Corticosteroids should be given to women having a premature birth to help mature the fetal lungs

Question 19

What is the management after birth for pre-eclampsia?

Answer 19

• BP is monitored closely after delivery
• BP will return to normal over time once the placenta is removed

For medical treatment, one or combined of:

• Enalapril (first-line)
• Nifedipine or amlodipine (first-line in black African or Caribbean patients)
• Labetolol or atenolol (third-line)

Question 20

What is used to manage the seizures in eclampsia?

Answer 20

IV magnesium sulphate

Question 21

What is HELLP syndrome?

Answer 21

HELLP syndrome is a combination of features that occurs as a complication of pre-eclampsia and eclampsia. It is an acronym for the key characteristics:

• Haemolysis
• Elevated Liver enzymes
• Low Platelets