Pre-Eclampsia

Question 1

Define pre-eclampsia

Answer 1

Multisystem disorder unique to human pregnancy characterised by hypertension and involvement of one or more other organ systems and/or the fetus.

It is placental in origin and is cured only by delivery.

Question 2

What are the clinical parameters needed to diagnose pre-eclampsia?

Answer 2

HTN - BP >140/90 >20wks PLUS >/=1 of:

1. Proteinuria - PCR > 30mg/mmol (0.3mg/m) or >300mg/day
   OR in the absence of proteinuria
2. Other maternal organ dysfunction:
   - Renal insufficiency
   - Haematological involvement
   - Liver involvement
   - Neurological involvement
   - Pulmonary oedema
3. Uteroplacental dysfunction (IUGR)

Question 3

What is the guideline used in the management of pre-eclampsia?

Answer 3

HSE CPG 2011 - The Diagnosis and Management of Pre-Eclampsia and Eclampsia (revised 2016)

Question 4

List the risk factors for pre-eclampsia

Answer 4

1. Primigravada
2. Previous hx PET
3. Pre-existing essential HTN
4. Family hx PET (mother/sister)
5. Diabetes
6. Autoimmune disease
7. Renal disease
8. Extremes of reproductive age
9. Multiple pregnancy
10. Molar pregnancy

Question 5

What is the incidence of pre-eclampsia?

Answer 5

2-3% of all pregnancies (5-7% of nulliparous women)

Question 6

What features are present in the history of a woman with pre-eclampsia?

Answer 6

Often asymptomatic
HTN detected at routine ANC
Later symptoms:
1. Frontal headache
2. Drowsiness
3. Nausea and vomiting 
4. Reduced fetal movements 
5. Visual symptoms (raised ICP)
6. Oliguria (renal failure)
7. Abdominal pain (distension of hepatic capsule)
8. Seizures (eclampsia)

Question 7

What signs are present on examination of a woman with pre-eclampsia?

Answer 7

General:

1. HTN
2. Oedema (esp facial and fingers)

Neurological:

1. Papilloedema
2. Hyper-reflexia clonus (cerebral oedema)
3. Fundoscopy - papilloedema

Resp:
1. Pulmonary oedema

Abdominal:

1. Small fundus (IUGR/oligohydramnios)
2. RUQ tenderness

Question 8

List the investigations done in suspected pre-eclampsia

Answer 8

Maternal:

• Bloods:
  
  1. FBC - reduced platelets
  2. Coag
  3. Uric acid
  4. U&E - abnormal renal function
  5. LFTs - abnormal LFTs
• Urine:
  
  1. Urinalysis/MSU - exclude UTI
  2. 24hr urine for proteinuria - >0.3g/34hr

Fetal:

1. US - fetal weight & growth, AFI, umbilical artery Doppler
2. CTG

Question 9

How do we cure pre-eclampsia?

Answer 9

Cured only by delivery of the fetus

Question 10

How can we manage pre-eclampsia?

Answer 10

• > 37wks = delivery by IOL
• Severe PET = delivery by LSCS
• <37wks = conservative treatment to prolong pregnancy subject to continuous fetal and maternal monitoring

Question 11

What conservative treatment measures can be used in pre-eclampsia?

Answer 11

1. Anti-hypertensives
2. Seizure prophylaxis
3. Corticosteroids

Question 12

What are the anti-hypertensive agents used in pregnancy?

Answer 12

1. Labetalol - mixed alpha and beta adrenergic antagonist that produces a significant reduction in maternal blood pressure without any pronounced fetla effects)
   * Aim to keep SP <130-155 and DP <80-100
2. Methyldopa - centrally acting antihypertensive which does not appear to have any adverse effect on the uteroplacental circulation
3. Nifedipine - calcium channel blocker
4. Hydralazine - IV

Question 13

What is used for seizure prophylaxis?

Answer 13

Magnesium sulphate - until 48hrs post partum

Question 14

Why and when are corticosteroids used?

Answer 14

Used for fetal lung maturation

Up to 36+6wks - betamethasone - 2 doses 24hrs apart

Question 15

List the complications of pre-eclampsia

Answer 15

Fetal:

1. IUGR
2. Oligohydramnios
3. Placental abruption
4. Death
5. Sequelae of prematurity

Maternal:

1. Eclampsia
2. Cerebrovascular accident
3. HEELP syndrome
4. DIC
5. Pulmonary oedema
6. ARDS
7. Liver failure
8. Renal failure
9. Death

Question 16

What is HELLP syndrome?

Answer 16

H = haemolysis
EL = elevated liver enzymes 
LP = low platelets

Question 17

What features would be present on history of HELLP syndrome?

Answer 17

1. Nausea and vomiting
2. Abdo pain
3. Headache
4. Visual disturbances

Question 18

What would you expect to find on examination of a patient with HELLP syndrome?

Answer 18

1. Jaundice
2. RUQ tenderness
3. Hepatomegaly
4. Easy bruising/purpura

Question 19

What investigations should be performed if HELLP syndrome is suspected?

Answer 19

1. LFTs - elevated AST, ALT, LDH

2. FBC - reduced platelets

Question 20

How is HELLP syndrome managed?

Answer 20

Delivery of the baby

Question 21

How can pre-eclampsia be prevented?

Answer 21

Aspirin in future pregnancy - from 12wks until birth

RISK IN FUTURE PREGNANCY = 1 in 6 (16%)