Pre(eclampsia)

Question 1

What are the types of hypertensive pregnancy disorders

Answer 1

Gestational hypertension: pregnancy-induced hypertension with onset after 20 weeks gestation Defined as a systolic blood pressure ≥ 140 mmHg or diastolic blood pressure ≥ 90 mmHg on 2 separate measurements at least 4 hours apart

Chronic hypertension: hypertension diagnosed < 20 weeks gestation or before pregnancy

Preeclampsia: gestational hypertension with proteinuria, renal insufficiency, thrombocytopenia, evidence of liver damage (e.g., elevated liver enzymes, epigastric pain), pulmonary edema, and/or cerebral edema (headache, visual blurring, vomiting, an altered mental status)

Superimposed preeclampsia: preeclampsia that occurs in a patient with chronic hypertension

HELLP syndrome: a life-threatening form of preeclampsia (HELLP is an acronym: H = hemolysis; EL = elevated liver enzymes; LP = low platelets) Eclampsia: severe form of preeclampsia with convulsive seizures and/or coma

Question 2

Risk factors for gestational hypertension and pre(eclampsia)

Answer 2

General risk factors -Thrombophilia (e.g., antiphospholipid syndrome) -Obesity (BMI ≥ 30) -Age < 20 or > 40 years -African-American race ( neeergers) -Diabetes mellitus or gestational diabetes -Chronic hypertension ( before 20 was gestation or before pregnancy) -Chronic renal disease (e.g., SLE) Pregnancy-related risk factors -Nulliparity -Previous gestational hypertensive disorders -Family history of preeclampsia -Multiple gestation (twins) -Chromosomal anomalies or congenital structural anomalies Hydatidiform moles/molar pregnancy (

Question 3

Pathophys of gestational hypertensive disorders

Answer 3

Placental hypoperfusion(fibrosed spiral arteries/ abnorm implantation) causes maternal hypertension by releasing infalmm vasoactive subs.

vasoactive subs cause vascular inflammation vasoconstriction and microthrombi formation.

vasoconstriction of kidney vessels→ RAAS→salt ant h20 retention→HTN & water retention

renal glom inflam→leaky→proteinuria

other sx are caused by systemic microthombi, vcons, and water retention

Question 4

causes of gestational hypertensive diseases

Fetal or placental

Answer 4

Fetal

• Abnormal placental (or trophoblast) implantation or development in the uterus → hypoperfusion of placenta and fetus d/2 defective development of uterine spiral arteries

Maternal

• -Arterial hypertension with systemic vasoconstriction causes placental hypoperfusion → release of vasoactive substances by placenta → ↑ maternal blood pressure to ensure sufficient blood supply of the fetus and worsening hypertension→ Systemic endothelial dysfunction causes placental hypoperfusion → ↑ placental release of factors(VEGF for angioplasty genesis ; ProstoGlandinF)→ endothelial lesions that lead to microthrombosis

Question 5

Effects of vasoconstriction and microthrombi on organs I’m GHD

Answer 5

Preeclampsia

Kidney

• • dysfunction of the glomerular endothelium allowing proteins to pass through into the urine and alter oncotic pressure (PROTEINURIA&;OEDEMA)
• -hypertension induced vasoconstriction of renal arteries (imparted renal function)

Blood

• -Systemic microthrombi and vasoconstriction → overactivation of the coagulation system and platelet consumption(DIC,thrombocytopenia)
• -microangiopathic hemolysis- rbc destruction by microthrombi (ANEMIA)

Eclampsia

Brain

-Hypertension-induced vasoconstriction and endothelial damage → disruption of cerebral microcirculation with microthrombi → vasospasms in the CNS (SEIZURES)

Question 6

Clinical signs of preeclampsia (Non severe)

Answer 6

• Onset: 90% occur after 34 weeks of gestation
• Usually asymptomatic
• Hypertension: 140/90 mmhg
• Visual disturbances, RUQ or epigastric pain, Rapid development of edema, Proteinuria

Question 7

Clinical signs of severe preeclampsia

Answer 7

• Severe hypertension (systolic ≥ 160 mmHg/diastolic BP≥ 110mmHg)
• Renal failure :Proteinuria&oliguria
• Headache (cerebral oedema, alarm signal for potentil seizure
• Visual disturbances (e.g., blurred vision, scotoma)
• RUQ or epigastric pain d/2 liver swelling irritating flies on capsule
• Pulmonary edema (sob, frothy pink sputum)
• Cerebral symptoms (e.g., altered mental state, nausea, vomiting, hyperreflexia, clonus)

Question 8

Clinical sign of HELLP syndrome ( type of severe preeclampsia)

Answer 8

Hemolysis

Elevated liver ez

Low Platelets

• Onset: most commonly > 27 weeks gestation (30% occur postpartum)
• severe Preeclampsia sx usually present (∼ 85%)
• Nonspecific symptoms:
  
  • anemia,
  • jaundice, RUQ pain (liver capsule pain; liver hematoma)
  • DIC, stroke,

Question 9

Clinical signs of eclampsia

Answer 9

• Onset: associated with severe preeclampsia (but can be associated with mild preeclampsia)
• CNS warning signs - deterioration w/ headaches -hyperreflexxia -visual changes
• Eclamptic seizures: generalized tonic-clonic seizures/ grand mal (usually self-limited) Eclamptic Seizure w

Question 10

Dg work up and screening in preeclampsia

Answer 10

Prenatal screening:

• Maternal blood pressure
• Maternal weight
• Maternal urine status (urine dipstick)

Work up

• BP:
• HTN on 2 occasions 4 hrs apart
• 24hr urine collection GOLD for proteinuria
• CBC (RBC, platelets)
• Liver function tests (transaminases)
• Peripheral smear (assess for hemolysis)
• coagulation studies are indicated if HELLP syndrome is suspected (i.e., thrombocytopenia and/or liver function impairment are present)
• Kidney function tests (creatinine)

Question 11

Criteria for dg of non-severe preeclampsia

Answer 11

• Hypertension (> 140/90 mmHg)
• Proteinuria ≥ 300 mg/24 h
• If proteinuria is absent, at least one of the following must be present:
  
  • Thrombocytopenia
  • Impaired renal function
  • Impaired liver function
  • Visual or neurologic changes
  • Pulmonary edema

Question 12

Criteria for dg of severe preeclampsia

Answer 12

• Severe hypertension
  
  • (> 160 mmHg systolic or > 110 mmHg diastolic)
• Thrombocytopenia < 100,000/μL
• Impaired renal function
  
  • (serum creatinine > 1.1 mg/dL or
  • doubling of serum creatinine)
• Impaired liver function (elevated transaminases)
• Pulmonary edema Cerebral or visual symptoms

Question 13

Criteria for dg of HELLP

Answer 13

H = Hemolysis: ↓ Hemoglobin, ↓ haptoglobin, ↑ LDH, ↑ indirect bilirubin

EL = Elevated Liver enzymes: ↑ AST, ↑ ALT

LP = Low Platelets elow 100,00

Question 14

Dg criteria for eclampsia

Answer 14

Primarily a clinical diagnosis:

patient with preeclampsia presenting with new-onset grand mal seizures without another causes

Question 15

What are the procedures for Fetal assessment in pre(eclampsia)

Answer 15

• US
  
  • Fetal growth in relation to gestational age
  • Placental implantation
  • amniotic fluid omount
• Obstetric Doppler ultrasound: non-invasive method for monitoring placental and fetal blood flow Increased resistance in the uterine arteries with an a_bnormal flow pattern_
• Cardiotocography (CTG): monitor fetal heart rate and uterine contractions (also called electronic fetal monitor)

Question 16

Dx of eclampsia

Answer 16

Epilepsy

Encephalitis

Metabolic disorders (e.g., hypoglycemia, hyponatremia) Hemorrhagic stroke// Ischemic stroke

Withdrawal syndromes

Question 17

Rx of gestational HTN & preeclampsia

drugs: Maternal Htn Never Lasts

Answer 17

Maternal monitoring (1–2 x/week):

• blood pressure,
• urine dipsticks,
• blood analysis (platelet count, liver enzymes, renal function)

Fetal monitoring:

• NST 1–2x weekly
• ultrasound every 3 weeks

Patient education Recognize signs of severe preeclampsia or fetal distress (e.reduced fetal movement, vaginal bleeding)

Avoid physical exertion but no bed rest d/2 DVT

Antihypertensive drug therapy for severe hypertension (systolic BP ≥ 160 mmHg or diastolic BP ≥ 110 mmHg)

First-line agents: Methyldopa Hydralazine Nifedipine Labetalol

Question 18

contra indicated in preeclampsia

Answer 18

ACE inhib and ARB d/2 teratogenicity

Question 19

Rx severe preeclampsia

Answer 19

Delivery is only cure Transvaginal delivery preferred but Caesarian if mother/ Fetus is unstable

• ideally over 34 wks gestation by vaginal delivery
• earlier if mother/ Fetus is unstable eg,
  
  • 32wks
    
    • magnesium sulfate for eclampsia prophylaxis
    • corticosteroids to stim Fetal lung maturity
    • induce labour./ ce-section
  • below 32
    
    • try and manage until 32 wks
    • bethamethasone for fetal maturity
    • antenatal care

Question 20

Rx of eclampsia

Answer 20

1)Stabilization

• Airway management -Supplemental oxygenation
• Anticonvulsive therapy !!Magnesium sulfate IV (first-line) ¡¡Antidote: calcium gluconate IV if early signs of magnesium toxicity (decreased deep tendon reflexes)
• Alternative or supportive: lorazepam or diazepam IV if unresponsive to magnesium sulfate
• -Position patient on left lateral decubitus position → prevent placental hypoperfusion through compression of the inferior vena cava and reduce the risk of aspiration in the mother

Delivery: once the mother is stable and seizures have stopped

• before 34 wks: CS delivery
• after 34 wks: vaginal delivery in 24 hrs

Question 21

Maternal complications of gestational hypertension disease

(7)

Answer 21

1. Placental abruption ( HTN is most common cause of displacement of placenta)
2. Cerebral hemorrhage, stroke( common cause of death)
3. Acute renal failure
4. DIC ( in HELLP) ARDE(common cause of death)
5. Retinal detachment
6. Maternal Aspiration pneumonia (during seizure)
7. Long-term: increased risk for cardiovascular disease, diabetes mellitus, and chronic kidney disease

Question 22

Fetal complications in preeclampsia

Answer 22

1. Fetal growth restriction
2. Preterm birth
3. Seizure-induced fetal hypoxia
4. Fetal death