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Pre-eclampsia (Risk factors (Prior pre-eclampsia, HELLP syndrome…
Pre-eclampsia
Risk factors
Prior pre-eclampsia
HELLP syndrome (haemolysis, elevated liver enzymes, low Plt)
Older age
FH
Obesity (BMI>30)
Primiparous
Multiple preg
Long birth interval (10y)
Foetal hydrops
Hydatiform mole
Medical conditions (HTN, renal, DM, antiphospholipid syndrome, thrombophilia, CT disease)
Pathophysiology
Unclear, placental cause
Ultimate management is delivery of the placenta
Failure of trophoblast invasion of spiral arteries,
so arteries stay vasoactive; BP increases to compensate
Normally trophoblast invasion of spiral arteries
prevents response to vasoactive mediators,
protecting the placenta
High BP also affects liver (enzymes, clotting)
and renal (proteinuria)
Reduced plasma vol increased peripheral resistance,
platelet ischemia, arterial microaneurysms, oedema
Clinical
presentation
Asymptomatic
Headache
Visual disturbance
RUQ pain
Facial/hand oedema
N+V
Diagnosis
Examination
Cardiovascular
Oedema of hands/face
Abdominal
RUQ tenderness (liver involvement)
Neurological
UMN signs (cerebral irritation)
Confusion
Fundoscopy
Papilloedema
Obstetric
Foetal movements,
lie, engagement
Pelvic
Uterine tenderness,
bleeding (abruption)
Investigations
Bedside
Mother: obs (BP - HTN)
Foetus: HR, CTG
Urine
Dipstick (proteinuria)
ACR/PCR
MCS
Bloods
FBC (high Hb/anaemia, low Plts), U+Es
LFTs (deranged?), clotting (deranged)
Imaging
USS
History
PC/HPC
Symptoms
Current preg
Gestation, scans/bloods, conception, movements
POH
gravity/parity, conception, delivery,
gestation, weight, complications
PGH
Known conditions, menses,
bleeding, STIs, smears
PMH
CVD, HTN, antiphos synd,
thrombophilia, CT disease
DH
Any meds, allergies
FH
Pre-eclampsia, HTN
SH
Occupation, smoking,
alcohol, BMI, support
Classification
Moderate
BP 150-159/100-110
Significant proteinuria
Asymptomatic
Severe
BP >160/110
Significant proteinuria
Maternal complications (symptomatic)
Mild
BP 140-150/90-100
Minimal/low proteinuria
Asymptomatic
Management
Moderate
Conservative
Admit if proteinuria 2+ or >300mg/24h
Maternal monitoring - BP (4h), urine (24h), bloods (2-3d)
Foetal monitoring - CTG (24h), Doppler/liquor (2/wk), USS growth (2wk)
Medical
Anti-HTNs
Indication: SBP>160/DBP>110
E.g. PO nifedipine (1L), IV labetalol (2L),
methyldopa (2L if asthmatic)
MOA: initially 2-3 nifedipine doses, labetalol if not controlled
Severe
Conservative
Admit to hospital
Maternal monitoring: bloods, fluid balance
Foetal monitoring: CTG, USS, Doppler
Medical
Anti-HTNs
Indication: SBP>160/DBP>110
E.g. PO nifedipine (1L), IV labetalol (2L),
methyldopa (2L if asthmatic)
MOA: initially 2-3 nifedipine doses, labetalol if not controlled
Steroids
Indication: <34wk gestation
MOA: improves foetal lung maturity
Surgical
Delivery
Indication: worsening Plts/clotting/LFTs/U+Es,
severe symptoms, HELLP, eclampsia, foetal distress
MOA: IOL if 37/40; use oxytocin in 3rd stage
(ergometrine/syntometrine CI due to risk severe HTN/stroke)
Mild
Conservative
Information and advice
Warn about symptoms
Weekly bloods
1-2wk BP, urine dip
Epidemiology
5%; severe 1%
Lead cause of maternal morbidity/mortality
Prevention
Screening
History (risk factors)
Plasma protein A (PAPP-A) screen (low)
USS artery Doppler (12 and 20wk scan)
Prophylaxis
At risk pts - low dose aspirin (75mg PO OD) next pregnancy
Complications
Foetus
Placental abruption
IUGR
Foetal compromise
Mother
HELLP syndrome
Definition
Variant of severe pre-eclampsia with
haemolysis, elevated liver enzymes, and low Plts
Epidemiology
5-20% pre-eclampsia patients
Maternal mortality 1%
Pathophysiology
Inc liver enzymes, low plts then haemolysis
May co-exist with eclampsia
Clinical presentation
Epigastric/RUQ pain
N+V
Tea coloured urine
Diagnosis
History: symptoms of eclampsia
Examination: neuro (seizures), abdo (RUQ tenderness,
tea coloured urine),
Management
As per eclampsia
Medical: MgSO4, anti-HTNs, Plt transfusion, steroids
Surgery: delivery ASAP
Eclampsia
Definition
Tonic-clonic seizure on
background of pre-eclampsia
OBSTETRIC EMERGENCY
Epidemiology
1-2% pre-eclampsia patients
Pathophysiology
Can be initial presentation, before HTN/proteinuria
Antenatally, intrapartum, postnatal
Severe disease, can be fatal
Management
Initial ABCDE
Definitive
Medical
MgSO4
Indication: seizure control and prophylaxis
MOA: reduces seizures and recurrence,
neruoprotection for the mother
careful monitoring (obs, urine, reflexes, toxicity)
Anti-HTNs
Indication: BP>160/110
E.g. IV labetalol (avoid in asthma)
Surgical
Delivery
Indication: ASAP once mother stable
MOA: vaginal, CS; use oxytocin in 3rd stage
(ergometrine/syntometrine CI due to risk severe HTN/stroke)
Conservative
Call help (obstetrics, SHO, anaesthatist)
Fluid restriction (risk of pulmonary oedema)
Monitoring: maternal/foetal obs, bloods
Clinical presentation
Seizures
Diagnosis
History:
symptoms of pre-eclampsia/HELLP
Examination:
neurology (seizures)
Investigations:
maternal/foetal obs, urine dip (proteinuria),
bloods (FBC, U+E, LFTs, clotting), imaging (USS, Doppler)
Others
ARDS
MOF
Renal failure
Cerebral haemorrhage
Definition
Multisystem disorder characterised
by HTN and protienuria