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what are the 2 main disorders of pregnancy induced hypertension called?
- 1. pre-eclampsia
- 2. transient hypertension
what % of pregnancies does Preeclampsia affect?
is PET more in primps or multips?
what are the 3 main aspects to the diagnosis of pre-eclampsia?
- 1. BP > 140/90
- 2. proteinuria >0.3g/24h
- 3. arising de novo after 20weeks gestation
- (in a previously normotensive woman, resolving completely by the 6th postpartum week)
what is the difference between mild, moderate and severe pre-eclampsia?
- mild: proteinuria, HTN <170/110mmHg
- moderate: proteinuria, HTN >=170/110mmHg
- mild: proteinuria, HTN < 32 weeks or with maternal complications
if there is no proteinuria but just hypertension, what is that called?
transient or gestational hypertension
what is the normal pattern of BP in pregnancy and why
- falls to a minimum level in the 2nd trimester by 30/15mmHg
- cause: reduced vascular resistance
- it then rises again to prepregnant levels by term
where is the origin of PET?
what is the only cure of PET?
what is eclampsia?
- serious and life threatening complication of preeclampsia
- convulsions occurring in a woman with established pre-eclampsia,
- in the absence of any other neuro or metabolic cause
- obstetric emergency
what is the main pathogenesis of PET?
- patchy or abnormal trophoblast invasion of spiral arteries
- spiral arteries retaining their muscular walls
- preventing the development of a high flow, low impedance uteroplacental circulation
- so get ischaemic placenta, more vasoconstriction
what are the main risk factors for pre-eclampsia?
- 1. nulliparity or first pregnancy with NEW PARTNER
- 2. extremes of age: young, old
- 3. medical: DM, obesity, CVD, renal disease
- 4. FH or previous PET
- 5. autoimmune disease: rheum, SLE, APS
- 6. twin/multiple pregnancies or molar - ie large placenta
what are the 3 ways of assessing urinary protein and what results would indicate significant proteinuria on each?
- 1. dipstick: =>2
- 2. protein:creatinine ratio > 30mg/nmol
- 3. 24h collection > 0.3g/24h is confirmed significant proteinuria
on doing a doppler of the uterine artery, what is the difference in signal between normal and preeclampsia at 20-22 weeks?
normally at 20-22 weeks, the dicrotic notch seen at 16 weeks of the uterine artery disappears; but in PET it persists
what are the signs and symptoms of pre-eclampsia? think top to toe
- 1. headache - frontal, very stressful
- 2. visual disturbance
- 3. vomiting
- 4. hypertension
- 5. epigastric pain/tenderness: suggests impending complications!
- 6. proteinuria
- 7. oedema (even tho find oedema in most pregnancies, in PET it may be massive, NOT postural or of sudden onset)
what are the complications of pre-eclampsia? think top to toe
- 1. head: intracerebral haemorrhage, fits (eclampsia)
- 2. chest: pulmonary oedema (careful not to fluid overload)
- 3. liver: high ALT, AST
- 4. HELLP
- 5. IUGR
- 6. clotting abnormalities - DIC, low platelets
- 7. placental abruption
name 4 complications of PET to fetes
- 1. IUGR
- 2. placental abruption
- 3. fetal hypoxia
- 4. preterm birth
what is HELLP syndrome?
- liver enzyme
what are 3 signs of haemolysis? (2 blood, 1 urine)
- 1. anaemia
- 2. elevated LDH
- 3. dark urine
what are 3 signs of elevated liver enzymes?
- 1. epigastric pain
- 2. liver failure
- 3. abnormal clotting
at what time in the pregnancy do most PET start?
late 3rd trimester
what are the typical PET bloods?
- 1. FBC: Hb up (haemoconcentrating 14/15), plt down
- 2. U&E: normal usually, unless renal failure rising creatinine
- 3. LFT: AST up, ALT up in HELLP
- 4. clotting: abnormal if platelet low - indicates DIC
what Ix are done to monitor fettle complications?
- USS estimate fettle weight at early gestations and assess fettle growth
- umbilical artery doppler: if abnormal, daily CTG to evaluate fettle well-being
what is the most commonly used screening test for PET?
uterine artery doppler at 23 weeks gestation: should NOT have dicrotic notch, if it persists baby may be IUGR and mother may get PET
which drug modestly reduces the risk of PET in high risk patients?
low dose aspirin
what is the criteria for admission in PET or suspected PET? (4 things)
- 1. symptoms: headache, visual disturbance, abdo pain, clonus, fits, SOB
- 2. proteinuria 2+ on dipstick, or >0.3g/24h collection
- 3. DBP >170/110
- 4. fetal compromise suspected
what is the management of mild PET?
- 1. monitor fettle growth (USS)
- 2. watch for progress of disease - MDU twice weekly, CTG, PET bloods
- 3. if >36/40 then proceed to delivery
- 4. control BP
how do we monitor fettle growth?
how do you watch for progress of disease? (3)
- 1. MDU
- 2. CTG
- 3. PET bloods
which 3 antihypertensives are safe in pregnancy? (ie safe for the baby)
- 1. methyldopa
- 2. labetolol (iv)
- 3. nifedipine (oral)
what is the principle of care in PET?
to stabilise the lady before delivery
what 5 things need to be done around delivery in PET patient?
- 1. control BP: not methyldopa in the acute setting as it takes 2-3 days to work, use nifedipine/labetolol/hydralazine
- 2. monitor fluid input: not more than 85ml/hr - preferably crystalloid (not too much fluid as don't want pulmonary oedema)
- 3. prevent fits: MgSO4 - safety as long as knee jerk reflex its ok (but note it is NOT an AED)
- 4. monitor UO and catheterise
- 5. delivery baby. remember PET does not mean you have to do CS. can induce the patient and aim for vaginal delivery
what does the BP have to be in PET to give antiHTN?
what are the complications of MgSO4 toxicity? and what is the sign that it may happen soon…?
- respiratory depression
- loss of patellar reflex happens before toxicity
which drug is used to promote fettle pulmonary maturity if gestation is < 34 weeks?
which drug that is routinely used in the 3rd stage of labour should be omitted in a lady with PET?
what should be avoided in 2nd stage of labour if BP > 170/110?
maternal pushing as risk of high ICP and cerebral bleed
what is the risk of giving too much fluid to PET patient?
not too much fluid as don't want pulmonary oedema
what needs to be done in the post natal management of PET?
- 1. PET bloods
- 2. fluid balance monitoring: if too much fluids go into pulmonary oedema. must check UO, if low then CVP will guide management.
- 3. BP maintained at 140/90
which drugs are given to control BP post natally?
- 2nd: nifedipine, ACEi - captopril safest in breastfeeding
if the UO is low, which Ix needs to be done? and how does this affect further management?
- CVP monitoring
- CVP high: suggests overloaded, need frusemide
- CVP low: give fluid, NOT ALBUMIN (ie give crystalloids)
- CVP normal and oliguria persists, renal failure is likely and if K+ rising, may need dialysis
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