Pre-eclampsia

• what is the difference between a term and pre-term delivery (exact dates):

  Term – delivery between 37 weeks to 41+6 weeks

  Pre-term – delivery before 37 weeks
• what is the basic structure of the placenta and its function:

  •Embeds into the decidual layer of the uterus•Separates maternal and fetal circulations.•Oxygen and nutrients in•Waste products and CO2 out
• what is the basic structure of the placenta and its function:

  •Embeds into the decidual layer of the uterus

  •Separates maternal and fetal circulations.

  •Oxygen and nutrients in

  •Waste products and CO2 out

  
• hypertension occurs in 10% of pregnancies and are associated with complications, list 3 complications associated with hypertension in pregnancy:

  • intrauterine growth restriction
  • pre-term
  • intrauterine death
• what are the three ways that hypertension can be classified in pregnancy:

  • chronic hypertension - prior to pregancy or before 20 weeks gestation
  • gestational hypertension - hypertension after 20 weeks of gestation, features of PET absent
  • Pre-eclampsia toxcemia (PET) - hypertensive diorder in pregnancy with multi-organ effects, see increased BP and proteinuria
• why is hypertension in the first and most of second trimester (about 20 weeks) suprising?

  normally during the first and second trimester there is a decrease in blood TPR which means that there is vasodilation/lumen is wider which decreases blood pressure so they could be slightly hypertensive rather than hypertensive

  this means that hypertension that occurs in the first and most of seconf trimester is due to other causes which is why hypertension before 20 weeks is classed as chronic hypertension
• if someone has hypertension and becomes pregnant what should you be concerned about for the safety of the baby's development?

  most common anti-hypertensives are contraindicated in pregnancy they are teratogenic and will interfere with the growth of the baby (reported renal effects and skull defects)
• what is the diagnostic criteria for pre-eclampsia and severe pre-eclampsia:

  pre-eclampsia (2 things to remember) - blood pressure more than 140/90 and significant proteinuria (urine dipstick 1+, protein/creatinine of 30mg/mmol)

  severe pre-eclampsia - more than 160/110 mmHg
• list signs of organ dysfunction you may see in pre-eclampsia:

  • renal insufficiency
  • liver involvement - elevated liver enzymes
  • neuro complications - eclampsia, altered mental status, stroke, clonus, headaches, visual scotomata
  • haematological complications - thrombocytopenia, haemolysis
  • uteroplacental dysfunciton -restricted fetal growth, still birth
• list 6 risk factors for pre-eclampsia:

  • diabetes
  • previous pre-eclampsia
  • BMI >35
  • first pregnancy
  • multiple pregnancy
  • pre-existing hypertension
  • CKD
• your patient is at risk of pre-eclampsia, what do you prescribe as a prophylaxis and for when?

  • aspirin -> antiplatelet and COX-1 inhibitor, decreases inflammatory mediator production and prevents platelet aggregation
  • shown to reduce the risk of developig pre-eclampsia
  • use from 12 weeks gestation
• what is the pathophysiology of pre-eclampsia?

  not fully understood

  abnormal development of the placenta, normally spiral areteries in the endometrium can dilate up to x10 their nomal size in pregnancy, in pre-eclampsia they can't which causes the narrowed blood vessels -> decreased placental blood flow -> decreased blood supply to the foetus
• how does pre-eclampsia affect the baby? how does pre-eclampsia affect the mother

  effect on baby: restricted uterine growth and foetal death when complicated

  effect on mother: decreased blood supply -> hypoperfused placenta -> inflammatory mediators -> endothelial cell dysfunction

  around the body causes vasoconstriction and in the kidney causes increased Na reabsorption = hypertension
• what are the clinical features of pre-eclampsia and how could you test for them?

  1. glomerular damage -> oligouria, proteinuria - test with urine output or urine dipstick
  2. retina -> flashing lights, blurred vision, scotomata (focal blurry/blind spots)
  3. liver -> liver swelling, elevated liver enzymes (LFTs), R upper quadrant/epigastic abdo pain, nausea/vomitting
  4. vascular permeability/oedema - hands/legs/face, pulmonary - see SOB and cough, cerebral - headaches and seizures
  5. localised vasospasma
• you believe your patient has pre-eclampsia as they have history of hypertension and previous pre-eclampsia in pregnancy, which investigations would you carry out?

  • BP - measure their blood pressure is it over 140/90?
  • urine dipstick/ protein-creatinine - do they have proteinuria?
  • blood tests - U&Es, LFTs, uric acid, RBCs (renal and liver function, reduced uric acid clearance associated with reduced GFR due to pre-eclampsia)
  • fetal ultrasound - wellbeing of the foetus and to check uterine artery blood flow
• Pre-eclampsia: immediate complications, what are the three immediate and very worrying complications associated with pre-eclampsia?

  1. placental abruption
  2. Eclampsia
  3. HELLP syndorme
• your patient has thrombocytopenia, derranged LFT results and evidence for anaemia which complication of pre-eclampsia are they presenting with?

  HELLP syndrome

  Haemolysis - thrombi formation caused by pre-eclampsia -> turbulent blood flow -> RBC destruction/death

  Elevated liver enzymes - vasospasm of the arteries to the liver cause liver swelling and elevated liver enzymes

  Low platelets - epthelial injury causes the formation of thrombi which uses up platelets which causes thrombocytopenia
• your patient comes in with vaginal bleeding and has a pre-eclampsia diagnosis, which complication of pre-eclampsia do you think they have?

  1. placental abruption - when the placenta detaches prematurely and compromises the fetus. It can cause heavy vaginal bleeding and can cause shock -> also less blood to the foetus which can cause fetal distress
• One of your patients on the ward is admitted with pre-eclampsia and they begin to have seizures, they have no history of this otherwise, what do you think is happening?

  1. Eclampsia = pre-eclampsia + seizures. New tonic-clonic seizures caused by cerebral oedema, most seizures occur post-natal. Eclampsia increases mortality for both the baby and the mother
• If you patient develops eclampsia from pre-eclampsia it is an obstetric emergency and the baby needs to be delivered as soon as the mother is stable, how do you manage pre-eclampsia?

  • obstetric emergency
  • IV magnesium sulphate (MgSO4) - for treatment and prevention
  • IV anti-hypertensives (hydralazine and labetalol)
  • monitor the baby and the child
  • emergency C-section when mother stable
• what is the sFLt-1 : PIGF ratio?

  a test to PREDICT the liklihood of developing PE, commonly see an elevated/higher ratio when there is a PE. Both are placental derived biomarkers

  sFLt-1 is a kinase that inhibits PIGF -> I think this is why the ratio rises

  could indentify who is at risk
• how would you change the management of a patient with PE compared to a normal pregnancy?

  • weekly blood test
  • frequent growth scans
  • frequent blood pressure checks
  • patient eduction on their condition and risks/complications
• patients with PE can be tx at home if stable, admit them if unstable, looks like there might be complications or symptomatic of foetal comprimise
• complications to pre-eclampsia may require preterm delivery, mother takes priority over the baby
• what are the 'delayed-complications to pregnancy?

  • 1 in 6 have PE again in late pregnancies
  • increased risk of health problems later in life (strokes, hypertension other major adverse cardiac event)
• what is a BIRTH REFLECTIONS SERVICE?

  support service for mothers who have a complicated or traumatic pregnancy, long hospitalisation, need to talk to someone:

  •If the mother has questions about the pregnancy/delivery they can arrange to discuss this with a midwife or obstetric doctor.

  •If they have questions about their baby’s time in the neonatal unit, they can arrange to meet with a member of the neonatal team.

  •If they need psychological support an appointment with a therapist can be arranged.