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Flashcards in Pre-clampsia and Eclampsia Deck (27)
1

1. What is preeclampsia?
3


2. What is HELLP syndrome?
3
(may be a part of what and without what?)

3. What is eclampsia? 2

1. Preeclampsia
New onset of
-HTN and
-proteinuria or
-end organ dysfunction after 20 weeks gestation in a previously normotensive pateint

2. HELLP
-Hemolysis,
-elevated liver enzymes,
-low platelets
(May be part of severe preeclampsia and May occur without preeclampsia)

3. Eclampsia
Preeclampsia has progressed and the patient now has
-seizures or
-coma

2

The underlying problem is endothelial dysfunction which leads to:
7

1. Hypertension
2. Activation of platelets
3. CNS changes
4. Edema
5. Renal dysfunction resulting in proteinuria
6. Hemolysis
7. Hepatic ischemia

3

WHAT CAUSES THE ENDOTHELIAL DYSFUNCTION?
-Many maternal, placental and fetal factors come into play such as?
5


-This MAY LEAD TO:
8

1. Underperfusion of the placenta
2. Immunologic factors
3. Increased sensitivity to angiotensin II
4. Genetic
5. Inflammation

1. Maternal death (10-15% of maternal deaths)
2. Placental abruption
3. Acute kidney injury
4. Cerebral hemorrhage
5. Hepatic failure or rupture
6. Pulmonary edema
7. DIC
8. Eclampsia (seizures)

4

PREECLAMPSIA-ECLAMPSIA
1. Essentials of dx? 2

2. If they have HTN but no proteinuria will meet criteria for preeclampsia if ?
5

1. Essentials of diagnosis
-Hypertension
-Proteinuria

2. If they have HTN but no proteinuria will meet criteria for preeclampsia if
-Low platelets ( 1.1 or doubling of the creatinine)
-Elevated liver enzymes (2X the ULN)
-Pulmonary edema
-Cerebral or visual symptoms
(Headache, visual changes)

5

PREECLAMPSIA-ECLAMPSIA
1. Can occur when?
2. Only cure?
3. Who are most frequently affected?
4. What ages are at risk?
5. Who else is at risk?

1. Can occur anytime after 20 weeks of gestation and up to 6 weeks postpartum

2. Only cure is delivery of the fetus and placenta

3. Primiparas are most frequently affected

4. Extremes of maternal age (less than 20 or older than 35)

5. Multiple gestation (twins, triplets)

6

PREECLAMPSIA-ECLAMPSIA
Associated with? 9

Associated with:
1. Chronic HTN,
2. diabetes,
3. renal disease,
4. collagen vascular and
5. autoimmune disorders and
6. Hydatidiform mole
7. New paternity
8. Previous preeclampsia or eclampsia or a
9. family history

7

PREECLAMPSIA-ECLAMPSIA
1, Symptoms not evident until when?
2. But when does the process begin?

3. Possible cause?

1. Symptoms not evident until 3rd trimester but
2. process begins as early as 2nd trimester

3. Cause:
-Imbalance in placental prostacyclin and thromboxane production

8

1. What is Prostacyclin?

2. Thromboxane?

1. = potent vasodilator and inhibitor of platelet aggregation

2. = potent vasoconstrictor and stimulates platelet aggregation

9

PREECLAMPSIA-ECLAMPSIA
1. In a normal pregnancy how do prostacyclin and thromboxane change? 2

2. How do they change in preeclampsia?

3. What does this result in? 3

1. In a normal pregnancy:
-Thromboxane is increased
-Prostacycline levels = thromboxane levels

2. In Preeclampsia:
Placenta produces 7x more thromboxane than prostacycline

3. Result:
-Vasoconstriction
-Platelet aggregation
-Reduced uteroplacental blood flow

10

PREECLAMPSIA-ECLAMPSIA
1. Only cure is what?

2. Primary goal of management is to what?

3. Important, if possible, to allow what to develop while preventing progression to severe disease and eclampsia?

4. Critical factors are what? 3

1. delivery of the placenta and fetus

2. allow pregnancy to progress as far as possible without jeopardizing maternal or fetal well-being

3. fetal lung maturity

4.
-The gestational age of the fetus
-Maturity of fetal lungs
-Severity of maternal disease

11

1. Preeclampsia at 36 weeks or more is managed by what?

2. Prior to 36 weeks, severe preeclampsia-eclampsia requires delivery except in unusual circumstances associated with what?

3. What are strong indication for delivery? 3

1. delivery regardless of how mild the disease is judged

2. extreme fetal prematurity, in which case prolongation of pregnancy may attempted

3.
-Epigastic pain,
-thrombocytopenia and
-visual disturbances

12

MANAGEMENT OF MILD PREECLAMPSIA
1. What may be attempted with mild preeclampsia and a stable home situation?

2. Med used? 2
3. Does this increase mother or fetal risk?
4. Recommended in high risk groups such as? 4

1. Home management with bedrest

2.
-Low dose ASA
60-80 mg/day
-Antihypertensive therapy

3. No increased maternal or fetal risk

4.
-Women with chronic HTN
-Hx of placental abruption
-PIH in previous pregnancy
-Systemic lupus

13

MANAGEMENT OF MILD PREECLAMPSIA
1. Antihypertensive therapy is used how?
2. Which drugs specifically? 2

1. To decrease BP enough to protect maternal organs without causing hypotension and threatening fetal oxygen supply

2.
-Hydralazine
-Methyldopa

14

MODERATE TO SEVERE PREECLAMPSIA
3

1. Hospitalization for those with moderate or severe preeclampsia

2. If patient is far enough along in her pregnancy that the fetus can be delivered safely, then deliver the baby

2. If this is not the case the patient needs to be hospitalized and started on a Magnesium Sulfate drip to prevent seizures

15

MODERATE TO SEVERE PREECLAMPSIA
Regular assessment of what?
10

1. Blood pressure
2. Reflexes
3. Urine protein
4. FHT and activity
5. CBC, platelet count and electrolytes plus liver enzymes q 6. 1-2 days
7. 24 hour urine collection for CrCl and protein
8. Fetal evaluation
9. Daily fetal kick counts
10. Consider amniocentesis to evaluate fetal lung maturity if hospitalization occurs at 30-37 weeks.

16

MODERATE TO SEVERE PREECLAMPSIA
Tx?

Steroids: Betamethsone (Diprolene), Dexamethasone (Decadron), can be given 12- 24 hour apart to mom, especially with fetus between 26-30 weeks of gestation

17

SEVERE PREECLAMPSIA
Defined as?
8

1. B/P: ≥ 160 systolic or ≥ 110 diastolic
2. Proteinuria: ≥ 500mg/24 hours or 4+ on dipstick
3. Oliguria of

18

SEVERE PREECLAMPSIA
Can have systemic associations such as?
4

1. Renal insufficiency
2. Placenta abruption
3. Pulmonary edema and pulmonary hypertension due to decreased CO
4. CNS

19

SEVERE PREECLAMPSIA
Can have systemic associations: CNS problems?

Multifocal petechial hemorrhages of the grey matter/white matter junction

20

1. What is HELLP a variant of?

2. Characterized by what? 3

1. Variant of severe preeclampsia

2. Characterized by:
-Hemolysis
-Elevated liver enzymes
-Low platelets

21

HELLP
1. SIGNS 3

2. SYMPTOMS 4

SIGNS
1. BP mildly elevated
2. Proteinuria +/-
3. Edema

SYMPTOMS
1. Malaise almost 100%
2. Epigastic pain
3. Nausea with or without vomiting
4. Right upper quadrant tenderness

22

HELLP
DIAGNOSIS
1. Hemolysis: What tests will show this? 3

2. What liver enzymes will be elevated? 2

3. Low platelets less than what?

1. Hemolysis
-Abnormal peripheral smear (burr cells and schistocytes or both)
-Elevated Bilirubin (>1.2 mg/dl)
-Increased Lactic Dehydrogenase (> 600 U/L)

2. Elevated Liver Enzymes
-SGOT (> 70 U/L)
-LDH (> 600 U/L)

3. Low Platelets
-less than 100,000

23

HELLP
COMPLICATIONS
8

Managment?

1. Placental abruption (7-20%)
2. Acute renal failure
3. Hepatic hematoma
4. Liver rupture
5. Ascites
6. Hemorrhage
7. Fetal death
8. Maternal death

Management: Delivery

24

1. PREECLAMPSIA becomes ECLAMPSIA when ________ are present

In addition other signs of severe preeclampsia are observed with eclampsia


1. seizures


25

ECLAMPSIA EMERGENCY CARE
-If patient is convulsing – supportive care
1. DOC?
2. Given how?
3. Blood levels checked q how often to maintain therapeutic level (4-6 mEq/L)?

4. What level is checked hourly?

5. Whatch for signs of what?

6. Loss of what?

7. Decrease in what?

8. Can be reversed with what?

9. Crosses the placenta?

10. Newborn suffers _________ properties of drug
-Effects subside as newborn excretes drug over following how many days?

1. Magnesium sulfate
DOC to control seizure activity

2. Given as bolus and followed with continuous IV infusion

3. 4-6 hours

4. Urine output checked hourly

5. Watch for signs of magnesium toxicity

6. deep tendon reflexes

7. respiratory rate and depth

8. Can be reversed with CALCIUM GLUCONATE

9. Readily crosses the placenta

10. sedative,
-3-4 days

26

ECLAMPSIA TREATMENT
DELIVER THE BABY!
-Postpartum
1. Continue what until postpartum resolution?
2. May take what?
3. In any case, continue what drip for how long?
4. Most reliable indicator of resolution is the what?

1. Magnesium Sulfate infusion

2. 1-7 days

3. Mag sulfate drip for 24 hours

4. onset of diuresis
-With this, drip can be discontinued

27

PREECLAMPSIA-ECLAMPSIA
1. The incidence of preeclampsia in the next pregnancy is what?

2. Some women have what afterwords?

1. not definite, but there is an increase risk with multiple pregnancies

2. chronic, manageable HTN afterwards