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51

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Obstetrics & Gynaecology

Question 19 of 180

A 23 year old woman presents to the Emergency Department complaining of headache and blurred vision. She is 31 weeks pregnant. You suspect she is suffering from pre-eclampsia. Which of the following is NOT a risk factor for pre-eclampsia?

Answer:

Women are at high-risk of pre-eclampsia if they have:
  • One of the following high risk factors
    • A history of hypertensive disease during a previous pregnancy
    • Chronic kidney disease
    • Autoimmune disease, such as systemic lupus erythematosus or antiphospholipid syndrome
    • Type 1 or type 2 diabetes
    • Chronic hypertension
  • Two or more of the following moderate risk factors:
    • First pregnancy
    • Aged 40 years or older
    • Pregnancy interval of more than 10 years
    • Body mass index (BMI) of 35 kg/m2 or greater at the first visit
    • Family history of pre-eclampsia
    • Multiple pregnancy

Pre-Eclampsia

Definitions

  • Hypertension in pregnancy is defined as a diastolic BP > 90 mmHg and/or systolic BP > 140 mmHg.
  • Severe hypertension is defined as diastolic BP > 110 mmHg and/or systolic blood pressure > 160 mmHg.
  • Gestational hypertension is new hypertension presenting after 20 weeks’ gestation without significant proteinuria.
  • Pre-eclampsia is new hypertension presenting after 20 weeks gestation and the coexistence of 1 or more of the following new-onset conditions:
    • Proteinuria
    • Other maternal organ dysfunction:
      • Renal insufficiency (creatinine 90 micromol/litre or more, 1.02 mg/100 ml or more).
      • Liver involvement (elevated transaminases [alanine aminotransferase or aspartate aminotransferase over 40 IU/litre] with or without right upper quadrant or epigastric abdominal pain).
      • Neurological complications such as eclampsia, altered mental status, blindness, stroke, clonus, severe headaches or persistent visual scotomata.
      • Haematological complications such as thrombocytopenia (platelet count below 150,000/microlitre), disseminated intravascular coagulation or haemolysis
      • Uteroplacental dysfunction such as fetal growth restriction, abnormal umbilical artery doppler waveform analysis, or stillbirth.
  • HELLP syndrome (Haemolysis, Elevated Liver enzymes, and Low Platelets syndrome) is a severe form of pre-eclampsia that is associated with high maternal and perinatal morbidity and mortality.
  • Eclampsia is the occurrence of one or more seizures in a woman with pre-eclampsia.

Risk factors

Women are at high-risk of pre-eclampsia if they have:

  • One of the following high risk factors
    • A history of hypertensive disease during a previous pregnancy
    • Chronic kidney disease
    • Autoimmune disease, such as systemic lupus erythematosus or antiphospholipid syndrome
    • Type 1 or type 2 diabetes
    • Chronic hypertension
  • Two or more of the following moderate risk factors:
    • First pregnancy
    • Aged 40 years or older
    • Pregnancy interval of more than 10 years
    • Body mass index (BMI) of 35 kg/m2 or greater at the first visit
    • Family history of pre-eclampsia
    • Multiple pregnancy

Clinical features

Symptoms of pre-eclampsia

  • Severe headaches (increasing frequency unrelieved by regular analgesics).
  • Visual problems, such as blurred vision, flashing lights, double vision, or floating spots.
  • Persistent new epigastric pain or pain in the right upper quadrant.
  • Vomiting.
  • Breathlessness.
  • Sudden swelling of the face, hands, or feet.

Complications

Pre-eclampsia is a multi-system disorder that is associated with significant maternal morbidity.

Complications of pre-eclampsia include:

  • Maternal complications
    • Eclamptic seizures
    • Acute renal failure
    • Liver dysfunction
    • Coagulation abnormalities
    • Intracranial haemorrhage
    • Cerebral infarction
    • Cerebral oedema
    • Acute respiratory distress syndrome and pulmonary oedema
    • Hepatic rupture and hepatic failure/necrosis
    • Death
  • Fetal complications
    • Placental abruption
    • IUGR
    • Preterm delivery
    • Stillbirth
    • Neonatal death

Management

  • For women assessed to be at high risk of pre-eclampsia, aspirin 75 - 150 mg daily is prescribed from 12 weeks gestation until birth.
  • For all pregnant women, dipstick the urine for protein and measure blood pressure at each visit.
    • If dipstick screening is positive [1+ or more], use albumin:creatinine ratio or protein:creatinine ratio to quantify proteinuria in pregnant women.
    • If using protein:creatinine ratio, use 30 mg/mmol as a threshold for significant proteinuria.
    • If using albumin:creatinine ratio, use 8 mg/mmol as a diagnostic threshold.
  • Assess for symptoms of pre-eclampsia at each visit. Advise the woman that she should seek immediate medical review if she develops any symptoms (including during the first four weeks postpartum).
  • If BP 140/90–159/109 mmHg in pre-eclampsia
    • Admit if any clinical concerns for the wellbeing of the woman or baby or if high risk of adverse events suggested by the fullPIERS or PREP‑S risk prediction models
    • Offer pharmacological treatment if BP remains above 140/90 mmHg
    • Aim for BP of 135/85 mmHg or less
    • BP should be measured at least every 48 hours, and more frequently if the woman is admitted to hospital
    • Measure full blood count, liver function and renal function twice a week
  • If BP 160/110 mmHg or more in pre-eclampsia
    • Admit
    • Offer pharmacological treatment to all women
    • Aim for BP of 135/85 mmHg or less
    • BP should be measured every 15–30 minutes until BP is less than 160/110 mmHg, then at least 4 times daily while the woman is an inpatient, depending on clinical circumstances
    • Measure full blood count, liver function and renal function 3 times a week
  • Choice of antihypertensive
    • Offer labetalol to treat hypertension in pregnant women with pre-eclampsia.
    • Offer nifedipine for women in whom labetalol is not suitable, and methyldopa if labetalol or nifedipine are not suitable.
    • Base the choice on any pre-existing treatment, side-effect profiles, risks (including fetal effects) and the woman's preference.
    • Treat women with severe hypertension who are in critical care during pregnancy or after birth immediately with 1 of the following:
      • labetalol (oral or intravenous)
      • oral nifedipine
      • intravenous hydralazine
  • Anticonvulsants
    • If a woman in a critical care setting who has severe hypertension or severe pre-eclampsia has or previously had an eclamptic fit, give intravenous magnesium sulfate.
    • Consider giving intravenous magnesium sulfate to women with severe pre-eclampsia who are in a critical care setting if birth is planned within 24 hours.
    • Consider the need for magnesium sulfate treatment, if 1 or more of the following features of severe pre-eclampsia is present:
      • ongoing or recurring severe headaches
      • visual scotomata
      • nausea or vomiting
      • epigastric pain
      • oliguria and severe hypertension
      • progressive deterioration in laboratory blood tests (such as rising creatinine or liver transaminases, or falling platelet count)
    • A loading dose of 4 g should be given intravenously over 5 to 15 minutes, followed by an infusion of 1 g/hour maintained for 24 hours. If the woman has had an eclamptic fit, the infusion should be continued for 24 hours after the last fit.
    • Recurrent fits should be treated with a further dose of 2–4 g given intravenously over 5 to 15 minutes.
    • Do not use diazepam, phenytoin or other anticonvulsants as an alternative to magnesium sulfate in women with eclampsia.

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  • Biochemistry
  • Blood Gases
  • Haematology
Biochemistry Normal Value
Sodium 135 – 145 mmol/l
Potassium 3.0 – 4.5 mmol/l
Urea 2.5 – 7.5 mmol/l
Glucose 3.5 – 5.0 mmol/l
Creatinine 35 – 135 μmol/l
Alanine Aminotransferase (ALT) 5 – 35 U/l
Gamma-glutamyl Transferase (GGT) < 65 U/l
Alkaline Phosphatase (ALP) 30 – 135 U/l
Aspartate Aminotransferase (AST) < 40 U/l
Total Protein 60 – 80 g/l
Albumin 35 – 50 g/l
Globulin 2.4 – 3.5 g/dl
Amylase < 70 U/l
Total Bilirubin 3 – 17 μmol/l
Calcium 2.1 – 2.5 mmol/l
Chloride 95 – 105 mmol/l
Phosphate 0.8 – 1.4 mmol/l
Haematology Normal Value
Haemoglobin 11.5 – 16.6 g/dl
White Blood Cells 4.0 – 11.0 x 109/l
Platelets 150 – 450 x 109/l
MCV 80 – 96 fl
MCHC 32 – 36 g/dl
Neutrophils 2.0 – 7.5 x 109/l
Lymphocytes 1.5 – 4.0 x 109/l
Monocytes 0.3 – 1.0 x 109/l
Eosinophils 0.1 – 0.5 x 109/l
Basophils < 0.2 x 109/l
Reticulocytes < 2%
Haematocrit 0.35 – 0.49
Red Cell Distribution Width 11 – 15%
Blood Gases Normal Value
pH 7.35 – 7.45
pO2 11 – 14 kPa
pCO2 4.5 – 6.0 kPa
Base Excess -2 – +2 mmol/l
Bicarbonate 24 – 30 mmol/l
Lactate < 2 mmol/l

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