Obstetrics & Gynaecology
Question 297 of 300
A 32 year old woman is brought to the Emergency Department complaining of a headache and blurred vision. She is 34 weeks pregnant and this is her first pregnancy. She has no past medical history. On examination you note significant swelling of her hands and feet. Her observations are recorded as:
- Heart rate: 79 beats per minute
- Blood pressure: 170/110 mmHg
- Respiratory rate: 18 breaths per minute
How should this patient be managed in the first instance?
Answer:
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. 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. Aim for BP of 135/85 mmHg or less.Pre-Eclampsia
Obstetrics & Gynaecology
Last Updated: 17th March 2021
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 |
