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what are the 2 main disorders of pregnancy induced hypertension called?
- 1. pre-eclampsia
- 2. transient hypertension
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what % of pregnancies does Preeclampsia affect?
2-3%
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is PET more in primps or multips?
primips (primigravid)
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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)
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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
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if there is no proteinuria but just hypertension, what is that called?
transient or gestational hypertension
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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
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where is the origin of PET?
placenta
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what is the only cure of PET?
delivery
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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
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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
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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
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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
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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
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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)
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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
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name 4 complications of PET to fetes
- 1. IUGR
- 2. placental abruption
- 3. fetal hypoxia
- 4. preterm birth
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what is HELLP syndrome?
- haemolysis
- elevated
- liver enzyme
- low
- platelet
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what are 3 signs of haemolysis? (2 blood, 1 urine)
- 1. anaemia
- 2. elevated LDH
- 3. dark urine
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what are 3 signs of elevated liver enzymes?
- 1. epigastric pain
- 2. liver failure
- 3. abnormal clotting
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at what time in the pregnancy do most PET start?
late 3rd trimester
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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
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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
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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
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which drug modestly reduces the risk of PET in high risk patients?
low dose aspirin
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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
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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
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how do we monitor fettle growth?
USS
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how do you watch for progress of disease? (3)
- 1. MDU
- 2. CTG
- 3. PET bloods
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which 3 antihypertensives are safe in pregnancy? (ie safe for the baby)
- 1. methyldopa
- 2. labetolol (iv)
- 3. nifedipine (oral)
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what is the principle of care in PET?
to stabilise the lady before delivery
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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
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what does the BP have to be in PET to give antiHTN?
>170/110
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what are the complications of MgSO4 toxicity? and what is the sign that it may happen soon…?
- respiratory depression
- hypotension
- loss of patellar reflex happens before toxicity
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which drug is used to promote fettle pulmonary maturity if gestation is < 34 weeks?
steroids
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which drug that is routinely used in the 3rd stage of labour should be omitted in a lady with PET?
ergotamine
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what should be avoided in 2nd stage of labour if BP > 170/110?
maternal pushing as risk of high ICP and cerebral bleed
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what is the risk of giving too much fluid to PET patient?
not too much fluid as don't want pulmonary oedema
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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
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which drugs are given to control BP post natally?
- BB
- 2nd: nifedipine, ACEi - captopril safest in breastfeeding
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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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