OB Exam 2; Preeclampsia

Preeclampsia is MOST often diagnosed after how many weeks gestation? What is the exception?
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Preeclampsia is MOST often diagnosed after how many weeks gestation? What is the exception?
After 20 weeks gestation except in the setting of gestational trophoblastic neoplasia
Women with early onset preeclampsia prior to 34 weeks have better outcomes compared to those that develop pre-e later in pregnancy. T/F
False; they often have a more progressive disease and worse outcomes.
A woman must have proteinuria, hypertension, and edema for a diagnosis of preeclampsia. T/F
False; in 2000 the edema criteria was eliminated because most pregnant women have some edema.
Choose the parameters for Preeclampsia without severe features.
A. BP > 140/90 after 20 wks gestation (on 2 occasions at least 4 hours apart)
B. Proteinuria: 300mg/24 hour or 1+ dipstick reading
C. serum creatinine >1.1 mg/dL
D. thrombocytopenia <100,000
E. BP > 160/100 (on 2 occasions at least 4 hours apart)
F. urine protein/creatinine ratio > 0.3
A., B., F
All are parameters for Preeclampsia with severe features EXCEPT which one:

A. Proteinuria: 300mg/24 hour or 1+ dipstick reading
B. serum creatinine >1.1 mg/dL
C thrombocytopenia <100,000
D. BP > 160/110 (on 2 occasions at least 4 hours apart)
E. impaired liver function
F. Severe persistent RUQ or epigastric pain
G. Pulmonary edema
H. Cerebral edema/visual disturbances
I. Proteinuria > 5gm/24 hour
J. Oliguria
K. IUGR (Intrauterine Growth Restriction)
L. Headache
M. Signs of HELLP syndrome
A.
Two of the most common causes of maternal death d/t Preeclampsia?
Pulmonary edema and Intracranial hemorrhage
Percent of patients with preeclampsia with severe features that will develop HELLP?
10%
In order for a patient to develop HELLP, she must first have preeclampsia with severe features. T/F
False; it is a subtype, but can develop as a unique condition.
AST and ALT will likely be lower or elevated with HELLP?
Elevated
BP must be elevated to receive a dx of HELLP. T/F
False; in 15% of cases BP will be normal
Percent of patients that will develop preeclampsia?6-8% of all US pregnanciesIf the annual number of women that develop preeclampsia is 150,000, how many of these will go on to develop preeclampsia with severe features?37,500 25% of women with preeclampsia will go on to develop preeclampsia with severe features.What is the leading causes of preterm delivery?PreeclampsiaRisk Factors for PreeclampsiaNulliparity Limited preconceptual exposure to paternal sperm Partner who fathered a preeclamptic pregnancy in another woman Hx of preeclampsia in another pregnancy Advanced maternal age >35yrs Family hx of preeclampsia Hx of placental abruption, IUGR, IUFD Hispanic Black Obesity Chronic HTN Thrombotic vascular disorder multiple gestation Hydatidiform mole:produces higher levels of HCGSmoking is another risk factor for pre-e. T/FFalse: reduces riskDescribe the pathophysiology of Preeclampsia• Abnormal placentation Decreased placental perfusion. Abnormal (superficial) placentation that does not allow uterine spiral arteries to vasodilate to accept increases in blood flow during later pregnancy. Leads to placental ischemia leading to maternal systemic endothelial alterations and a release of catecholamines.The Genetic influence on preeclampsia include: A. an excess production of thromboxane causing vasoconstriction and platelet aggregation. B. Polymorphisms in the genes controlling the expression of inflammatory mediators such as interleukins. C. obesity due to an excess of diet D. Beta carotene and Vitamin E deficiencyB. The other responses have been shown to possibly contribute to preeclampsia but option B is the only genetic influence.Cardiovascular findings in preeclampsia include:Hyperdynamic state Vasoconstriction Vascular hyperreactivity Increased SVR Normal L/R cardiac filling pressures Decreased Preload (often)Preload is often reduced in preeclampsia d/t third spacing and the reduction of intravascular volume. T/FTrueTreatment of reduced preload is through volume replacement. However, what can occur?1. Increased release of Atrial Natriuretic Peptide (ANP) 2. CO may increase to 3-4x that of baselinePulmonary edema affects what percent of all preeclamptic women?3%Reasons for pulmonary edema?Third-spacing and endothelial capillary leakageThird-spacing and pulmonary edema occurs d/t decreased or increased plasma colloid oncotic pressure?Decreased plasma colloid oncotic pressure.Women with preeclampsia have decreased or increased GFR?Decreased. Normal pregnancy has a dramatic increase GFR, but preeclampsia causes diminished GFR.A woman with preeclampsia can be expected to have (select all that apply) A. oliguria B. Increased BUN d/t decreased uric acid clearance C. Proteinuria D. Decreased GFR E. Decreased RBFA, B, C, D, EA patient has Preeclampsia and reports RUQ pain. This is a sign of?hepatic subcapsular hematomasHepatic rupture commonly occurs in pregnancy. T/FFalse; however if it does occur has a high risk of deathDue to decreased intravascular volume in preeclampsia you can expect the Hct to be ?Elevated; d/t hemoconcentrationDIC rarely occurs until platelet count is ?<100,000CNS changes in preeclampsia include (7):1. Loss of cerebrovascular autoregulation 2. Visual disturbances 3. Headache 4. cerebral vasospasms 5. cerebral edema 6. cerebral hemorrhage 7. hyperreflexiaPossible prevention of preeclampsia-low-dose aspirin -Heparin -Calcium Supplementation -Antioxidant supplementation -Vitamin supplementationLow-dose ASA is thought to help how?Inhibits thromboxane. Thromboxane is associated with vasoconstriction, platelet aggregation, decreased uterine blood flow, and increased uterine activity.A patient has been on sub-q Heparin for preeclampsia/DVT prophylaxis. She takes 5,000 units of sub-q Heparin BID. How long do you have to wait before placing an epidural?No time, there is no risk of hematoma formation with this dose. If Heparin is IV, then stop infusion for 4 hours and wait till PTT is normal. Can resume heparin infusion after block is placed, but must stop Heparin infusion for 4 hours before pulling the epidural catheter and then can resume infusion 1 hour after the catheter is removed.The 5 principles of management of Preeclampsia:1. Treatment of HTN (nitro?) 2. Fetal and maternal monitoring 3. Administration of corticosteroids 4. Seizure prophylaxis 5. Timing and route of delivery **The only cure is delivery of fetus and placentaDosing for Hydralazine5-10 mg IV q 20 Slow onset Can cause tachycardia, HA, flushing, & anginaDosing for Labetalol20-40 mg IV q 10 min up to 1-3 mg/kg Can cause scalp tingling, vomiting, heart block, bradycardiaDosing for Nifedipine10-20 mg PO q 20-30 min. Can cause HA, tachycardia, synergistic with MgSO4Dosing for Nitroprusside:0.25-0.50 mcg/kg/minWhy is Esmolol controversial?Can lead to fetal bradycardiaMag Sulfate Dosing4-6 grams IV loading dose followed by 1-2 gram/hr Therapeutic range is 4-8 mEq/L Side Effects include: flushing, sweating, weakness, drowsiness, sedation, nausea, blurred vision, Headache (during loading dose), chest tightness, SHOB, palpitations, pulmonary edema (rare), neonatal depressionFirst sign of Mag ToxicityLoss of DTRsFirst-line treatment of mag toxicityCalcium glucinate 1 gram or Calcium chloride 300 mgAbsolute Indications for Delivery of the baby:1. Convulsions/seizures 2. Cerebral irritability 3. Oliguria with UO <20 ml/hr 4. Uncontrollable HTN 5. Rising serum creatinine 6. Thrombocytopenia 7. DIC 8. Placental abruption 9. Fetal distressRelative Indications for Delivery of the baby when mother has pre-e:-Severe HTN -RUQ pain -Heavy proteinuria -Abdominal pain -Fetal IUGRThe definition of Eclampsia is:The new onset of seizure or unexplained coma during pregnancy or the postpartum woman with s/s of preeclampsia without a preexisting neurological disorder.If the mother seizes outside of the hospital, what is the mortality rate?11%T/F: Eclampsia can only occur before delivery of the baby and placenta.False; can occur several weeks AFTER deliveryMost common cause of HTN in pregnancy?Gestational HypertensionChronic HTN patients that get pregnant are at an increased risk of developing?superimposed preeclampsiaPreferred Anesthetic technique for patients with preeclampsia?Epidural and CSEWhy is early administration of epidural in pts with preeclampsia preferred?-Decreases hypertensive response to pain -Decreases circulating catecholamines -Possibly improves intervillous blood flow -Can be used for emergency deliveries (c/s or instrumented)Clinical guidelines before choosing an anesthetic technique-Coagulation Studies -Prompt Treatment of hypertension -IV hydration consideration -Airway assessment -Renal function -Thrombocytopenia (watch trends and only place epidural/spinal if stable) -Comorbidities such as chronic HTN and IDDMInvasive monitoring considerationsArterial catheter (especially if using Nitro [per book]) CVP monitoringAdvantage of Epidural in the preeclamptic pt:-blunts hormonal and hemodynamic responses -better hemodynamic stability -increases both renal and uteroplacental blood flow -allows for slow dosingAdvantage of spinal with preeclampsia:less potential for hematoma; because needle is smallerFor platelet count between 50,000-100,000 you shouldinvestigate further; watch trends.For platelet count less than 50,000 you shouldconsider GETAWhat epidural catheter is less likely to cause epidural vein trauma?flexible wire-reinforced cathetersTo reduce the risk of epidural hematoma in the thrombocytopenic patient, you should check platelet count prior to removing an epidural catheter. T/FTrueWhich signs are consistent with a diagnosis of preeclampsia? (select 3) A. Vasoconstriction B. Increased Thromboxane C. Increased Prostacyclin D. Seizures E. Proteinuria F. Impaired platelet aggregationA, B, and E