• Pre-eclampsia
    • Definitions
      • PIH
        • Rise in BP in 2nd half of pregnancy without proteinuria
        • No risk to mother or fetus
      • Hypertension in pregnancy
        • DBP >110 on any occasion
        • DBP >90 on 2 occasions
      • BP during pregnancy
        • Usually decreases in 1st trimester
      • Proteinuria
        • >300mg per 24hrs
        • ++ on dipstick
    • Drugs used
      • Hydralazine
        • 5mg IV every 20 mins; 5-20mg/hr infusion
      • Labetalol
        • 20-50mg increments IV; 100mg increments PO; infusion 20-160mg/hr
      • Methyldopa
        • 1g TDS PO
      • Nifedipine
        • 20mg PO
      • SNP
        • 0.25μcg/kg/min
      • GTN
        • 10μcg/min
    • Systemic effects
      • Maternal
        • CVS
          • Vasoconstriction
          • Increased SVR
          • Increased vascular permeability
          • Decreased circulating blood volume
        • CNS
          • Headaches
          • Hyper-reflexia
          • Cerebral haemorrhage
          • Convulsions
          • Papilloedema
        • Renal
          • Reduced GFR
          • Proteinuria
          • Hypoproteinaemia
          • Oliguria
        • Respiratory
          • Pulmonary oedema
          • Facial and laryngeal oedema
          • ARDS
        • Liver
          • Abnormal LFTs
          • Liver rupture
          • Subcapsular haemorrhage
        • Coagulation
          • Increased turnover of fibrinogen, fibrin and platelets
          • Thrombocytopenia
          • DIC
          • HELLP
      • Fetal
        • Decreased placental perfusion
        • IUGR
        • Preterm labour
        • Abruption
    • HELLP syndrome
      • Can be diagnosed if only 1 element is present
      • May occur if hypertension/proteinuria not present occasionally
      • Associated with increased risks of complications
      • Worsens rapidly for 24-48 hrs. Usually resolves in 6 days
    • Management
      • General measures
        • Management of BP, prevention of convulsions and delivery are the goals of management
        • Regular bloods
        • Meticulous fluid balance
        • Careful volume expansion before vasodilators given
        • Maintain MAP 100-140
        • Liaise with haematologists in HELLP
        • Close monitoring with possibility for lines
        • Volume expansion may be beneficial with IV fluids
          • Crystalloid at 1-2ml/kg/hr
          • Oliguria treated with 250ml bolus of crystalloid
          • Keep CVP 3-5mmHg
          • Maintain UO of 0.5ml/kg/hr
      • Timing of delivery
        • Close liaison with obstetric, paediatric and anaesthetic teams
        • Epidural is the preferred choice
          • Improved placental circulation
          • Reduced stress response
          • Platelets <50 a contraindications to CNB
          • >50 may be acceptable if CS normal
          • TEG may be useful
          • Placental flow maintained despite drop in BP (also the case with spinals)
        • GA
          • High risk of failed intubation
          • May be easier to control convulsions
          • Consider AFOI
          • Obtund the response to laryngoscopy
            • Magnesium 40mg/kg
            • Alfentanil 10μcg/kg
            • Esmolol 0.5mg/kg
            • Lignocaine 1.5mg/kg
          • Ensure there is a leak prior to extubation as oedema can worsen
        • Post-delivery
          • Avoid fluid overload
          • Dieresis is common
        • Eclampsia
          • 40% antepartum, 20% intrapartum, 40% postpartum
          • 4g magnesium over 5-10 mins then 1g/hr
    • Pre-eclampsia
      • Aetiology
        • Unknown, genetic and autoimmune likely
        • Deficient placental implantation
        • Increased TXA
        • Decreased prostacyclin
        • Leads to systemic vasoconstriction and platelet dysfunction
      • Multi system disorder occurring after 20th week of pregnancy
      • Main features are proteinuria and hypertension
      • Risk factors
        • FHx
        • Hypertension
        • Diabetes mellitus
        • Multiple pregnancy
        • Increasing maternal age
      • Severity
        • Severe
          • SBP >160mmHg or DBP >110
          • Proteinuria >5g/24hrs
          • Oliguria <400ml/24hrs
          • Cerebral irritability
          • R UQ pain (capsule pain)
          • Pulmonary oedema
    • CEACCP
      Link:ceaccp.oxfordjournals.org/content/3/2/38.full.pdf