Snapshot A 36-year-old woman at 34 weeks gestation presents to the emergency room for abdominal pain and headaches. She reports noticing these symptoms last night but attributed it to eating some take-out last night. On physical exam, she has tenderness to palpation in the epigastrium. Her blood pressure is 166/115 mmHg. She begins having tonic-clonic seizures. She is immediately prepped for delivery via cesarean section and started on anti-seizure medications. (Eclampsia) Introduction Overview hypertension during pregnancy can be chronic hypertension, gestational hypertension, preeclamspia, or eclampsia some consider HELLP syndrome to be a form of preeclampsia/eclampsia although this is controversial Diagnosis of preeclampsia hypertension (> 140/90 mmHg on 2 separate occasions, or 160/110 mmHg) and proteinuria can also be diagnosed without proteinuria if one of the following signs of severe preeclampsia blood pressure >160/110 hepatic dysfunction renal insufficiency visual/cerebral disturbances pulmonary edema thrombocytopenia Spectrum of Hypertensive Disorders in Pregnancy Chronic Hypertension Gestational Hypertension Preeclampsia Eclampsia HELLP Syndrome History of hypertension (> 140/90 mmgHg) before pregnancy or before 20 weeks of gestation Hypertension persists after delivery Hypertension after 20 weeks of gestation Hypertension returns to baseline by 6 weeks post-partum Common in multiple gestations Hypertension (> 140/90 mmHg on 2 separate occasions, or >160/110 mmHg) plus proteinuria Preeclampsia plus seizures Hemolysis Elevated Liver enzymes Low Platelets Epidemiology incidence preeclampsia/eclampsia 2-6% HELLP syndrome 0.1-0.6% risk factors preeclampsia/eclampsia nulliparity multiple gestations hyatidiform mole diabetes chronic hypertension chronic renal disease HELLP syndrome maternal age > 34 years multiparity Caucasian/European descent Pathogenesis mechanism preeclampsia/eclampsia impaired vasodilation of spiral arteries cause placental ischemia this results in increased vascular tone, increased vasoconstriction, and decreased vasodilation other factors considered to contribute include maternal immunologic intolerance, inflammatory changes, and abnormal placental implantation HELLP syndrome thought to be due to endothelial activation, consumption of platelets, microangiopathic hemolysis, and microvascular injury complement dysfunction may also play a role Prognosis preeclampsia/eclampsia maternal mortality 14% HELLP syndrome maternal mortality 1-3% most resolve after delivery Presentation Symptoms there is often overlap between preeclampsia/eclampsia and HELLP syndrome common symptoms headache epigastric or right upper quadrant pain visual changes pulmonary edema oliguria water retention Physical exam inspection hypertension > 140/90 mmHg tonic-clonic seizures hyperreflexia periorbital and extremity edema altered mental status jaundice Studies Serum labs proteinuria 1-2+ on dipstick > 300 mg on 24-hour urine protein/creatinine ratio > 0.3 best confirmatory test is a spot urine protein to creatinine ratio thrombocytopenia hemoconcentration elevated liver enzymes in HELLP syndrome hemolysis in HELLP syndrome elevated lactate dehydrogenase elevated bilirubin hemolysis on peripheral smear schistocytes, helmet cells, or burr cells Differential Acute fatty liver of pregnancy key distinguishing factor characterized primarily with fulminant liver failure Treatment Medical antihypertensive medication indications preeclampsia/eclampsia and HELLP syndrome blood pressure > 160/100 mmHg risk of decreased utero-placental blood flow drugs labetalol methyldopa hydralazine intravenous steroids indications thrombocytopenia HELLP syndrome intravenous magnesium sulfate or diazepam indications seizure prophylaxis and treatment preeclampsia/eclampsia and HELLP syndrome magnesium toxicity can occur hyporeflexia presents before bradypnea treatment calcium gluconate Surgical delivery indications the only definitive treatment if mild preeclampsia or stable with HELLP syndrome, can monitor for progression if severe preeclampsia, eclampsia, or unstable, deliver immediately Complications Complications preeclampsia/eclampsia maternal cerebral hemorrhage disseminated intravascular coagulopathy acute respiratory distress syndrome abruptio placentae recurrence of preeclampsia HELLP syndrome maternal complications cerebral hemorrhage disseminated intravascular coagulopathy acute renal failure hepatic rupture risk of recurrence in subsequent pregnancies increased risk of preeclampsia, preterm delivery, and placental abruption neonatal complications prematurity intrauterine growth retardation fetal demise other complications increased risk of cardiovascular disease
QUESTIONS 1 of 5 1 2 3 4 5 Previous Next Lab Values Blood Hematologic Cerebrospinal Sweat, Urine, and BMI Blood, Plasma, Serum Reference Range ALT 8-20 U/L Amylase, serum 25-125 U/L AST 8-20 U/L Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL Calcium, serum (Ca2+) 8.4-10.2 mg/dL Cholesterol, serum Rec: < 200 mg/dL Cortisol, serum 0800 h: 5-23 μg/dL //1600 h: 3-15 μg/dL 2000 h: ≤ 50% of 0800 h Creatine kinase, serum Male: 25-90 U/LFemale: 10-70 U/L Creatinine, serum 0.6-1.2 mg/dL Electrolytes, serum Sodium (Na+) 136-145 mEq/L Chloride (Cl-) 95-105 mEq/L Potassium (K+) 3.5-5.0 mEq/L Bicarbonate (HCO3-) 22-28 mEq/L Magnesium (Mg2+) 1.5-2.0 mEq/L Estriol, total, serum (in pregnancy) 24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL 28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL Ferritin, serum Male: 15-200 ng/mLFemale: 12-150 ng/mL Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL Female: premenopause: 4-30 mIU/mL midcycle peak: 10-90 mIU/mL postmenopause: 40-250 pH 7.35-7.45 PCO2 33-45 mmHg PO2 75-105 mmHg Glucose, serum Fasting: 70-110 mg/dL2-h postprandial:<120 mg/dL Growth hormone - arginine stimulation Fasting: <5 ng/mLProvocative stimuli: > 7ng/mL Immunoglobulins, serum IgA 76-390 mg/dL IgE 0-380 IU/mL IgG 650-1500 mg/dL IgM 40-345 mg/dL Iron 50-170 μg/dL Lactate dehydrogenase, serum 45-90 U/L Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL Female: follicular phase: 5-30 mIU/mL midcycle: 75-150 mIU/mL postmenopause 30-200 mIU/mL Osmolality, serum 275-295 mOsmol/kd H2O Parathyroid hormone, serume, N-terminal 230-630 pg/mL Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L Phosphorus (inorganic), serum 3.0-4.5 mg/dL Prolactin, serum (hPRL) < 20 ng/mL Proteins, serum Total (recumbent) 6.0-7.8 g/dL Albumin 3.5-5.5 g/dL Globulin 2.3-3.5 g/dL Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h Thyroxine (T4), serum 5-12 μg/dL Triglycerides, serum 35-160 mg/dL Triiodothyronine (T3), serum (RIA) 115-190 ng/dL Triiodothyronine (T3) resin uptake 25%-35% Urea nitrogen, serum 7-18 mg/dL Uric acid, serum 3.0-8.2 mg/dL Hematologic Reference Range Bleeding time 2-7 minutes Erythrocyte count Male: 4.3-5.9 million/mm3Female: 3.5-5.5 million mm3 Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/hFemale: 0-20 mm/h Hematocrit Male: 41%-53%Female: 36%-46% Hemoglobin A1c ≤ 6 % Hemoglobin, blood Male: 13.5-17.5 g/dLFemale: 12.0-16.0 g/dL Hemoglobin, plasma 1-4 mg/dL Leukocyte count and differential Leukocyte count 4,500-11,000/mm3 Segmented neutrophils 54%-62% Bands 3%-5% Eosinophils 1%-3% Basophils 0%-0.75% Lymphocytes 25%-33% Monocytes 3%-7% Mean corpuscular hemoglobin 25.4-34.6 pg/cell Mean corpuscular hemoglobin concentration 31%-36% Hb/cell Mean corpuscular volume 80-100 μm3 Partial thromboplastin time (activated) 25-40 seconds Platelet count 150,000-400,000/mm3 Prothrombin time 11-15 seconds Reticulocyte count 0.5%-1.5% of red cells Thrombin time < 2 seconds deviation from control Volume Plasma Male: 25-43 mL/kgFemale: 28-45 mL/kg Red cell Male: 20-36 mL/kgFemale: 19-31 mL/kg Cerebrospinal Fluid Reference Range Cell count 0-5/mm3 Chloride 118-132 mEq/L Gamma globulin 3%-12% total proteins Glucose 40-70 mg/dL Pressure 70-180 mm H2O Proteins, total < 40 mg/dL Sweat Reference Range Chloride 0-35 mmol/L Urine Calcium 100-300 mg/24 h Chloride Varies with intake Creatinine clearance Male: 97-137 mL/minFemale: 88-128 mL/min Estriol, total (in pregnancy) 30 wks 6-18 mg/24 h 35 wks 9-28 mg/24 h 40 wks 13-42 mg/24 h 17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 hFemale: 2.0-8.0 mg/24 h 17-Ketosteroids, total Male: 8-20 mg/24 hFemale: 6-15 mg/24 h Osmolality 50-1400 mOsmol/kg H2O Oxalate 8-40 μg/mL Potassium Varies with diet Proteins, total < 150 mg/24 h Sodium Varies with diet Uric acid Varies with diet Body Mass Index (BMI) Adult: 19-25 kg/m2 Calculator ( ) xy AC 7 8 9 ÷ 4 5 6 × 1 2 3 - 0 . = + Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK You have 100% on this question. Just skip this one for now. Take This Question Anyway (M1.RP.17.4753) A 19-year-old primigravid woman at 33 weeks gestation arrives at her obstetrician's office. She complains she is feeling very tired and is sick of being pregnant. She notes that the swelling in her feet has been much worse recently. She has been having headaches and feels that her vision has been blurry today. Her blood pressure is 170/110 mmHg. Further testing is done showing serum aspartate aminotransferase of 110 U/L, serum alanine aminotransferase of 90 U/L, and 2+ protein on urine dipstick. Her peripheral blood smear is shown in Figure A. What is the most likely diagnosis for this patient? Review Topic | Tested Concept QID: 108692 FIGURES: A Type & Select Correct Answer 1 Eclampsia. 9% (8/92) 2 HELLP Syndrome. 82% (75/92) 3 Gestational Hypertension 4% (4/92) 4 Hepatorenal syndrome. 2% (2/92) 5 Normal pregnancy. 3% (3/92) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 You have 100% on this question. Just skip this one for now. Take This Question Anyway (M1.RP.13.2) A 36-year-old primigravida woman visits her gynecologist during the 28th week of her pregnancy. Physical examination reveals pitting edema around her ankles and elevated systolic blood pressure. 24-hour urine collection yields 4 grams of protein. If left untreated, the patient is most at increased risk for which of the following: Review Topic | Tested Concept QID: 100502 Type & Select Correct Answer 1 Urethral infection 4% (7/180) 2 Thrombocytosis 24% (43/180) 3 Hemolysis 54% (97/180) 4 Gestational diabetes 7% (13/180) 5 Placenta accreta 7% (13/180) L 4 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK
All Videos (1) Podcasts (0) Login to View Community Videos Login to View Community Videos Pre-eclampsia Keshav Mudgal Reproductive - Preeclampsia / Eclampsia / HELLP Syndrome 3/9/2016 36 views