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 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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? QID: 108692 FIGURES: A Type & Select Correct Answer 1 Eclampsia. 10% (11/115) 2 HELLP Syndrome. 81% (93/115) 3 Gestational Hypertension 4% (5/115) 4 Hepatorenal syndrome. 3% (3/115) 5 Normal pregnancy. 3% (3/115) M 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic (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: QID: 100502 Type & Select Correct Answer 1 Urethral infection 4% (7/199) 2 Thrombocytosis 22% (44/199) 3 Hemolysis 58% (115/199) 4 Gestational diabetes 7% (13/199) 5 Placenta accreta 7% (13/199) M 4 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK
All Videos (1) Login to View Community Videos Login to View Community Videos Pre-eclampsia Keshav Mudgal Reproductive - Preeclampsia / Eclampsia / HELLP Syndrome D 3/9/2016 59 views 5.0 (1)