A 25-year-old primigravida at 30 weeks of gestation presents to a local hospital, body swelling of 2 days duration, severe headache, & blurred vision. On admission, she is edematous, with a blood pressure of 170/110 mmHg and temperature of 36.50C. Urine ward test reveals 2+ of proteinuria. She is transferred to a tertiary hospital for further management. On arrival, blood pressure and proteinuria remain the same. She complains of right hypochondriac pain. She has hyperreflexia accompanied by clonus.
- What is the diagnosis? (5 marks)
Severe pre-eclampsia
2 . List 5 life threatening systemic complications of this condition. (10 marks)
Cerebral heamorrahage Pulmonary oedema Liver rupture HELLP syndrome Disseminated intravascular coagulation
3. Discuss the management of this patient, giving the underlying principles. (40 marks)
Delivery of the baby is the treatment of choice in pre-eclampsia. Weighing the balance of risk of fetal prematurity versus maternal risk is important to take the decision of delivery. Therefore, accurate diagnosis is important. Of course, in this case the combination of severe hypertension with 2+ proteinuria, hyperreflexia and positive ankle clonus are diagnostic of severe pre-eclampsia, still it is important to consider the possibility to blood pressure reading errors (due to digit preference, not correct cuff size etc) and contamination of urine sample if there is any suspicion.
blood samples to be sent for FBC, LFT, SE, S.Cr, APTT/PT/INT and Group and save to identify the other organ involvement and to assess the severity.
Stabilizing the maternal condition- UK confidential inquiries into maternal deaths have revealed that the cerebral heamorrhages and the pulmonary edema are the causes for maternal deaths due to pre-eclampsia.
Therefore, it is essential to control the blood pressure.
Mean arterial pressure of this patient is 130 mmHg which requires intravenous antihypertensives IV labetalol 50 mg over 5min , ( maximum 4dose), can repeat every 5minutes
if she is asthmatic hydralazine bolus 5mg over 15min, can repeat every 20min if required, maximum 4doses.
BP should be checked every 15minutes, if BP not controlled after IV boluses , start iv infusion
MgSo4 needs to be given >> 4g over 5-10 minutes( 8ml of 50% MgSo4 diluted to 20ml with normal saline) ,
then 1g/hr infusion for24hrs/ 24hrs from the last fit( 20ml (10g) 50% MgSO4 diluted to 50ml with normal saline , infuse at 5ml/hr)
if seizure occurs 2g MgSO4 over 5minutes ( 4ml of 50% MgSO4 diluted to 10ml with normal saline)
mgso4 toxicity should be monitored>> absence of deep tendon reflex, reduced respiratory rate , reduced urine output, cardiac toxicity
Proteinuria is best determined by 24 hour urinary protein excretion and more than 300mg/24 hours is considered abnormal.
However, urinary dipstick test also considered significant in clinical setup.
fluid intake should be restricted 80ml/hr, IP/OP should be monitored.
Assess the systemic involvement Fetal assessment >>> dexamethasone 12mg IM 12 hrly 2doses. Plan the delivery Future risk assessment
4. Briefly evaluate the preventive strategies for reducing the risk of preeclampsia. (25 marks)
Identify the risk factors
Address the modifiable risk factors
Counsel the patient giving information
Prophylaxis low dose aspirin 75-150 mg daily from 12 weeks
Calcium supplementation 1000 mg daily
Blood pressure monitoring chart for high risk pregnancies from the beginning of 3rd trimester
Check blood pressure and urine every antenatal clinic visit
- Describe newer screening methods useful to identify women at risk of developing preeclampsia. (20 marks)
In pre-eclampsia, serum fms like tyrosine kinase 1 (sFlt-1) levels and serum endoglin levels are increased due to relative placental ischemia.
Vascular endothelial growth factor receptors like placental growth factors (PlGF) are down regulated.
Therefore, increased sFlt-1/PlGF serum levels are better predication of preeclampsia and currently using in developed countries.
In addition to elevated sFlt-1, elevated serum endoglins (sEng) also being studied as a newer marker for pre-eclampsia prediction which show promising results.
2nd trimester serum hCG and maternal serum alpha feto protein (AFP) levels indicates two fold increase risk of preeclampsia
Low pregnancy associated plasma protein A (PAPP-A) predicts higher risk in late pregnancy. However, specificity for pre-eclampsia is debated according to some studies.
Urinary excretion of calcium, Microalbuminuria, Prostacyclin metabolites and Urinary kallikrein: creatinine ratio are still at research level for the preeclampsia prediction.
RBP4-Retinol Binding Protein 4 measured at either 15 or 27 weeks was associated with a 4-8 fold increase in early onset but not term pre-eclampsia.
Biophysical tests: uterine artery doppler
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