Pathophysiology
Why is aggressive fluid therapy contra-indicated for volume contracture of preeclampsia?
Increased capillary leak and decreased colloid oncotic pressure
This leads to increased pulmonary capillary wedge pressure leading to pulmonary edema
What are the blood pressure diagnostic criteria for gHTN/PreE and severe preeclampsia
gHTN/PreE: SBP >=140 or DBP >=90 >4 hours apart after 20 weeks with previously normal BP
Severe PreE: SBP >=160 or DBP >=110 can be within minutes of each other to facilitate antihypertensive treatment
What is the NNT for magnesium prophylaxis in symptomatic cases (severe headache, photophobia, blurred vision, scotoma, hyperreflexia, epigastric pain) of severe preeclampsia vs asymptomatic
36 and 129
Preeclampsia/gestational HTN
Severe PreE (bonus, previability)
37 weeks
34 weeks or sooner (soon after maternal stabilization)
Which transaminase is predominantly elevated in preeclamptic disease and what is it related to?
AST and it is related to periportal necrosis. ALT is the primary elevated enzyme in other parenchymal liver disease
What are diagnostic lab criteria for diagnosis of severe preeclampsia
Platelets less than 100
transaminitis more than twice the ULN without an alternative etiology
Serum creatinine >1.1 or doubling
What is the risk reduction of aspirin prophylaxis for preterm preeclampsia? What about term preeclampsia
60% (1.6 vs 4.3%)
Did not affect risk of term preeclampsia
GDMA1
GDMA2
39w0d - 40w6d
39w0d - 39w6d
What causes oliguria in severe preeclampsia?
Intrarenal vasospasm with an approximate 25% reduction in GFR.
Vasospasm is caused by interaction of various vasoactive agents such as prostacyclin, thromboxane A2, nitric oxide, and endothelia's
What are the diagnostic criteria of HELLP?
LDH > 600 (hemolysis)
LFT > 2x the ULN (elevated liver enzymes)
Platelets < 100 (low platelets)
Describe the escalating effects of magnesium toxicity and the therapeutic range and levels at which we expect these effects.
5-9 Therapeutic
>9 Loss of patellar reflexes
>12 respiratory paralysis
>30 Cardiac arrest
Mono-mono twins
Oligohydramnios
32w0d - 34w0d
36w0d - 37w6d or at diagnosis if later
Name 3 of the 7 proposed mechanisms of preeclampsia
Chronic uteroplacental ischemia
Immune maladaptation
VLDL toxicity
Genetic imprinting
Increased trophoblast apoptosis or necrosis
Exaggerated maternal inflammatory response to deported trophoblasts
Imbalance of angiogenic factors
What are the most common precipitating symptoms of eclampsia and what percentage of patients experience them?
What causes these symptoms?
Signs of cerebral irritation such as severe persistent occipital or frontal headaches, blurred vision, photophobia, and altered mental status. 78-83%
Caused by elevated cerebral perfusion pressure, cerebral edema, and hypertensive encephalopathy
Describe the HYPITAT trial and its outcomes?
Compared expectant management or induction of labor for women w/ gHTN/PreE after 36 weeks.
Induction was associated w/ significant reduction in composite of new onset severe PreE, HELLP, eclampsia, pulmonary edema, or placental abruption (30% reduction)
FGR
FGR severe
FGR reversed end diastolic flow
38w0d-39w0d
37w0d
30w0d - 32w0d