Pre-Eclampsia

A pregnancy-specific multi-system disorder with unpredictable, variable and widespread manifestations

Aetiology

Risk factors

  • Maternal age >40 years
  • Maternal BMI >30 years
  • Family history
  • Parity (more likely in first pregnancy)
  • Multiple pregnancy
  • Previous PE
  • Birth interval >10 years
  • Molar pregnancy/triploidy
  • Mutiparous women develop more severe disease
  • Pre-existing conditions
    • Pre-existing renal disease
    • Pre-existing hypertension
    • Diabetes
    • Connective tissue disease
    • Thrombophilias

Pathophysiology

  • Diffuse vascular endothelial dysfunction with widespread circulatory disturbance
  • Classified as early or late
    • Early: <34 weeks, uncommon, associated with placental dysfunction
    • Late: ≳34 weeks, accounds for ~9/10 cases
  • Stage 1 - abnormal placental perfusion (placental ischaemia)
  • Stage 2 - maternal syndrome (an anti-angiogenic state associated with endothelial dysfunction)

Liver disease

  • HELLP syndrome - Haemolysis, Elevated Liver enzymes, Low PLatelets
  • Abnormal liver enzymes
  • Hepatic capsule rupture

Placental disease

  • Fetal growth restriction
  • Placental abruption
  • Interuterine death

Clinical presentation

  • Hypertension, proteinuria and oedema
  • Women may be asymptomatic at the time of their first presentation

Symptoms

  • Headache
  • Visual disturbance
  • Epigastric/RUQ pain
  • Nausea and vomiting
  • Rapidly progressive oedema

Signs

  • Hypertension
  • Proteinuria
  • Oedema
  • Abdominal tenderness
  • Disorientation
  • Hyper-reflexia/involuntary movements/clonus
  • SGA fetus
  • Intra-uterine fetal death

Investigations

  • Bloods: U+Es, serum urate, LFTs, FBC, coag screen
  • Urine - protein creatinine ratio
  • CTG
  • US - fetal assessment

Management

  • Low dose aspirin (150 mg) - may be more beneficial in preventing severe early onset pre-eclampsia
    • Used for high risk women
    • Safe in pregnancy
    • Commence before 16 weeks
  • The only 'cure' for pre-eclampsia is birth
    • Mother must be stabilised before birth
    • Consider expectant management if pre-term
    • Steriods/magnesium sulphate
    • Most women delivered within 2 weeks of diagnosis

Complications

  • Eclampsia
  • HELLP syndrome (Hemolysis, Elevated Liver enzymes and Low Platelets)
  • Pulmonary oedema
  • Placental abruption
  • Cerebral haemorrhage
  • Cortical blindness
  • Disseminated intravascular coagulation (DIC)
  • Acute renal failure
  • Hepatic rupture