Lyana : I’m Lyana Sisca
Lynne : And I’m Lynne Solis
Lyana : And you’re listening to Perils of the Pelvis
Lynne : This is a pod cast designed for busy medical students like yourself, so that
you could learn important topics in OBGYN on the go.
Lyana : I’m Lyana and I’m a fifth (5th) year old Obstetrics and Gynecology
resident at the University of Toronto.
Lynne : And I’m Lynne and I’ve just finished my OBGYN residency at the
University of Toronto. So this is really a common problem that you’re
bound to see during your rotation in OBGYN. You’ll see this in clinics,
during patient’s pre-natal visits. You’ll see this in Triage when you’re
assessing patients and you’ll definitely see this on Labor and Del ivery
Lyana : So this is a very important topic, and the other thing we really want to get
across is that it’s often asymptomatic. So unless you’re aware of it and
looking for it, you may actually miss it. So you know, we have to screen
our patients for this.
Lynne : Right and the other tricky thing is that, there’s quite an extensive
classification system to define Hypertension in Pregnancies. So if you
kind of get complicated, there was a guideline that, relatively rece ntly
came out by SOGC, so you can look it up on their website.
Lyana : Yeah and they’re free so you just click, go right into the Society of
Obstetricians and Gynecologists of Canada, go to the guideline link and
that’s where we’re getting this information
Lynne : Right, and that it’s called the Hypertensive Disorders in Pregnancy
Guideline. So what I think would be a good idea is to maybe just start
talking about some of the definitions and how we classify Hypertension in
Pregnancies so that when you get on your rotation, you know, the lingo
that people are using are familiar; is familiar to you.
Lynne : Yes, it’s very important to understand the lingo. We’re also going to talk
about the signs and symptoms to ask about and to look out for in pre-
Lyana : And also how to diagnose pre-eclampsia
Lynne : And how to manage and monitor these patients you have for eclampsia.
Lyana : And then we’ll also want to talk about the related maternal and fetal
complications of this disorder
Lynne : And finally we’ll talk about parental strategies and prognosis for
Lyana : That’s great. So maybe we’ll just start off with going through the very
basics, not because we think that you guys need that but you know, I think
it’s a good place to start just talking about what Hypertension is. So when
we say Hypertension we’re talking about
a diastolic blood pressure of greater than or equal to 90 mmHg
And we do that on two actual measurements. So if a patient comes in
triage and only has the one, we always ask you guys to repeat it. So do
that and the second one is
Severe Hypertension and that’s when their blood pressure is greater
than or equal to 160/110 mmHg
Lynne : Ok so a Hypertension is defined as
Diastolic blood pressure of greater or equal than 90
And Severe Hypertension is
Greater or equal than 160/110
Lyana : That’s right, that’s perfect
Lynne : Ok
Lyana : Perfect. So the next distinction is between Gestational Hypertension and
Lynne : OK
Lyana : So Pre-existing Hypertension is when either you know that the patient has
a history of hypertension from you know, just when they were younger
Lynne : so like their past medical history
Lyana : exactly, you get it from past medical history or when it’s first diagnosed
before twenty (20) weeks gestational age.
Lynne : OK and the thought there is that, it’s diagnosed early in pregnancy and
possibly and likely, it preceded pregnancy and we just missed. Either
these patients haven’t gone to see their family doctor or they haven’t had
their blood pressures checked recently. So the thought is that this is
actually pre-existing although it was first detected early in pregnancy. It’s
probably not because of the pregnancy.
Lyana : That’s right. That is exactly right. And then the second one is Gestational
Hypertension which is exactly what it sounds like. It’s a high blood
pressure that’s first diagnosed in pregnancy. And we once again use the
20 weeks gestational age as a way of saying “well this is probably due to
the pregnancy” because at the beginning of the pregnancy their blood
pressure was normal.
Lynne : So it’s a hypertension diagnosed after 20 weeks gestation.
Lyana : You got it Lynne
Lynne : Ok so, Pre-existing is diagnosed prior to pregnancy or before 20 weeks.
And then Gestational Hypertension is diagnosed after 20 weeks of
Lyana : Perfect
Lynne : Ok.
Lyana : So now, that we got that straight, we are gonna talk about Pre-eclampsia
which is another term you’re going to hear on the labor floor.
Lynne : Ok. So, my understanding is that pre-eclampsia can be associated with
Gestational Hypertension or pre-eclampsia can be associated with Pre-
Lyana : Yeah with both. So, actually it’s got a little bit different definition
depending on which type of hypertension you have.
Lynne : Ok, so why don’t you walk us through that Lyana
Lyana : Ok, so for starters if you have Gestational Hypertension, (so the one after
20 weeks gestational age), its associated with new onset proteinuria. And
proteinuria if you can remember is defined as 0.3 grams per day of protein
in the urine or severe proteinuria is 0.5 grams per day and this is done in a
24 hour collection. So you just get the patient to collect their urine over
24 hours and you see how much protein is in it.
Lynne : OK so if you have Gestational Hypertension and now you develop
proteinuria you’re classified as pre-eclampsia.
Lyana : That’s right.
Lynne : Ok
Lyana : And then one other factor like could move you into pre-eclampsia is if you
have one of a number of these adverse clinical conditions which I think we
should actually go through separately than to kind of illustrate what those
Lynne : So we’ll talk about that later
Lyana : Yeah
Lynne : Ok. So we know that with Gestational Hypertension you could become
pre-eclamptic, or have pre-eclampsia if you have new onset proteinuria, or
if you have these other conditions that we are gonna talk abo ut.
Lyana : Right
Lynne : Later
Lyana : Right
Lynne : Ok. So now what happens if you have Pre-existing Hypertension, how do
you move into the Pre-eclampsia realm?
Lyana : Yeah, so it’s basically the same thing. You have some people who have
previous hypertension; don’t have proteinuria, so if you have new onset
proteinuria again, that would qualify or if you have worsening proteinuria.
Lynne : Ok
Lyana : Resistant Hypertension is the second thing. So if you’re trying a lot of
blood pressure medications and its not working, that would be another
thing that would move you into the pre-eclampsia realm and then finally
once again one or more of the other adverse clinical conditions would
Lynne : Ok, so why don’t we talk about those adverse conditions right now.
Lyana : Sure, why don’t you go through it Lynne.
Lynne : Ok, so the adverse conditions that would move patients from Gestational
Hypertension or Pre-existing Hypertension into Pre-eclampsia are broken
down into Maternal Conditions and Fetal Conditions:
Lyana : Ok
Lynne : So, Maternal Conditions are the following. I am gonna give you a little bit
of a list here
Lyana : Ok
Lynne : So, there’s:
If the patient is having a headache
If they’re having visual disturbance
If they’re having abdominal or Right Upper Quadrant pain.
If they’re having chest pain
If they’re having dyspnea,
Nausea and vomiting
If they have a placental abruption
Abnormal lab values
or if they have eclampsia
Lyana : Ok, so what’s the difference between Pre-eclampsia and eclampsia again
Lynne : Ok, so we went through the definition of Pre-eclampsia just a minute ago.
Eclampsia are actually seizures that can’t be attributed to any other cause,
and are thought to be caused by the pre-eclampsia
: Ok, so we’re gonna move on to tell you about the Fetal Conditions and
IUGR or Intra Uterine Growth Restrictions
Ultrasound Doppler Abnormalities
and Fetal Demise
: Ok, so a quick recap. So, if a patient has these adverse conditions, and
they have Pre-existing or Gestational Hypertension they’re now classified
as having Pre-eclampsia.
Lyana : Excellent, excellent that makes a lot of sense.
Lynne : Ok, so Lyana I’ve heard the term Severe Pre-Eclampsia. Can you help
define that term for us?
Lyana : Absolutely. So severe pre-eclampsia Lynne is actually when
The pre-eclampsia is diagnosed before 34 weeks Gestation,
Or if they have heavy proteinuria (which I described before)
Or once again if they have one of those adverse clinical conditions
Lynne : So Lyana, you actually went to talk to doctor Dr. Nan Okun about this
Lyana : Yeah, actually I went there last weekend and we had an interview at her
office so why don’t we just listen to that to get some more answers to
some of our questions.
Lynne : Ok, let’s take a listen to that:
Lyana : Hi Dr. Okun
Dr. Okun : Hi Lyana
Lyana : I was just wondering if you wouldn’t mind telling the 3 rd year students
what you do and where you work.
Dr. Okun : Sure. So I’m one of the Maternal Fetal Medicine Specialist at Mr. Sinai
Hospital, so that means that I’ve done residency in Obstetrics and
Gynecology and then sub-specialty for 2 more years, essentially in high
risk Obstetrics, Fetal and Maternal problems
Lyana : So you must see a lot of hypertension and pre-eclampsia in your practice
Dr. Okun : Lots of it.
Lyana : Can you speak to some of these outcomes that we can expect when
someone has or when a patient comes to you and you suspect or diagnose
them with pre-eclampsia? What does that mean for that mother and then
maybe you can speak of what it means, for the pregnancy.
Dr. Okun : Sure, so in terms of the mother really, the blood pressures in the pre-
eclampsia are somewhat different. The reason that we’re concerned about
severe hypertension in the mother is really to prevent Cerebrovascular
The issue with severe hypertension is strokes and intra-cranial accidents
for mothers. So even by treating hypertension we can prevent these types
of intra-vascular cerebral accidents, we still can not prevent pre-eclampsia.
So the issue with pre-eclampsia from the maternal point of view is that it
can lead to eclampsia which can be fatal and in some countries that
certainly is. Also can lead to complications of renal shut down or renal
compromise rarely can be associated with long term renal morbidities.
So, those are the main issues with the mother. And convulsions are the
end stage really of pre-eclampsia. Unfortunately, among all women who
develop pre-eclampsia we don’t really have a way of differentiating those
that will and won’t develop eclampsia. But that is the concern of
Lyana : And so, let me see if I understand you correctly. So, even though we’re
treating their hypertension and we can get the numbers down, that doesn’t
necessarily mean that pre-eclampsia is not still evolving, is that correct?
Dr. Okun : That is right.
Lyana : And then for the fetus then?
Dr. Okun : And then for the fetus, the issues are disorders related to decrease in blood
supply to the fetal placental unit. So, on an acute basis it could be
something like an abruption from separation of the placenta which is
And on a chronic basis it can be things related to chronic compromise in
blood supply. So, low amniotic fluid volume (which is a result of low
perfusion of blood within the fetal body system to spare the head and the
heart, so therefore, they don’t make as much urine, they don’t perfuse the
kidneys), so you’ll get oligohydramnios. You’ll get head sparing IUGR
and also you’ll get, on the fetal side, as the placenta has become more and
more damaged from the reduced blood supply from the mother’s side, the
placenta infarct becomes damaged, scarred fibrotic and that increases the
resistance to blood flow from the fetal side to the placenta. So you’ll get
changes in umbilical artery Doppler flow which are essentially early signs
and very good predictors for future chronic things such as
oligohydramnios, IUGR and ultimately if left unattended intrauterine fetal
Lyana : Wow, so it’s very serious.
Dr. Okun : It can be very serious. And interestingly with pre-eclampsia sometimes it
actually presents with fetal problems and maternal pre-eclampsia is not
even diagnosed often until intra-partum or even post partum.
Lyana : Wow, so you have to kinda keep your …
Dr. Okun : Keep your antenna up
Lyana : Yeah, yeah
Dr. Okun : It’s a very curious type of syndrome. The more number of times you see
this, the more number of individual variations you’ll see.
Lyana : Ok, that’s really good for us to know. And so, what is the path, what do
they suspect the pathophysiology of this? Why do some women get it in
their pregnancy and other women are unscathed?
Dr. Okun : Yeah, it’s an interesting question and again over the years there have been
many many different types of theoretical reasons why it might happen ,
anything from toxins getting into the mother’s blood. But the latest theory
which seems to be upheld for the longest is that the disorder actually starts
very very early in pregnancy and it only becomes manifested as a clinical
disease in the 2 nd and 3 rd trimester.
So what seems to happen in these women is that very early on in
pregnancy the placenta doesn’t implant as deeply into the uterine wall.
So, in a normal pregnancy the placenta will implant deeply enough into the
maternal uterine wall to pass through the decidua and into these actual
spiral arterials which are arterials that come off the arquate ar tery of the
uterine artery and essentially these spiral arterials are filled with an
elastic lining and they respond to changes in mother’s circulation . And
what is meant to happen in normal pregnancy is that the placenta invades
so deeply that it actually destroys the elastic lining of the spiral arterials
and creates a type of a circulation that essentially poses no resistance to
flow from the mother side. And that’s a good physiological way of
making sure that the maternal circulation comes in close enough contact
with the fetal circulation so that all of the nutrients and toxins can cross
via various thin separations without being dependent on any maternal
catecholamines or adrenergic influences.
So in normal pregnancy the placenta implants so deeply that the spiral
arterials are in a sense destroyed (their elastic lining).
In a pre-eclamptic pregnancy, if they fail, if the placenta fails to implant as
deeply, the spiral arterials continue to have their elastic lining and
ultimately the placenta does not achieve as much oxygenation and blood
flow which can sometimes make the placenta either over react by
hypertrophying and getting thicker but very abnormal or can be scarred
and basically dysfunctional.
So either one of those morphologic changes in the placenta results in a
dysfunctional placenta that doesn’t do its job, and then for some reason
that seems to lead to some sort of imbalance between different
prostacyclins and thromboxanes which seem to herald a cascade of events
which lead to essentially the vasospasm throughout the mother’s body and
the uteroplacental unit, which in a sense wherever you get the vasospasm
then, is where you get the complications of pre-eclampsia.
Lyana : Ok. And when you see these patients, are you screening? Do you screen
every patient you have for this? Or how do you pick up which patients
have these problem?
Dr. Okun : So essentially Gestational Hypertension is one of the more common
medical disorders along with diabetes, its some where in the 4% to 6%
range of all pregnant women. So yes, every pregnant women who ’s
screened clinically, we screen them by our histories.
We ask them whether they have any predisposing factors, hypertension,
some other factors that can lead to onset of hypertension and pr e-
eclampsia or multiple pregnancies, older pregnancies, history of diabetes
or other background medical disorders, thrombophilias. Many things that
we know can increase the risk of hypertension and pre-eclampsia so we
screen by taking good history and we also screen by doing a physical exam
at the first pre-natal visit. And if you’re lucky enough to be in a primary
practice you would know the patient from before hand and know even
being able to begin to talk to her before she conceives if it’s a situation
where you know that she’s gonna be at an increase risk, and there are some
things that you can do to optimize pregnancy outcome even before
Lyana : Wow
Dr. Okun : So we can screen ideally for people who do primary care, screen patients
even prior to them becoming pregnant when you know that they’re hitting
their reproductive age time.
Lyana : That’s good. That’s really very good. Can you talk to us about some of
the things that you can do or is there something prophylactically that you
can give to these women to try to prevent pre-eclampsia or is that
Dr. Okun : Yeah, again there have been lots of studies that have been done for
primary and secondary prevention for women who don’t have any risk
factors so called primary prevention. The only thing that seems to be
useful is a good calcium intake. Making sure that women either get
enough calcium, a thousand milligrams in their natural food or
supplementing them at least in early pregnancy to get a good calcium
intake and lots of other things that women can do like style related weight
control, proper nutrition and proper vitamin intake. Adjust to optimizing
life style types of situations.
For women that are on medications, those medications would be useful to
review because some of them are not useful and might be contraindicated
in pregnancy. Things like ACE inhibitors, diuretics and putting them on
optimal antihypertensives prior to getting pregnant is also a good idea.
But for low risk women, primary prevention, the only thing that seems to
be useful is a good calcium intake.
Lyana : OK
Dr. Okun : For other women that might be at increase risk of pre-eclampsia, calcium
intake is also important but there’s good evidence to suggest that if they
have risk factors, that a single baby aspirin a day 75 to 80 mgs is a very
low risk intervention that might again prevent if somebody is at already at
some clinical risk that might prevent complications of those disorders.
Lyana : Ok, that’s really good to know. And when you have these patient and
you’re following them in your practice, do you do? What would you do
differently? I guess for that patient once you’ve recognized that perhaps
they’re, lets say it was someone who didn’t have pre-gestational
hypertension but is now at 32 weeks pregnant, they’re 32 weeks pregnant
and you’ve started to see that there’s, you know, their blood pressure is
starting to increase and you’re suspicious that they, you know, maybe
going down this route, is there something you would do differently when
you’re monitoring these patients?
Dr. Okun : Yeah, yeah… more and more these days we’re beginning to put some of
the patient’s care into her own hands which many women like. So one of
the first things that we do is we know that it’s almost inevitable that the
blood pressure we get in a clinic setting is gonna be higher than the usual
Lyana : White coat ahhh
Dr. Okun : Yeah so we encourage them to get a monitor and monitor their blood
pressure at home. It’s an easily achievable skill. I like it better than
the drug store just because again, they can do it in the comfort of their
own home and they can also learn to sort of modify the number of times
that they do it, depending on the severity of what’s going on. So, we’ll
often find that even by keeping a record of their blood pressure and not
only do they get a more accurate reading but they can even see in their
own lives what types of things induce higher blood pressure than other
Lyana : Right
Dr. Okun : One of the early interventions that we do is reducing stress and reducing
work loads. So, while there’s no evidence for bed rest for preventing pre -
eclampsia, I don’t think there is any question that taking somebody off
work reduces blood pressure over the day. And women often will be
resistant to this and they don’t really see it until they have actually done it
and then they recognize how stressed they are in their daily lives and how
just the active going off-work can actually improve. And this is useful
because if we don’t have to use medications then we would like to stay
away from them. And many women just by home monitoring and cutting
back on stress and deadlines and work can find that they can actually get
much farther in the pregnancy and either avoid medications altogether or
just use them towards the end of pregnancy, if needed.
Lyana : Yeah. That’s good. And you mentioned that there’s certain medications
that we tend to use for our pregnant patient’s who are hypertensive that are
different than, you know, maybe the average patient who might have had
hypertension prior to pregnancy. And you said that diuretics and ACE
inhibitors, we don’t tend to use. Can you tell us what medications we do
use to help these women?
Dr. Okun : Yeah, there seem to be three, about three classes of medications that we
use both on an in-patient basis and an out-patient basis. Just slightly
different ways of giving them. So, on an out-patient basis often one of the
first things we use is something called alphametholdopa which I think as
we go on, we’ll probably start to see used less and less.
It’s a very traditional medication that we know is safe. It’s probably not
the best anti-hypertensive but it has a very low side effect profile.
So, we all start with some alphametholdopa or aldomet, start with maybe
250 mgs 2x a day. We can go all the way up to 4gms a day if necessary.
Lyana : Wow
Dr. Okun : And then more and more, we’re starting to use Beta blockers and Calcium
channel blockers. So the main Beta blocker that is used is Labetalol or
Trandate and that also has been found to be safe over the years. There’s
some concern with Beta blockers particularly atenolol which we don’t use
but there’s some concern about the aggressiveness of treating blood
pressure so there’s right now an on-going trial at least one looking at
whether we should be more aggressive, i.e. getting women’s diastolic
pressure to about 80 or less aggressive keeping their diastolic pressure
around the 90 level.
So the concern of obviously too much over treatment is reduced blood
flow to the uteroplacental unit and potentially translating it to IUGR.
Lyana : Right
Dr. Okun : So Beta blockers we tend to watch a little bit more carefully but they’re
very useful anti-hypertensives. And then the Calcium channel blockers are
used sometimes along with if we’re having trouble with one medication,
we’ll add another medication. So adalat is the one that we commonly use
in various preparations, short acting, and long acting adalat.
So we tend to use those three classes mostly.
Lyana : Ok. And you said that once the blood pressure is down it doesn’t mean that
the risk is gone. So you must be using something else to monitor the
pregnancy as it goes on and it sounded like you use Ultrasound wit h the
Doppler you mentioned to assess how the fetus is doing and clinically I’m
assuming how the patient’s symptomatic.
I know we order blood work on patients, can you talk to the medical
students about some of the lab work we might order to monitor how
they’re doing, once they’re, lets say someone has come in to the hospital
and we’re trying to manage their blood pressure. There are certain blood
values that would show more concern or is it all the same.
Dr. Okun : So, I think we tend to over order a lot of blood work for pre-eclampsia.
The things that really matter that go together with HELLP Syndrome are
the CBC and mostly again we’re concentrating on the platelet count. If
anything, the hemoglobin will increase because of the vasoconstriction in
actual constriction of the intravascular fluid volume. So we don’t expect a
drop in hemoglobin unless you’re truly to get hemolysis which I must say
I’ve not seen in the pure pre-eclampsia syndrome
Lyana : Ok
Dr. Okun : Low platelets are very common. So concentrate on the platelets and then
similarly, people will often order all kinds of things for biochemistry but
the liver enzymes, Uric acid are very useful.
So the Uric Acid is non specific. It again is a reflection of intravascular
volume constriction, but when you put it together with sort of the global
gestalt of the patient. it can be very useful to help figure out whether
you’re getting close to a time that you might think about delivering
Lyana : Ok
Dr. Okun : And similarly the liver enzymes. So, the ones that we’re interested in
specifically are the SGOT, SGPT or AST ALT now we want to call them.
Alk phos is not useful because it’s elevated in pregnancy anyhow.
Many people will do things like PTT’s and INR’s and fibrinogen’s and but
unless you have a complicated pre-eclampsia syndrome or you have
another differential diagnosis such as hemolytic Uremic syndrome or TTP
then usually those features are not a part of the pre-eclampsia syndrome.
We rarely see a bleeding disorder with pure pre-eclampsia, only if its
turned into one complicated by abruption or if in fact there is another
diagnosis that we’re missing going on. So if those things are awry then I
would be looking for another serious diagnosis; acute fatty liver of
pregnancy, TTP that are sometimes treated differently and important to
Lyana : Ok and I know when I was in medical school it was really stressed up
when we all waited to deal with this problem; is to actually deliver the
patient. And I know that we’re always trying to balance the risk of pre-
maturity versus the risk of continuing the pregnancy. I guess once the
woman has reached term, let’s say 37 weeks, would you say that most
people would deliver a patient if they have pre-eclampsia at that point or is
there any value?
Dr. Okun : Oh, I think so. I mean I think if you really, if you have pre-eclampsia, i.e.
you’ve got hypertension complicated by significant proteinuria there is no
other cure but delivery.
Lyana : Right
Dr. Okun : So, as you said, the only thing that we do from time to time when the
situation is appropriate is to try and temporize long enough to optimize the
outcome of the mother and the fetus. So certainly after 34 weeks pre -
eclampsia one would not hesitate to deliver.
Between about 24 and 34 weeks you might think about temporizing long
enough to do things, like transfer to a tertiary care center, give steroids to
help induce lung maturity and optimize perinatal outcome and
occasionally in gestational ages where we know that if we can just buy
another week or so, some times we can temporize by a combination of
treating high blood pressure, giving steroids, very close monitoring of the
mother and fetus and try and get that baby a little bit farther along before
Under 24 weeks is really considered to be non-viable and as cold as it
sounds, we really consider the mother as the primary patient then, because
we know that we are not able to do anything for that fetus. So we don’t
wanna take chances with mother’s health.
Lyana : I guess the prognosis for these patients, so let’s say, you know poor
patients been through all these, what is the risk that subsequent
pregnancies will end the same way
Dr. Okun : Develop the same thing.
Lyana : Yeah
Dr. Okun : So it really depends on the severity and the timing and gestation that it
happened as well as the consideration of any other background,
predisposing factors that you may or may not have uncovered during the
pregnancy. So these patients we take very seriously. We see them in post
partum for a very thorough assessment of any background disorders that
we may have missed and we sit down and discuss every (individually),
what we think that the risk might be in the next pregnancy and some ways
that we can help to temporize, if possible, things that we can do in
between pregnancies and things that we can do during the next pregnancy
early which may make a difference.
Lyana : Ok. That’s great Dr. Okun. Thank you so much for answering all those
questions. Is there anything else that you would want to tell the 3 rd year
medical students, you know, particular anecdote or a particular point that
you’d really like to stress when they’re just about to start their rotation,
may meet a patient like this. Is there anything that they should, I don’t
know, take to the floor with them that you can… Any last words of
Dr. Okun : I think, you know, I think just a few things… I think when you’re starting
out; one of the most important things is not to ignore this disorder.
Women, because they’re not symptomatic will tend to think that you’re
over reacting but I always advise the students when they’re starting their
own practice, no matter what your practice setting, if it’s a small role
town, if it’s a tertiary level area, make sure that if your suspicious that you
If that means admitting a patient over night to hospital and evaluating their
blood pressure over that period of time, giving you a chance to do the
blood work and assess the fetus, you’ll never go wrong by doing that. So
that’s one very important point and also not ever to sort of let down your
guard. It is one of the most common disorders and it can present in so
many different ways. Even people will come in with, to emergency there’s
always the urban legend of women coming in to emergency with right
upper quadrant pain and being diagnosed with hepatitis.
So be very wary of all the signs and symptoms that can be a part of their
pre-eclampsia syndrome because you will see them present in such sort of
sinister ways that you have to always keep your guard up. Even babies
that are small for gestational age, watch out for that happening if you
know it, that later in that part of pregnancy. So its just a disease that
worldwide is one of the top three causes of maternal and perinatal
morbidity and mortality, still and still bares… is easily uncovered with
good pre-natal care and easily addressed to with interventions that are very
effective in reducing maternal particularly mortality and morbidity and
often can improve perinatal outcome as well.
Lyana : That’s excellent Dr. Okun. We thank you so much for joining us today
and doing this interview. I know our 3 rd year medical students have
learned a lot from this and I know I have too. So, thank you very much for
spending your time with us.
Dr. Okun : Pleasure
Lynne : That was really great Lyana. So now what we thought we’d do is talk to
you guys about how to go through a practical approach to patients with
pre-eclampsia so when you see a woman in triage or in a clinic you know
exactly how to approach the patient.
Lyana : So like always, you want to take a full history which includes the:
age of the patient
their gravida peri status
and then the usual like
The chief complaint
Obstetrical history which is unique to OB
Past medical history
Past surgical history
Past Gyne history
and then of course
Your family and social history
Lynne : And specifically in the HPI this is very important. You want to ask what
the following symptoms so
Right Upper Quadrant pain
Chest Pain and
Shortness of breath
Lyana : Then you’re gonna be moving on to your physical exam which should
always start with
Height and weight of the patient and
their Vital Signs
Lynne : And you want to pay careful attention obviously to their blood pressure.
And as we said before a diastolic pressure of greater than 90 on two (2)
readings is a definition of hypertension
Lyana : And then you might want to
assess their visual fields for scotomas
do a cardiovascular and respiratory exam
then were gonna move on to the abdominal exam with the
focus on any Right Upper Quadrant tenderness and while
you’re there you’re gonna want to see that they’re symphyis
fundal height is appropriate for gestational age
and then finally we’ll assess the patient’s reflexes and
presence of clonus.
Lynne : Good and then finally, you’ll do some important investigations. So you’ll
do investigations for the mom and for the baby.
Lyana : Right
Lynne ; So the investigation is for the mom, you’ll do:
You’ll do urine dip stick for protein coz as we’ve talked
about, that will help you determine whether
this patient has hypertension or just or has
Lyana : And so a dip stick is a 2+ Lynne is that it?
Lynne : Yeah but it’s greater than 2+ is its definition of proteinuria or you can
always do a 24 hour urine collection. But if you want to kind of one spot,
it’s the urine dip. Then you’ll order some laboratory investigations and
those will consist of a
CBC, you’ll want to look at your hemoglobin and your
LDH and your
Coagulation factor profile
Lyana : Perfect
Lynne : And then you want to do an investigation of the fetus. So investigation of
the fetus will include an
An NST (a non stress test)
and an Ultrasound
In Ultrasound your looking for the
estimated fetal weight
and then the Umbilical Artery Doppler
Lyana : Perfect
Lynne : Perfect
Lyana : I guarantee you guys if you do this, your resident and staff will be
Lynne : Absolutely. If I had a medical student that came back and told me that this
patient has clonus or doesn’t have clonus or actually did their reflexes, I’d
be very impressed. It just tells your resident that you actually know what
pre-eclampsia is and you know what you’re looking for. You got means
like you actually know what these adverse conditions are. So this would
really really really impress me.
Lyana : So we hope that this pod cast has helped teach you about Hypertensive
disorders of pregnancy
Lynne : Good luck with your rotation and good luck studying for your exam.
Lyana : This is Lyana Sisca
Lynne : And this is Lynne Solis
Lyana : And you’ve been listening to Perils of the Pelvis