Pre Eclampsia

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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
            subsequent pregnancies.

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
            Pre-existing Hypertension.

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-
            existing Hypertension.

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
            qualify you.

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
            those are:

                      Oligohydramnios
                      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
            didn’t you?
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
               unattended pre-eclampsia.
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
               acutely infarcted.

               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
               pregnancy begins.

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
               we deliver.

               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
               wisdom for…
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
               monitor carefully.

               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
                             HPI and
                       Obstetrical history which is unique to OB
                       Past medical history
                       Past surgical history
                       Past Gyne history
                       Medications
                       Allergies
                      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

                         Headache
                         Visual disturbance
                         Right Upper Quadrant pain
                         Nausea
                         Vomiting
                         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
                        your Electrolytes
                        your Creatinine
                        BUN
                        Liver Enzymes
                        Uric Acid
                        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
                       Biophysical profile
                       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

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