Information Sheet for Candidates:

You are a locum GP in a suburban general practice. Your

nest patient is a 25 year old Mrs. Jones in her first
pregnancy who presents for a general check-up at 30
weeks. The practice nurse has noted a BP of 175/100, P of
72, RR 20, T 37. She also performed a urine office test
which showed proteinuria (+++) on dip stick.
At previous antenatal visits she had been quite well with
normal vital signs and urine office tests.
Your task is to:
Take a focused history
Perform an examination (you have to ask the examiner
for specific findings you are looking for, because you
will only be given the results of findings you ask for!)
Explain you diagnosis and management plan to the
patient.

HOPC:
This is Mrs. Jones first pregnancy and she was quite well during her pregnancy so far, all
antenatal visits were o.k., including a normal U/S 12 weeks ago and she feels alright at
the moment. She really hasnt had any problems, specifically no headaches, no bleeding,
no nausea or vomiting, no heartburn, no swelling of ankles, hand or face, no cramps, no
back or abdominal pain, no visual disturbances.
She is quite amused about the fuss your practice nurse made when she took the blood
pressure and did the urine examination.
She wants to know what this is all about.
PHx: unremarkble, no illnesses, no diabetes, no kidney problems, no operations.
FHx: parents alive and well, 2 sisters well.
SHx: married, works as real estate agent, no financial problems, no stress, non smoker,
has not had alcohol during pregnancy, no allergies, no medication.
EXAMINATION: (LOOK, LISTEN, FEEL !!!!):
Pat. looks well, no obvious peripheral oedema.
BP is indeed 175/110, P 72 and regular, afebrile, SaO2 98% on room air.
Uterus 6 cm above umbilicus (= c/w 24 26 weeks pregnancy), non tender, foetal heart
audible, foetal movements felt, normal presentation and position.
No hyperreflexia or clonus!
DIAGNOSIS: pre-eclampsia!!!
Pre-eclampsia is the development of hypertension, proteinuria or oedema between the
20th week of pregnancy and the end of the first week postpartum.
The aetiology is not certain but it can lead to multisystem disorder affecting maternal
liver, kidneys, brain and clotting system and placental dysfunction. Generally we classify
three grades as mild, moderate and sever pre-eclampsia, mainly differentiated by higher
bloodpressure and increasing proteinuria and evidence of any other endorgan
dysfunction.
If untreated pre-eclampsia can suddenly develop in to fully blown eclampsia!
Signs and symptoms of pending eclampsia may include:
- persistent, severe frontal or occipital headache
- visual disturbances (blurred vision/photophobia) papilloedema
- right upper quadrant or epigastric pain, nausea and/or vomiting
- sudden rise in blood pressure (BP).
- diminished urine output. Oliguria (< 120 mls :3 hours) increasing proteinuria
- hyper-reflexia and clonus
- altered level of consciousness
- mental state/restlessness.

The main risks for the mother are seizures, CVA, renal failure, DIC, cardiac failure and
progression into eclampsia! There are also significant risks for the foetus: hypoxia,
abruptio placentae, intrauterine death and premature delivery.
INVESTIGATION:
Urinanalysis (proteinuria sign of capillary permeability, casts and cells)
LFTs
Uric acid
UECs
FBE
Coagulation profile
CXR (ARDS)
ECG
CTG
U/S
RISK FACTORS (not necessarily for this patient!:
Primigravidas, prior pre-eclampsia, multiple pregnancy, hydatidiform mole, multigravida
with a new partner, positive family
MANAGEMENT :
Treatment aims at preserving life and health of the mother, although the fetus usually also
survives.
Mild pre-eclampsia can be treated at home with bedrest and regular (every second day)
review by GP. If not improving the patient needs hospital admission.
Severe pre-eclampsia is a medical and obstetric emergency and hospital admission to a
tertiary hospital is required.
Delivery is the only cure, but the timing depends on severity, progress and gestational
age. A trial of conservative treatment can be instituted but if no significant improvement
is shown in 24 hours delivery is indicated!
MANAGEMENT OF PRE-ECLAMPSIA AND ECLAMPSIA:
Bedrest in left lateral position
ANTICONVULSANTS: MgSO4 i.v. infusion (calcium channel blockade in
smooth muscle, reducing cerebral vasospasm), phenytoin, diazepam
ANTIHYPERTENSIVES: Hydralazine in 5 mg boluses (up to 20 mg).
Alternatives are nifedipine or nitroprusside. Aim for a reduction of systolic BP by
20-30 mmHg and diastolic BP by 10-15 mmHG. Greater reduction can cause
foetal ischaemia.
Close monitoring of fluid balance to avoid APO and cerebral oedema
Correction of coagulation abnormalities with FFP
Monitoring: BP, urinary output (IDC), urine protein, coagulation, CTG for fetus!!!
Promote foetal lung maturity with corticosteroids (betamethasone
Possibly emergency delivery , usually by Caesarean section (it is the FINAL
TREATMENT!!!!!)

Follow-up post delivery

HELLP SYNDROME:
HAEMOLYSIS
ELEVATED LIVER ENZYMES
LOW PLATELETS