Preeclampsia

Preeclampsia

Q. 1

Which of the following is not a predisposing factor for Preeclampsia?

 A Anti-phospholipid antibody

 B

Smoking

 C

Gestational diabetes

 D

Molar pregnancy

Q. 1

Which of the following is not a predisposing factor for Preeclampsia?

 A

Anti-phospholipid antibody

 B

Smoking

 C

Gestational diabetes

 D

Molar pregnancy

Ans. B

Explanation:

Ans:B.)   Smoking REF: William’s obstetrics 22nd edition

Although smoking during pregnancy causes a variety of adverse pregnancy outcomes, ironically, smoking has consistently been associated with a reduced risk of hypertension during pregnancy (Bainbridge and associates, 2005; Zhang and colleagues, 1999). Placenta previa has also been reported to reduce the risk of hypertensive disorders in pregnancy (Ananth and colleagues, 1997).

Underlying Causes of Chronic Hypertensive Disorders:

Essential familial hypertension (hypertensive vascular disease)

Obesity

Arterial

abnormalities

Renovascular hypertension

Coarctation of the aorta

Endocrine

disorders

Diabetes mellitus

Cushing syndrome

Primary aldosteronism

Pheochromocytoma

Thyrotoxicosis

Glomerulonephritis (acute and chronic)

Renoprival

hypertension

Chronic glomerulonephritis

Chronic renal insufficiency

Diabetic nephropathy

Connective

tissue

diseases

Lupus erythematosus

Systemic sclerosis

Periarteritis nodosa

Polycystic kidney disease

Acute renal failure


Q. 2

Specific treatment of severe pre eclampsia is?

 A Magnesium sulfate
 B Termination of pregnancy
 C Anti convulsants
 D

Anti hypertensives

Q. 2

Specific treatment of severe pre eclampsia is?

 A Magnesium sulfate
 B Termination of pregnancy
 C Anti convulsants
 D

Anti hypertensives

Ans. A

Explanation:

Magnesium sulfate REF: Current Diagnosis & Treatment Obstetrics & Gynecology, 10th edition Chapter 19

In Severe Pre eclampsia During labor, magnesium sulfate is administered for seizure prophylaxis as an IV loading dose of 4-6 g over 20-60 minutes, followed by a maintenance dose of 1-2 g/h.


Q. 3 Duration of latent phase of labour is affected by

 A

Early use of conduction anaesthesia and seda­tion

 B

Unripe cervix

 C

Pre-eclampsia

 D

Option a and c both

Q. 3

Duration of latent phase of labour is affected by

 A

Early use of conduction anaesthesia and seda­tion

 B

Unripe cervix

 C

Pre-eclampsia

 D

Option a and c both

Ans. D

Explanation:

Ans. is a and c i.e. Early use of conduction anaesthesia & sedation; and Unripe cervix

St- of Labour

Pre labour                                                                                   Labour

These changes occur prior to the onset of labour              • Although labour is a dynamic, continuous process,

& may last from a few days to few weeks.                               it is divided into three functional stages :

  • It is associated with an increase in oxytocin             First stage – It starts with onset of true labour pain

receptors in myometrium.                                                        & ends with full dilatation of cervix (10 cms)°. Dura‑

  • The changes seen are :                                                tion is 12 hours in primi° & 6 hours in multipara°.

–  Lightening : i.e. the decrease in fundal height                    Second stage – It starts with full dilatation of cervix

seen at term. This is due to the formation of the                   & ends with expulsion of fetus from birth canal. Du‑

lower segment of the uterus which allows the                         ration is 0 minutes to 2 hours in primi & 30 minutes

presenting part to descend into the pelvis.                             in multipara.

It brings a sense of relief to the mother.                                  Third stage – ft begins after expulsion of fetus &

–  Cervical ripening i.e. softening of the cervix.                       ends with expulsion of placenta & membranes

False labour pains.                                                                   (after births). Duration is about 15 minutes in both primi & multipara. The duration is, however, reduced to 5 minutes in active management.

First stage i.e. the stage of cervical effacement and dilatation and is further divided into 2 phases.

Latent phase

It is the preparatory phase of the uterus & the cervix, before the actual onset of labour. It starts at the point at which the mother perceives regular uterine contractions.

Its duration 8.6 hours in nulliparous (average 6 – 8 hrs.)° & 5.3 hours in multiparous (average 4 – 6 hours).°

  • Mainly concerned with cervical effacement

Active phase

It begins with cervical dilatation of 3 – 4 cms, with regular uterine contractions & normal minimum cervical dilatation rate of 1.2 cm/hr for nulliparous°

&  1.5 cm/hr for parous women°. Minimum of 1cm/hr.

  • Mainly concerned with cervical dilatation

Prolonged latent phase

Latent phase is said to prolonged if it is – • Greater than 20 hours in nullipara.°

Greater than 14 hours in multipara.°                      according to fernando
arias

According to Williams 23/e, p 406-Latent-phase should not last longer than 8 hours.

Causes of Prolonged Latent Phase

—         Excessive sedation or conduction analgesia.

—         Poor cervical conditions (e.g., Thick. uneffaced or undilated).

—         False labour (most common cause in multipara).

Diagnosis : The diagnosis of prolonged labour is made by observation of the .- ,iedman’s curve. Management : Either of the 2 options are used for managing prolonged latent phase
              Therapeutic Rest                                                            Oxytocin stimulation

15 mg of morphine is given intramuscularly. Most of the patients are asleep within 1 hour & awake 4 to 5 hours later, in active labour or in no labour.

Amniotomy is not useful and should be avoided in patients in prolonged latent phase. Also, there is no indication of cesarean section in this case.


Q. 4 True about complete hydatidiform mole is :

 A

Chromosome pattern is XX

 B

Associated with preeclampsia

 C

Enlarged ovarian cyst occurs

 D

All

Q. 4

True about complete hydatidiform mole is :

 A

Chromosome pattern is XX

 B

Associated with preeclampsia

 C

Enlarged ovarian cyst occurs

 D

All

Ans. D

Explanation:

Ans. is a, b and c i.e. Chromosome pattern is XX; Enlarged ovarian cyst occurs; and Associated with preeclampsia

  • The incidence of H. mole is maximum in oriental and south east countries (maximum incidence is in
    Philippines: 1 in 80 pregnancies) Le., it is more common in developing countries option ‘a ruled out).

H, mole can be categorized as either complete or partial mole on the basis of Gross morphology, histopathology and karyotype.

Complete H. mole – shows no evidence (If fetal tissue at all,

  • Complete hydatiform moles exhibit characteristic swelling and trophoblastic hyperplasia. Most common karyotype is 46XX (10% may have a 46XY karyotype).
  • The molar chromosomes are entirely of paternal origin, although mitochondrial DNA is of maternal origin.
  • The complete moles arises from an ovum that has been fertilized by a haploid sperm, which then duplicates
    its own chromosomes called as Androgenesr. The ovum nucleus may be either absent or inactivated.

Clinical features;

Symptoms:

  • Amenorrhea of varying duration followed by continuous or intermittent brown or bloody discharge (usually not profuse) evident by – 12 weeks.
  • Passage of vesicles per vaginum
  • Hyperemesis (due to the high levels of circulating HCG).

Signs:

  • Uterus:

–     The fundal height of uterus is more than the period of amenorrhea in 50% cases. In 35% it corresponds to the gestational period and in the rest it may be smaller.

–   Uterus is doughy in consistency (due to absence of amniotic fluid).

–    Fetal parts will not be felt.

–    Fetal heart sounds will not be heard (even on doppler).

–    External and internal ballottement can not be elicited.

  • Theca lutein cysts :

–     May be felt in the ovaries in about 25 to 60%.

–     Due to overstimulation of the luteal elements by the large amounts of circulating HCG°

–     Persistent trophoblastic disease is more likely in women with theca lutein cysts.

  • Early onset preeclampsia

When hypertension appears before 24 weeks, it is important to rule out hydatidiform mole.

  • Thyrotoxicosis seen due to the thyrotrophin-like effect of HOG.°
  • Spontaneous expulsion occurs at around 18 weeks° and rarely delayed beyond 28 weeks.°

Characteristics of partial H. mole

  • Some embryonic or fetal tissue identifiable.
  • Partial moles generally have a triploid karyotype (69 chromosomes); the extra haploid set of chromosomes usually is derived from the father
  • Chorionic villi of varying size with focal hydatidiform swelling, cavitation, and trophoblastic hyperplasia whereas complete mole shows diffuse hydatidiform swelling and trophoblastic hyperplasia.
  • Marked villous scalloping.
  • Prominent stromal trophoblastic inclusions.

–    When a fetus is present in conjunction with a partial mole. it generally exhibits the stigmata of triploidy, including growth retardation and multiple congenital malformations such as syndactyly and hydrocephaly.



Q. 5

All of the following are associated with placental abruption, EXCEPT:

 A

Cocaine abuse

 B

Cigarette smoking

 C

Hypotension

 D

Pre-eclampsia

Q. 5

All of the following are associated with placental abruption, EXCEPT:

 A

Cocaine abuse

 B

Cigarette smoking

 C

Hypotension

 D

Pre-eclampsia

Ans. C

Explanation:

Placental abruption occurs when a previously normally implanted placenta separates from the endometrial wall.
This can occur secondarily to vascular changes or mechanical sheer forces.
 
Both cocaine and cigarette smoking result in vascular constriction which results in acute vasospasm, elevated total peripheral resistance, and an acute increase in maternal blood pressure.
These phenomena are believed to be associated with an increased rate of placental abruption. Hypertension, not hypotension, is associated with abruption.
Acute hypotension can, however, cause fetal distress if untreated and may result in a similar fetal heart rate tracing to that associated with an abruption.
Similarly, pre-eclampsia with elevated blood pressures is associated with abruptions. 
 
Ref: Cunningham F.G., Leveno K.J., Bloom S.L., Hauth J.C., Rouse D.J., Spong C.Y. (2010). Chapter 35. Obstetrical Hemorrhage. In F.G. Cunningham, K.J. Leveno, S.L. Bloom, J.C. Hauth, D.J. Rouse, C.Y. Spong (Eds), Williams Obstetrics, 23e.

Q. 6

Low maternal serum 25-hydroxyvitamin D is associated with all of the following pregnancy and neonatal outcomes, EXCEPT:

 A

Gestational Diabetis

 B

Pre-eclampsia

 C

Caesarian Section

 D

Smal for Gestational Age Neonate

Q. 6

Low maternal serum 25-hydroxyvitamin D is associated with all of the following pregnancy and neonatal outcomes, EXCEPT:

 A

Gestational Diabetis

 B

Pre-eclampsia

 C

Caesarian Section

 D

Smal for Gestational Age Neonate

Ans. C

Explanation:

Vitamin D insufficiency is associated with an increased risk of gestational diabetes, pre-eclampsia, and small for gestational age infants.

Pregnant women with low 25-OHD levels had an increased risk of bacterial vaginosis and lower birth weight infants, but not delivery by caesarean section.
 
Note: This is an important new question.
 
Ref: Association between maternal serum 25-hydroxyvitamin D level and pregnancy and neonatal outcomes: systematic review and meta-analysis of observational studies, BMJ 2013; 346, Published 26 March 2013.

Q. 7

What changes in GFR is expected in a 30-year-old lady with pre-eclampsia?

 A

Decreases

 B

Increases

 C

Remains the same

 D

None of these

Q. 7

What changes in GFR is expected in a 30-year-old lady with pre-eclampsia?

 A

Decreases

 B

Increases

 C

Remains the same

 D

None of these

Ans. A

Explanation:

Pre-eclampsia is a state of hypertension in pregnancy associated with proteinuria but with or without pathological edema.
It is defined as a multi-system disorder of unknown etiology characterised by development of hypertension to the extent of 140/90 mm Hg or more with protienuria after the 20th week of pregnancy in a previously normotensive and a normoproteinuric patient.
The typical pathological features are endothelial dysfunction and intense vasospasm. In pre-eclampsia, the glomerular filtration rate decreases.

The decrease in glomerular filtration rate is as a result of the following physiological changes:
Afferent glomerular arteriolar vasospasm
Occlusion of the lumen of the glomerulus resulting from glomerular endotheliosis and fibrin deposits in the basement membrane
Decreased renal blood flow

Ref: Textbook of Obstetrics By D.C. Dutta, 6th Edition, Pages 221-3131


Q. 8

Which of the following conditions poses the greatest risk for development of pre-eclampsia?

 A

Chronic glomerulonephritis

 B

Polycystic kidney disease

 C

Renal artery stenosis

 D

Polyarteritis nodosa

Q. 8

Which of the following conditions poses the greatest risk for development of pre-eclampsia?

 A

Chronic glomerulonephritis

 B

Polycystic kidney disease

 C

Renal artery stenosis

 D

Polyarteritis nodosa

Ans. D

Explanation:

The risk of developing pre–eclampsia is only mild in chronic glomerulo nephritis and polycystic kidney disease.
The risk is mild to moderate in Renal artery stenosis and severe in Polyarteritis nodosa.

Ref: Karla Philip, 3rd Edition, Page 302.

 


Q. 9

A 25-year-old lady, Neethu, in her 22nd week of pregnancy develops hypertension and mild proteinuria. Due to the baby’s gestational age, her obstetrician chooses to carefully monitor the mother for any sign of developing complications rather than to immediately deliver the baby. Which of the following complications account for the most maternal deaths in preeclampsia? 
 

 A

Cerebral edema and laryngeal edema

 B

Cerebral hemorrhage and adult respiratory distress syndrome

 C

Convulsions and renal tubular necrosis

 D

Hemolysis and hepatic infection

Q. 9

A 25-year-old lady, Neethu, in her 22nd week of pregnancy develops hypertension and mild proteinuria. Due to the baby’s gestational age, her obstetrician chooses to carefully monitor the mother for any sign of developing complications rather than to immediately deliver the baby. Which of the following complications account for the most maternal deaths in preeclampsia? 
 

 A

Cerebral edema and laryngeal edema

 B

Cerebral hemorrhage and adult respiratory distress syndrome

 C

Convulsions and renal tubular necrosis

 D

Hemolysis and hepatic infection

Ans. B

Explanation:

The disease is preeclampsia, which may be complicated by a wide variety of serious conditions.
Historically, the appearance of convulsions defined the transition from preeclampsia to eclampsia; however the concept of eclampsia is probably flawed because many other serious complications can occur even in the absence of seizures.
Statistically, the most common causes of maternal death in preeclampsia are cerebral hemorrhage and pulmonary complications, notably adult respiratory distress syndrome.

Cerebral edema and laryngeal edema, hemolysis and hepatic infarction, and hepatic rupture and renal cortical necrosis can all be complications of preeclampsia, but are not the most common causes of maternal mortality.
 
Convulsions and renal tubular necrosis can be complications of preeclampsia, but convulsions indicate that eclampsia has developed.
 
Other complications of preeclampsia not listed in the answer choices include retinal detachment, cortical blindness, pulmonary edema, disseminated intravascular coagulation, low platelet counts, and in the fetus, brain damage and death from asphyxia.

Q. 10 A 35 weeks pregnant multigravida is diagnosed of having pre-eclampsia. If she develops seizures, what is the BEST regimen for treatment?

 A

Lytic cocktail regimen

 B

Pritchard’s (MgSO4) regimen

 C

Phenytoin regimen

 D

Diazepam regimen

Q. 10

A 35 weeks pregnant multigravida is diagnosed of having pre-eclampsia. If she develops seizures, what is the BEST regimen for treatment?

 A

Lytic cocktail regimen

 B

Pritchard’s (MgSO4) regimen

 C

Phenytoin regimen

 D

Diazepam regimen

Ans. B

Explanation:

MgSO4 is the drug of choice for severe preeclampsia and eclampsia.

Mechanism of action:

  • It reduces motor endplate sensitivity to acetylcholine and thereby reduces neuromuscular irritability.
  • It also blocks neuronal calcium influx.
  • It induces cerebral vasodilatation, dilates uterine arteries, increases production of endothelial prostacyclin and inhibits platelet activation.

Benefits from other regimens:

  • No detrimental effects on the neonate within therapeutic level.
  • Excellent result with maternal mortality of 0.4%.

Ref: Textbook of Obstetrics by D.C. Dutta, 6th edition, Page 236.


Q. 11 A 28 weeks pregnant multigravida with preeclampsia presented with fulminant signs. Urgent C-section was planned. Best method for the diagnosis of lung maturity is:

 A

L/S ratio in amniotic fluid

 B

Phosphtidyl glycerol estimation in amniotic fluid

 C

Bilirubin in amniotic fluid

 D

Amniotic fluid creatinine

Q. 11

A 28 weeks pregnant multigravida with preeclampsia presented with fulminant signs. Urgent C-section was planned. Best method for the diagnosis of lung maturity is:

 A

L/S ratio in amniotic fluid

 B

Phosphtidyl glycerol estimation in amniotic fluid

 C

Bilirubin in amniotic fluid

 D

Amniotic fluid creatinine

Ans. B

Explanation:

  • Phosphatidylglycerol (PG) is a minor constituent of surfactant. 
  • It begins to increase appreciably in amniotic fluid several weeks after the rise in lecithin. 
  • Its presence is more indicative of fetal lung maturity because PG enhances the spread of phospholipids on the alveoli.
 
Ref: Mehta S.H., Sokol R.J. (2007). Chapter 13. Methods of Assessment for Pregnancy at Risk. In A.H. DeCherney, L. Nathan (Eds), CURRENT Diagnosis & Treatment Obstetrics & Gynecology, 10e.

Q. 12

Which of the following laboratory findings is known as ‘biochemical marker of pre-eclampsia’?

 A

Low platelets

 B

Raised serum Na

 C

Elevated liver enzymes

 D

Serum uric acid

Q. 12

Which of the following laboratory findings is known as ‘biochemical marker of pre-eclampsia’?

 A

Low platelets

 B

Raised serum Na

 C

Elevated liver enzymes

 D

Serum uric acid

Ans. D

Explanation:

A serum uric acid level (biochemical marker of pre-eclampsia) of more than 4.5 mg/dl indicates the presence of pre-eclampsia.
Blood urea level remains normal or slightly raised.
Serum creatinine level may be more than 1 mg/dl.
There may be thrombocytopenia and abnormal coagulation profile of varying degrees.
Hepatic enzyme levels will be increased.
Ref: Textbook of Obstetrics D C Dutta, 6th edition, Page 227.


Q. 13

A 34 weeks pregnant female with increased urinary frequency diagnosed of having transient-diabetes insipidus. This patient may have the following associated pathology:

 A

Severe pre-eclampsia

 B

Hydramnios

 C

Multiple pregnancy

 D

IUGR

Q. 13

A 34 weeks pregnant female with increased urinary frequency diagnosed of having transient-diabetes insipidus. This patient may have the following associated pathology:

 A

Severe pre-eclampsia

 B

Hydramnios

 C

Multiple pregnancy

 D

IUGR

Ans. A

Explanation:

The development of new-onset diabetes insipidus in the third trimester is usually due to increased vasopressinase activity either due to increased placental production or decreased hepatic vasopressinase metabolism due to liver damage from various causes including preeclampsia, acute fatty liver of pregnancy, or HELLP, syndrome.
This phenomenon is called transient vasopressin-resistant diabetes insipidus (DI) of pregnancy.
Ref: Mehta N.D., Chen K.K., Monzon C., Rosene-Montella K. (2012). Chapter 223. Common Medical Problems in Pregnancy. In G.V. Lawry, J. Matloff, D.D. Dressler, D.J. Brotman, J.S. Ginsberg (Eds), Principles and Practice of Hospital Medicine.


Q. 14

A 28 weeks pregnant found to have blood pressure of 140/90 mm of Hg in her prenatal visit. Her urine was sent to laboratory for finding out the presence of proteins. Which of the following is a risk factor for progressing to pre eclampsia in this patient?

 A

Family history of preeclampsia

 B

Age

 C

Hydatidiform mole

 D

All of the above

Q. 14

A 28 weeks pregnant found to have blood pressure of 140/90 mm of Hg in her prenatal visit. Her urine was sent to laboratory for finding out the presence of proteins. Which of the following is a risk factor for progressing to pre eclampsia in this patient?

 A

Family history of preeclampsia

 B

Age

 C

Hydatidiform mole

 D

All of the above

Ans. D

Explanation:

Risk Factors for Preeclampsia:

  • Age 35 years
  • Nulliparity
  • Multiple gestation
  • Hydatidiform mole
  • Diabetes mellitus
  • Thyroid disease
  • Chronic hypertension
  • Renal disease
  • Collagen vascular disease
  • Antiphospholipid syndrome
  • Family history of preeclampsia

Ref: Miller D.A. (2013). Chapter 26. Hypertension in Pregnancy. In A.H. DeCherney, L. Nathan, N. Laufer, A.S. Roman (Eds), CURRENT Diagnosis & Treatment: Obstetrics & Gynecology, 11e.


Q. 15

36 week a pregnant female, a case of pre-eclampsia, presented with blurred vision and headache. Her blood pressure is 160/110 mmHg. Next step in management is:

 A

Admit & give antihypertensives, MgSO4 and terminate

 B

Admit & give antihypertensives, MgSO4 and observation

 C

Only admit & watch the patient

 D

Give antihypertensives and send home

Q. 15

36 week a pregnant female, a case of pre-eclampsia, presented with blurred vision and headache. Her blood pressure is 160/110 mmHg. Next step in management is:

 A

Admit & give antihypertensives, MgSO4 and terminate

 B

Admit & give antihypertensives, MgSO4 and observation

 C

Only admit & watch the patient

 D

Give antihypertensives and send home

Ans. A

Explanation:

Termination of pregnancy is the only cure for pre-eclampsia. Headache, visual disturbances, or epigastric pain is indicative that convulsions may be imminent, and oliguria is another ominous sign.
Severe preeclampsia demands anticonvulsant and usually antihypertensive therapy followed by delivery.

Ref: Cunningham F.G., Leveno K.J., Bloom S.L., Hauth J.C., Rouse D.J., Spong C.Y. (2010). Chapter 34. Pregnancy Hypertension. In F.G. Cunningham, K.J. Leveno, S.L. Bloom, J.C. Hauth, D.J. Rouse, C.Y. Spong (Eds), Williams Obstetrics, 23e.

Q. 16 Doppler ultrasonography in IUGR & Preeclampsia shows notch in which artery :

 A

Umbilical artery

 B

Uterine artery

 C

Internal iliac artery

 D

Vitiline artery

Q. 16

Doppler ultrasonography in IUGR & Preeclampsia shows notch in which artery :

 A

Umbilical artery

 B

Uterine artery

 C

Internal iliac artery

 D

Vitiline artery

Ans. B

Explanation:

Uterine artery



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