2OBJECTIVES At the end of this session you should be able to: Outline diagnostic features of pre-eclampsiaClassify pre-eclampsia according to severityOutline risk factors for pre-eclampsiaOutline maternal and fetal complications of pre-eclampsia.Describe the management of pre-eclampsia and eclampsia.
3I. INTRODUCTION Synonyms: Toxemia of pregnancy, pre-eclampsia, EPH gestosis, pregnancy induced hypertension.Pre-eclampsia commonly manifests after the 20th week of pregnancy.Prevalence of pre-eclampsia: varies from one place to anotherSevere pre-eclampsia and eclampsiaAre serious and potentially fatalThird commonest cause of maternal mortalityOccurs prior to, during or after delivery
4II. DIAGNOSIS OF PRE-ECLAMPSIA When SBP > 140 mm Hg, DBP > 90 mm Hg in a woman known to be normotensive prior to pregnancy.The diagnosis requires 2 such abnormal BP measurements recorded at least 6 hours apart.
5III. RISK FACTORSYoung maternal ageNulliparity: 85% of pre-eclampsia occur in primigravida.Increased placental tissue for gestational age: Hydatiform moles, twin pregnanciesFamily history of pre -eclampsiaDiabetes mellitusRenal diseases,Chromosomal abnormality in the fetus (eg, trisomy).
6Worrisome signs for pre-eclapmsia development RISK FACTORS contWorrisome signs for pre-eclapmsia developmentRapid increase of weight during the latter ½ of pregnancyAn upward trend in diastolic BP even while still within normal range
7IV. CLASSIFICATION OF PRE ECLAMPSIA: ACCORDING TO SEVERITY Mild pre-eclampsiaModerate pre-eclampsiaSevere pre-eclampsiaMild to Moderate Pre eclampsiaDiagnostic FeaturesSystolic BP is mmHgDiastolic BP is 90 – 100 mmHgProteinuria up to ++
82. Severe pre-eclampsia Also called – Imminent eclampsia Symptoms Severe & persistent occipital or frontal headachesVisual disturbance: blurred vision, photophobiaEpigastric and/or right upper-quadrant painSignsDiastolic BP > 11ommHg, systolic BP > 160mmHgProteinuria +++ or moreAltered mental statusHyper-reflexiaOliguria
9Is a severe form of pre-eclampsia HELLP SYNDROMEIs a severe form of pre-eclampsiaAffects approx 10% of women with severe preeclampsia and 30-50% of women with eclampsia.Characterized by:Hemolysis,Elevated liver enzymesLow platelet count.Increased mortality rate and DIC
10V. PATHOPHYSIOLOGYThere are several theories and etiologic mechanisms.Vasospasm theory: Most favored theoryVasospasms → vasoconstriction → resistance → arterial BPEclampsia:Cerebral arterial vasospasm → cerebral edema or infarction and/or cerebral hemorrhage
11VI. COMPLICATIONS OF SEVERE PRE-ECLAMPSIA AND ECLAMPSIA Maternal complicationsCVSHaemoconcentration (cause: vasoconstriction and vascular permeability)Hamatological changes – HELLP → DICKidneysDecr RBF→ ↓GFR → RTN and RCN→ acute RFProteinuria – due to ⇈permeability to large protein,Oliguria – both renal perfusion and GFR decrease.
12COMPLICATIONS OF SEVERE PRE ECLAMPSIA AND ECLAMPSIA cont BrainCerebral edemaInfarction, cerebral hemorrhageBlindness: Due to -?retinal artery vasospasms and retinal detachmentFever 39ºC: a grave sign, may be a consequence of intracranial hemorrhage.Coma – may be a result of CVA
13COMPLICATIONS OF SEVERE PRE ECLAMPSIA AND ECLAMPSIA cont RS : Pulmonary oedema and cyanosisUtero-placental perfusionVasospasms → decr perfusion → distress and deathHistological changes in the placental bed: acute artherosis – lipid rich cells of the uteroplacental arteriesFetal complicationsIUFD, IUGR
14MAJOR CAUSES OF MATERNAL DEATH Cerebrovascular accident (CVA)Pulmonary oedemaCardiac failure,Renal failure
15VII. WORK UP - INVESTIGATIONS Urine analysisProteinuriaA 24-hour urine collectionQuantity of urine and proteinUric acid level:GFR and creatinine clearance decrease →in ↑uric acid levels.LFT – TransaminasesUSS – fetal wellbeing, if the GA is < 20/40 R/O moles.
16VIII. MANAGEMENT OF PRE ECLAMPSIA MILD - MOD PRE ECLAMPSIAA: Dispensary & Health centreAntihypertensivesAldomet 250 mg 8 hourly for 7 days,Bed rest at homeREFER within one week to Hospital for further management
17MANAGEMENT OF PRE ECLAMPSIA 1. MILD - MOD PRE ECLAMPSIA contB. HospitalAntihypertensives: Aldomet,Bed rest at home,Sequential work ups,Fetal movements monitoring,Schedule antenatal clinic every 2 weeks up to 32 wks and weekly thereafter
18MANAGEMENT OF PRE ECLAMPSIA 1. MILD - MOD PRE ECLAMPSIA contB. HospitalStrongly advice the woman to deliver in a hospitalPlan delivery at 38/40Advice the mother to come to the health facility in case of severe headache, blurred vision, nausea or upper abdominal pain.Manage as severe pre-eclampsia: If not responding to treatment i.e. if the systolic BP is > 160 mmHg, or the diastolic BP is > 100mmHg or there is proteinuria +++
19MANAGEMENT OF SEVERE PRE ECLAMPSIA AND ECLAMPSIA Note: Severe pre-eclampsia is managed likeeclampsiaManagement protocol for eclampsiaKeep airway clearControl convulsionsControl BPControl fluid balanceAntibioticsInvestigationsDeliver the mother
20MANAGEMENT CONT BP CONTROL Keep SBP between mm Hg and DBP between mm Hg?Why these levels: Avoid potential reduction in either uteroplacental blood flow or cerebral perfusion pressure.Drugs:Anti HPTs: Hydralazine, nifedipine, or labetalolDiuretics are not used except in the presence of pulmonary edema
21MANAGEMENT: CONTROL CONVULSIONS I. An overview on MgSO4.Mechanism:Cerebral vasodilator → reducing cerebral vasospasm → ↓ischemia (brain).Superior to other anti-convulsants used to control and prevent fits;Important part of mgt of eclampsiaRecurrence rate after MgSO4 = %Improves maternal and fetal outcome
22CONTROL CONVULSIONS - REGIMEN 1. INTRAMUSCULAR REGIMENi. Loading doseGive MgSO4 4 g (i.e. 20mls of 20% solution) + 200mls NS or sterile water I.V over 5 minutesFollow promptly with 10g (i.e. 20ml of 50% solution), 5g in each buttock as deep I.M with 1ml of 2% lignocaine in the same syringe
23CONTROL CONVULSIONS - REGIMEN MANAGEMENT CONTCONTROL CONVULSIONS - REGIMEN1. INTRAMUSCULAR REGIMEN contii. Maintenance doseMgSO4 5 g (i.e. 10ml of 50% solution) + 1 ml lignocaine 2% 4 hourly in alternate buttocks.NOTE:IM inj. are painful and are complicated by local abscess formation in 0.5% of cases.The intravenous (IV) route is therefore preferred
24MgSO4 4 g (i.e. 20mls of 20% solution) + 200mls NS I.V over 5 minutes MANAGEMENT CONTCONTROL CONVULSIONS - REGIMEN2. INTRAVENOUS REGIMENi. Loading doseMgSO4 4 g (i.e. 20mls of 20% solution) + 200mls NS I.V over 5 minutesii. Maintenance doseMgSO4 4 g (i.e. 20ml of 20% solution) IN 500ml NS 4 hourly for 24 hrs after the last fits
25Recurrent fits (any regimen): MANAGEMENT CONTCONTROL CONVULSIONS - REGIMENRecurrent fits (any regimen):Therapeutic dose may not have been reachedGive 2g (i.e. 10ml of 20% solution) i.v. over 5 minutesTreatment duration:Continue for 24 hours after delivery or last convulsion, whichever occurs first
26Causes loss of deep tendon reflexes, followed by MANAGEMENT CONTMagnesium toxicityCauses loss of deep tendon reflexes, followed byrespiratory depression and ultimately respiratoryarrest.Thus, before repeating MgSO4, ensure that;RR ≥ 16/minPatellar reflexes are presentUrinary output is at least 30ml per hour over 4 hoursOtherwise withhold or delay MgSO4Keep antidote readyIn case of respiratory arrest: Assist ventilation and administer calcium gluconate
27Delivery should be within 6-8 hours of onset of fits MANAGEMENT CONTDELIVER THE MOTHERDelivery should be within 6-8 hours of onset of fitsVaginal delivery is the safest mode of deliveryAssessmentR/O contraindications to SVDBishop scoreIf the cervix is favourable - induce labourOtherwise prepare for C/S
28MANAGEMENT CONT Management of labour 1st stage Relieve pain: pethidine 25 mg iv every 2-4 hoursAugmentation of labourMonitor FHR,2nd stage: Assist with vacuum extraction3rd stage: Active managementOxytocin 10 IU i.m after delivery of anterior shoulderCord tractionSqueezing clots after delivery of the placenta
29MANAGEMENT CONTManagement of labourIf there is delay perform C/SPost delivery:Continue observation for at least 48 hrs post deliveryRecord and monitor BP and urine output for at least 48 hours after delivery,Keep the pt in hospital until BP stabilizes,Continue with aldomet PO until BP back to normal