Pre-eclampsia -Pre-eclampsia (formerly known as PET: pre-eclamptic toxaemia) - an idiopathic (= cause unknown) -condition of pregnancy characterized by proteinuria and hypertension - after 20 weeks of pregnancy in a woman who previously had normal blood pressure. - can be mild, moderate or severe, and may be pre-eclampsia or eclampsia -Pre-eclampsia occurs in 3% of all pregnancies

-some will proceed to multisystem complications. -maternal &fetal death recorded. Pre-eclampsia known as a disease of theories the path physiology is not fully understood. it arises from the influence of placental tissue as it can arise in molar pregnancies (gestational trophoblastic disease) where there is placental tissue but no fetal tissue

Management in pregnancy -aspirin from 12 weeks of pregnancy until the baby is born . Women at high risk have one of the following: hypertensive disease during a previous pregnancy chronic hypertension chronic kidney disease autoimmune disease, especially antiphospholipid syndrome (APS) or systemic lupus erythematosus (SLE)

A sso cia t e d f a ct o r s f o r de v e lo ping pr e - e cla m psia Maternal factors Primipaternity (first pregnancy with a new partner) Extremes of maternal age (<20 and >40 years) Family history of pre-eclampsia Pre-eclampsia in a previous pregnancy Pregnancy after assisted reproductive technology Obesity Pre-existing diabetes mellitus type 1 Pre-existing hypertensive disease Pre-existing medical conditions, e.g. renal disease, systemic lupus erythematosus (SLE), rheumatoid arthritis

Pregnancy related factors First pregnancy Multiple pregnancy Developing a medical disorder during pregnancy, e.g. venous thromboembolic disease (VTE), such as antiphospholipid (Hughes) syndrome (APS), gestational diabetes, gestational hypertension Developing infection with inflammatory response Hydropic degeneration of the placenta(GTD) -Early recognition of pre-eclampsia at an antenatal - referral to an obstetrician is necessary for investigations, - responsibility for the diagnosis lies with the doctor.

Pre-eclampsia can be recognized by: blood pressure: systolic >140 mmHg or diastolic >90 mmHg proteinuria edema Ankle edema is a common phenomenon in pregnancy and tends to diminish overnight. More generalized edema that pits on pressure on the pre-tibial surface, face, hands, abdomen and sacrum, The severity of the edema increases with the severity of the pre-eclampsia.

Investigation ; Urine sample or 24 hour urine collection to quantify the proteinuria (>300 mg) and determine the ratio of protein to creatinine (>30 mg/mmol). CBC ( platelet , haemolysis),haemoconcentration. Urea and electrolytes Liver enzymes. ultrasound to monitor growth and volume of amniotic fluid and Doppler velocimetry of the umbilical arteries. -hospital admission

-Labetalol is the first-line treatment (unless the woman has asthma) - -methyldopa -nifedipine - vitamins C and E supplementation to be associated with an increased risk of gestational hypertension. -Whilst drugs will treat the hypertension, the solution for pre-eclampsia is to expedite the birth of the baby and placenta.

-IOL at 37 weeks for mild pre-eclampsia -at 34–36 weeks for moderate pre-eclampsia - at 34 weeks for severe hypertension - corticosteroids to assist with fetal lung maturity -Birth should be earlier in the ; @event of uncontrolled blood pressure @ fetal complications @ antenatal complications

C. S for: 1-urgent clinical situations 2- if the fetus is very preterm Prepare neonatal intensive care and anaesthetist teams

Management in labour -continuous fetal monitoring. - An epidural anaesthetic after review of the platelet count -Oxytocin is used to control hemorrhage during the third stage of labour avoid syntometrine or ergometrine. -Blood pressure measured hourly - alert for signs of fulminant eclampsia

Postnatal management -regular measurement of blood pressure -Bp measured four times a day whilst in hospital - recorded daily at home until the third day and once between days 3 to 5. -midwife ask about severe headache and epigastric pain -Methyldopa is usually discontinued or replaced by another antihypertensive drug.

-If the BP is >150/100 mmHg refer the woman for medical care, where the dosage of antihypertensive is likely to be increased. -Don’t discharge woman until BP & maternal condition becomes stable -review after 2 weeks postnatally - then between 6 and 8 weeks to assess the hypertension

Management of pregnancy with pre-eclampsia De t e r m ining pr o t e inur ia in pr e g na ncy If using a dipstix to test the urine, ensure the reagent strips are in date and read according to the stipulated times along the exterior label. A mid-stream specimen of urine (MSSU) may be necessary to exclude urinary tract infection (UTI) as a cause of proteinuria. .

Significant proteinuria is diagnosed when the urinary protein : creatinine ratio is >30 mg/mmol, or if a 24-hour urine collection result shows > 300 mg protein. Ensure 24 hour urine collections are complete before sending to the laboratory for analysis.

Severe pre-eclampsia and eclampsia - high blood pressure of systole >160 mmHg or diastole >110 mmHg on two occasions and significant proteinuria. - Modern definitions also include women with moderate hypertension who have at least two of the features below: low blood platelet count <100 ×106/l abnormal liver function liver tenderness Haemolysis Elevated Liver enzymes and Low Platelet count (HELLP) syndrome clonus (intermittent muscular contractions and relaxations) papilloedema ( edema of the optic disc )due to increase intra cranial pressure epigastric pain vomiting severe headache visual disturbance (flashing light similar to migraine) This condition, can lead to eclampsia with risk of mortality and morbidity.

-The woman must be admitted to a high-risk obstetric ward for medical treatment to: 1- bring her blood pressure under control 2- reduce the risk of fluid overload 3- prevent seizures. -Oral labetalol or nifedipine may be used - if the BP is >170/110 mmHg, intravenous (IV) labetalol or hydrallazine are given in bolus doses to lower the BP and then as a continuous IV infusion (IVI). -Intravenous magnesium sulphate may also be administered as this drug can reduce the chance of an eclamptic seizure by 50%. -

Fluid restriction - a low salt diet -monitored a fluid balance chart - regular urinalysis to assess proteinuria. - be aware of magnesium toxicity as a reduced urine output of <10 ml per hour. increased risk of iatrogenic pre-term birth before 33 weeks IUGR and consequent admission to neonatal intensive

Fulminant eclampsia acute worsening of symptoms headache, epigastric pain and vomiting accompanied by high blood pressure, indicating that severe eclampsia is developing into eclampsia and that a convulsion is imminent. emergency intervention is required.

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