2. Pre-eclampsia the presence of hypertension and proteinuria occurring after 20 th week of gestation

3. Indications of Severe Pre-eclampsia AbnormalityMildSevere Diastolic BP< 100 mmHg110 mmHg ProteinuriaTrace to 1+Persistent ≥ 2+ HeadacheAbsentPresent Visual disturbanceAbsentPresent Upper abdominal painAbsentPresent OliguriaAbsentPresent ConvulsionsAbsentPresent Serum creatinineNormalElevated ThrombocytopeniaAbsentPresent Liver enzyme Minimal  Markedly  Fetal growth restrictionAbsentObvious Pulmonary edemaAbsentPresent

4. Incidence – Philippine Setting According to Dept. of Health, Maternal Mortality Rate (MMR) – 162 out of 10,000 live births (Family Planning Survey 2006) – Maternal deaths account for 14% of deaths among women For the past 5 years, all of the causes of maternal deaths exhibited an upward trend. – Pre-Eclampsia showed an increasing trend of 6.89%, 20%, 40%, and 100% – 10 women die everyday in the Philippines due to pregnancy and childbirth-related causes, such as pre- eclampsia

5. Severe Pre-eclampsia BP 160/110 mmHg Proteinuria: – at least 4 g/day or persistent > +2 on dipstick Oliguria: – <400 cc/day – Signifying decreased renal blood flow and diminished glomerular filtration rate Severe headache and visual disturbance Pulmonary edema or cyanosis – Due to hemodynamic changes (inc. afterload)

6. Severe Pre-eclampsia Abdominal pain (epigastric or RUQ location) – distention of glisson’s capsule of the liver due to heptocellular edema and/or necrosis Hemolysis – inc. serum LDH, hemoglobinuria, hyperbilirubinemi, presence of schistocytes Elevated liver enzymes – Due to hepatocellular necorsis Thrombocytopenia – Due to microangiopathic hemolysis induced by spasm

7. Signs to identify include: Cardiovascular system: hypertension, vasoconstriction leading to cool peripheries, peripheral oedema Respiratory system: pulmonary edema, facial and laryngeal edema, acute respiratory distress syndrome (ARDS) Renal system: proteinuria, oliguria, acute renal failure Central nervous system: hyperreflexia, clonus, cerebral haemorrhage, convulsions (eclampsia), papilloedema, coma Others: HELLP (Haemolysis, Elevated Liver Enzymes and Low Platelets), thrombocytopenia, DIC (disseminated intravascular coagulopathy) Fetal signs include: CardioTocoGraphy (CTG) abnormalities, pre-term labour, and intrauterine growth retardation.

8. Risk factors associated with pregnant women: First pregnancy Age under 20 or above 35 High BP before pregnancy Previous pre-eclamptic pregnancy Short interpregnancy intervals Family history Obesity DM, kidney disease, rheumatioud arthritis, lupus, or scleroderma Low socio-economic status Poor protein or low calcium in the diet

9. Risk factors associated with the pregnant women’s husband: First time father Previously fathered a pre- eclamptic pregnancy Risk factors associated with the fetus: Multifetal pregnancy Hydrops/triploidy Hydatidiform mole

10. Risk factors and their odds ratio for pre-eclampsia Nulliparity3:1 Age >40 y3:1 African-American race1.5:1 Family history5:1 Chronic renal disease20:1 Chronic hypertension10:1 Antiphospholipid syndrome10:1 Diabetes mellitus2:1 Twin gestation4:1 High body mass index3:1 Angiotensinogen gene T235 Homozygous20:1 Heterozygous4:1

11. PE Findings BP > 160/110 mmHg Proteinuria 2.0g/24 hrs or > 2+ dipstick Serum creatinine > 1.2 mg/dL unless previously elevated Platelets < 100,000 mm3 Microangiopathic hemolysis: Elevated LDH

12. PE Findings Persistent headache, visual disturbance, epigastric pain Increase serum transaminase Obvious growth restriction Pulmonary edema: increase permeability in maternal circulation

13. Laboratory Tests 1.Hematocrit – Increased hematocrit levels in pre-eclampsia 2.Proteinuria – More than 300 mg/24h or dipstick values of 1+ denotes poor prognosis 3.Serum uric acid – Correlate with the development and severity of pre-eclampsia, and increased perinatal mortality

14. Ultrasound Doppler velocimetry – Diastolic notch – Increased systolic/diastolic index (Stuart index) – Pulsatility index – Absence or reversed end diastolic blood flow

18. TREATMENT

19. 3 cardinal principles: A. control of convulsions B. Control of hypertension C. Delivery at optimum time and mode

20. CONTROL OF CONVULSION D.O.C : MAGNESIUM SULFATE – Versus Diazepam: reduced recurrence of convulsions; reduced maternal mortality; fewer APGAR scores <7 at 5 mins. – Versus Phenytoin: reduced recurrence of convulsions; fewer admissions to NICU and fewer babies who died – Versus Lytic cocktail: reduced recurrence of convulsions; less respiratory depression; less maternal deaths

21. CONTROL OF CONVULSION Thus, Magnesium Sulfate: - reduces risk of eclampsia - Reduces risk of maternal death SIDE EFFECTS: - neutropenia - nosocomial infections in infants - Lower fetal biophysical profile by decreasing breathing - Increased incidence of nonreactive NST - Decreased variability of FHR - Disturbed fetal and maternal calcium homeostasis and bone density

22. CONTROL OF CONVULSION DOSE: a.Loading dose – 4 gm IV slowly over 5 mins Maintenance dose -1-2 Gms per hour IV drip b.Loading dose – 4 Gm IV slowly over 5 mins and 10 gm IV (5gm on each buttock) Maintenance – 5 Gms IM every 6 hours

23. CONTROL OF CONVULSION Monitoring: – Presence of DTRs – RR of >12 per minute – Urine output at least 100cc every 4 hours – Serum magnesium

24. CONTROL OF HYPERTENSION Use of anti-hypertensives for BP at least 160/110 mmHg – to prevent maternal CVA-Hemorrhage – D.O.C: HYDRALAZINE Initial dose: 5 mg IV bolus followed by 5 mg incremental increases half-hourly if diastolic BP does not improve up to a total dose of 20mg – Beta blockers (labetalol) Lowers systolic and diastolic BP Prevent more severe forms of PIH Prevent ventricular arrythmia, tachycardia and pulmonary edema ADVERSE EFFECTS on fetal growth and fetal hemodynamics

25. CONTROL OF HYPERTENSION Calcium-channel blocker – Nifedipine Reduce maternal BP, proteinuria and improve renal function Given sublingually: prevent erythrocyte aggregation – Nicardipine: More selective on peripheral vasculature Less inotropic effect: tachycardia, flushing and hot flushes Lower rate of placental transport with limited exposure of fetal tissues

26. CONTROL OF HYPERTENSION Sodium nitroprusside – For signs of severe hypertensive encephalopathy ACE inhibitors – Not recommended due to fetal side effects (defective skull ossification, oligohydramnios, neonatal anuria) Diuretics – Not used unless with evidence of pulmonary edema or congestion

27. OPTIMUM TIME AND MODE OF DELIVERY 5 Factors: 1.Age of gestation 2.Severity of disease 3.Fetal status 4.Maternal condition 5.Nursery capabilities

28. OPTIMUM TIME AND MODE OF DELIVERY General guidelines: 1.Hospitalize all patients once signs or symptoms of pre-eclampsia are evident 2.Immediate delivery done for: a)All cases of eclampsia regardless of age of gestation b)Severe pre-eclamptics at least 34 wks in presence of mature fetal lung and adequate nursery facilities; - Complications may mandate delivery <34 wks AOG thus, steroids are advised

29. OPTIMUM TIME AND MODE OF DELIVERY c. Severe maternal disease - uncontrollable hypertension of 160/110 - oliguria <400 hours - thrombocytopenia <100,000/cu SGPT - pulmonary edema - impending eclampsia d. Fetal compromise - abnormal fetal movement counting - CTGs - BPS - ARED patterns on Doppler velocimetry

30. OPTIMUM TIME AND MODE OF DELIVERY 3. Presence of clinical disease at <34 wks AOG - conservative management: - evaluation of maternal and fetal status - therapy with anticonvulsant, antihypertensive, low dose aspirin and high dose calcium 4. Labor and Delivery options: - cervical ripening with oxytocin or prostaglandins - amniotomy - vaginal or cesarean delivery

31. OPTIMUM TIME AND MODE OF DELIVERY Similar treatment protocol with Parkland hospital but we are more liberal on use of CS especially if: – Intact fetus is growth restricted – Bishop’s score <5 – Fetal BPS score <6/10 – CTG tracing shows persistent late or severe variable decelerations

32. PREVENTION

33. BMI and Diet BMI > 30 increases the risk of pre-eclampsia Obesity  augmented placental production of leptin, adinopectin or triglycerides and inflammation Drinking water avoid salty foods, junk foods and foods that are fried Avoid alcohol and caffeinated beverages exercise

34. Low dose aspirin Doses are kept at 60-80 mg/day Selective thromboxane (TXL-A2) suppression with resultant dominance of endothelial prostacyclin (PGI) Monitoring of platelet counts, coagulation profiles, fetal ductus arteriosus, urine production/amniotic fluid. Indications: – High-risk – Started during the 2 nd trimester to prevent fetal malformations Contraindications: – Aspirin allergy or hypersensitivity (acid peptic disease or coagulopathy

35. High Dose Calcium oral intake of calcium (2g/day) Reduction in IUGR and BP levels Exerts a negative feedback effect on parathyroid hormone  decrease calcium  smooth muscle relaxation and diminished responsiveness to pressor stimuli

36. Associated with higher levels of calcium excretion which is coupled with an ion exchange with magnesium sulfate Increased levels of magnesium sulfate  smooth muscle relaxation in blood vessels  control of hypertension

37. Thank You!