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Hypertension:
Systolic BP 140 mm. of Hg (or a rise
of 30 mm. of Hg)
Diastolic BP 90 mm. of Hg. (or a
rise of 15 mm. of Hg)
Either or both
Proteinuria:
Urinary protein excretion > 300 mg. in 24
hours
Or >1g/l in a random sample
HYPERTENSION
Blood pressure
≥ 140/90 mm. of Hg
Two readings taken six hours apart with
the woman
Comfortably resting
At 45 degrees
Peculiar to pregnancy
Of placental origin
Cured by delivery
PRE-ECLAMPSIA
Hypertension after 20 weeks = PIH
PIH + proteinuria = Pre-eclampsia
Spiral
artery flow
reduction
Abnormal
Uteroplacental uterine
flow reduction artery
waveform
Exaggerated
inflammatory
response
Exaggerated
inflammatory
response
Endothelial
cell damage
↑ vascular
permeability Vasoconstriction
Clotting
abnormality
Oed Protei HT
Eclampsi
a
ema nuria IUGR
Liver
damage
PATHOPHYSIOLOGY
Extravasation
Subcapsular haemorrhages
Stage 1:
Development of the disease
Occurs before 20 weeks
No symptoms
Incomplete trophoblastic invasion
Impaired materno-fetal interaction may
be caused by altered immune responses
+ spiral arterioles may have
atheromatous lesions
TO SUMMARIZE THE PATHOPHYSIOLOGY
Stage 2:
Manifestation of the disease
Occurs after 20 weeks
The ischaemic placenta, via an
exaggerated maternal inflammatory
response causes the clinical
manifestations
Vascularendothelial damage with
vasospasm, transudation of plasma,
and ischemic & thrombotic sequelae
AETIOLOGY
Exact “Cause” – still unknown: possible altered
immune response
Predisposing factors
Nulliparity
Previous history of pre-eclampsia
Large placenta (twins, molar pregnancy, hydrops
fetalis)
Family history of pre-eclampsia
New partner
Extremes of maternal age (particularly older age)
Long inter-pregnancy interval
Obesity
PCOS
Pre-existing microvascular diseases
Chr. HT/chr. renal dis, diabetes, antiphospholipid syndrome
SEVERITY OF PRE-ECLAMPSIA
Mild:
Systolic: 140 – 149
Diastolic BP 90 – 99
Moderate:
Systolic BP 150 - 159
DBP 100 – 109
Severe
Systolic BP 160
DBP
Proteinuria - > 1g/l
CLINICAL FEATURES
Symptoms
Usually asymptomatic
Headache, visual disturbances, epigastric pain,
nausea, vomiting in severe disease
Signs
Oedema
But, is common in most pregnant women
Therefore, is of little diagnostic value
But, in pre-eclampsia
May develop suddenly
May be massive
Not postural
Hypertension
Urine shows proteinuria
CLINICAL FEATURES OF “SEVERE” PRE-ECLAMPSIA
IUGR
Fetal distress
Prematurity
Fetal death
DIAGNOSIS AND MONITORING
Clinical features
Symptoms
Signs
Investigations
Confirm proteinuria – Dipstick / P:C ratio
If proteinuria - exclude urinary infection
Serum uric acid – whether high (pregnancy normal range
is lower)
To monitor maternal wellbeing
Platelet count – whether low
Clotting studies – whether deranged
Liver enzymes – AST, ALT, LDH – whether high / rising
Renal function – creatinine – whether high
To monitor fetal wellbeing (whether IUGR)
Ultrasound scan (+ Doppler studies)
CTG
MANAGEMENT
DELIVERY CURES
Timing of delivery depends on
Severity of the disease
Gestational age
Till then…..
Outpatient management possible in
Women with mild disease
No proteinuria
Check BP twice weekly
Check urine for protein twice weekly
Ultrasound scans for fetal growth
Check blood for uric acid, platelet count
Antihypertensives if appropriate
Admit if
Moderate or severe disease
Proteinuria - ++ or more
Anytime the disease worsens or fetal compromise appears
MANAGEMENT IN HOSPITAL
Rest
Traditionally adviced, benefits doubtful
Family disruption, expensive, stressful
Risk of DVT
Regular BP check
Check proteinuria daily
Salt restriction
Should not be done
Antihypertensives
Severe disease - Mandatory
Milder disease – Often given, but role uncertain
Monitor the baby
Ultrasound scan
CTG
DRUGS USED
Antihypertensives
These do not modify the course of the disease
These are given to try and prevent maternal
complications (cerebral haemorrhage) and may
help in prolonging the pregnancy
Given if BP > 160/110 mm.of Hg
Methyl dopa
Nifedipine
Labetalol
Hydralazine
Magnesium sulphate
Treatment of eclampsia
Prevention of eclampsia
DRUGS USED
Role of antihypertensives in mild disease is
debatable
Some use it while some don’t
Steroids (Betamethasone)
For fetal lung maturity if delivery < 36 weeks is
anticipated
DRUGS TO AVOID
Avoid
ACE inhibitors
Captopril, lisinopril
Angiotensin receptor antagonists
Losartan
Antepartum – 50%
Intrapartum – 25%
duration
ECLAMPSIA
Management:
Turn the patient to her side
Avoids aspiration
Secure the airway if possible
Give oxygen by mask
Control fits
I.V. Magnesium sulphate – 4 g loading dose i.v.,
then 1 g/hour
I.V. Diazepam – 10 mg slow i.v., repeat after 10
min if required
Once the patient stabilizes, plan for
delivery
Nurse in a quiet room
ECLAMPSIA
Send bloods for
Complete haemogram
Platelet count
Clotting screen
PT / APTT
Fibrinogen
LFT
Antihypertensive
I.V. labetalol, hydralazine
In hypertensive crisis – sodium nitroprusside,
nitroglycerine
Anticonvulsants
Magnesium sulphate – most commonly used
Diazpam
Pethidine+chlorpromazine+promethazine – Lytic
cocktail
Phenytoin
ECLAMPSIA
Mode of delivery
Often caesarean section
Labour may be induced if
Cervix is favourable
Maternal condition is stable
Cephalic presentation
BP every 15 min.
ECLAMPSIA
Anaesthesia
Epidural is okay if no clotting disorder
Avoid hypotension as much as possible
In labour
Monitor maternal wellbeing
BP, fluid balance, analgesia, progress of labour
Treat eclampsia
Prevent recurrent convulsions
Safe drug
HOW MAG SULPH WORKS
Still
obscure
Possibly acts by
Inducing cerebral vasodilatation
Antagonising the excitatory glutamate
N-methyl-D aspartate receptors.
Increasing the production of
prostacyclins which is an endothelial
vasodilator, inhibits platelet
activation and protects endothelial
cells form injury mediated by free
radicals.
MAGNESIUM SULPHATE REGIMENS
ZUSPAN - Loading dose 4g (diluted in
normal saline) – slow i.v. over 10 – 15
mins
Followed by i.v. infusion 1g/hour x 24
hours
PRITCHARD - Loading dose 4g (diluted
in normal saline) – slow i.v. over 10 –
15 mins
5g i.m. in each buttock followed by 5g
every 4 hours x 24 hours
MAGNESIUM SULPHATE
How to monitor for toxicity
Monitor knee jerk – whether present
Calcium
gluconate – 1 g (10 ml) i.v. if
magnesium toxicity
ECLAMPSIA
Puerperium
Reduce antihypertensives in a stepwise manner