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

Section C

MadularaMagno

MagsinoMalig

MallariMamba

MangubaMangubat

MansukhaniManzana

Severe Pre-Eclampsia

Pre-eclampsia

• the presence of hypertension and proteinuria occurring after 20th week of gestation

Indications of Severe Pre-eclampsiaAbnormality Mild Severe

Diastolic BP < 100 mmHg 110 mmHg

Proteinuria Trace to 1+ Persistent ≥ 2+

Headache Absent Present

Visual disturbance Absent Present

Upper abdominal pain Absent Present

Oliguria Absent Present

Convulsions Absent Present

Serum creatinine Normal Elevated

Thrombocytopenia Absent Present

Liver enzyme Minimal Markedly Fetal growth restriction Absent Obvious

Pulmonary edema Absent Present

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

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)

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

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.

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

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

Risk factors and their odds ratio for pre-eclampsia

Nulliparity 3:1

Age >40 y 3:1

African-American race 1.5:1

Family history 5:1

Chronic renal disease 20:1

Chronic hypertension 10:1

Antiphospholipid syndrome 10:1

Diabetes mellitus 2:1

Twin gestation 4:1

High body mass index 3:1

Angiotensinogen gene T235  

Homozygous 20:1

Heterozygous 4:1

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

PE Findings• Persistent headache, visual disturbance,

epigastric pain • Increase serum transaminase• Obvious growth restriction• Pulmonary edema: increase permeability in

maternal circulation

Laboratory Tests1. 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

Ultrasound

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

TREATMENT

TREATMENT

• 3 cardinal principles: A. control of convulsionsB. Control of hypertensionC. Delivery at optimum time and mode

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

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

CONTROL OF CONVULSION

• DOSE: a. Loading dose – 4 gm IV slowly over 5 mins

Maintenance dose -1-2 Gms per hour IV dripb. Loading dose – 4 Gm IV slowly over 5 mins and

10 gm IV (5gm on each buttock)Maintenance – 5 Gms IM every 6 hours

CONTROL OF CONVULSION

• Monitoring: – Presence of DTRs– RR of >12 per minute– Urine output at least 100cc every 4 hours– Serum magnesium

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

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

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

OPTIMUM TIME AND MODE OF DELIVERY

• 5 Factors: 1. Age of gestation2. Severity of disease3. Fetal status4. Maternal condition5. Nursery capabilities

OPTIMUM TIME AND MODE OF DELIVERY

• General guidelines: 1. Hospitalize all patients once signs or symptoms

of pre-eclampsia are evident2. Immediate delivery done for:

a) All cases of eclampsia regardless of age of gestationb) 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

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

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

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

PREVENTION

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

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 2nd

trimester to prevent fetal malformations

• Contraindications:– Aspirin allergy or

hypersensitivity (acid peptic disease or coagulopathy

High Dose Calcium

• oral intake of calcium (2g/day)

• Reduction in IUGR and BP levels

• Exerts a negative feedback effect on parathyroid hormone decrease calciumsmooth muscle relaxation and diminished responsiveness to pressor stimuli

• 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

Thank You!