Overview of Pre-eclampsia

1. Androu Waheeb

2. Blood Pressure in normal
pregnancy
 6/52: 5-10 (sbp) /10-15 (dbp) mmHg
 26/52: nadir
 after 26/52:
 Less than pre-pregnancy

3. Hypertension in Pregnancy
Hypertension in
Pregnancy
>140 or 90 mmHg
2 consecutive times 6 hours apart
Pregnant patient
Pregnancy Induced Chronic Hypertension
Hypertension
>20/52 <20/52
Gestational Preeclampsia Eclampsia
Hypertension
-ve protrinuria + proteinuria (≥300mg/24 or 1+) + unexplained grand mal seizures
+/- nondependant edema (face &
hands)

4. Preeclampsia - Definition
 Presence of
Hypertension
• SBP ≥ 140 or DBP ≥ 90
• 2 readings 6 hours apart
• > 20/52 gestation
Proteinuria
• ≥ 1+ Urine dipstick (not sensitive)
• ≥ 300 mg / 24
Nondependent Edema
• Hand
• Face
• Not sensitive or specific

5. Preeclampsia – Incidence
30
25
2000 (per 1000 F)
20
1994 (per 1000 F)
15
1987 to 2004 (PE:MM per
10
100,000 births)
5 2008 (MMR per 100,000
births)
0
UK US South Saudi Bahrain World
(EURO (AMRO Africa Arabia
A) A) (AFRO
E)

6. Preeclampsia – Cause of Death
(2006)

7. Preeclampsia - Pathophysiology
 Systemic Inflammatory Response
 Endothelial Activation
 Maternal symptoms
 Generalized transudative edema
  intravascular depletion
  symptoms of ischemia, necrosis, hemorrhage
 Vascular damage
  imbalance of prostacyclin (VD) & thromboxane (VC)
 Generalized arteriolar Constriction (Vasospasm)

8. Preeclampsia – Pathology (1)
 Vascular Theory
 Poorly perfused placenta
 Abnormal placentation
 Maternal microvascular disease
 ‘Relative’: due to hyperplacentosis
  placental ischemia
  release of factors by placenta
  cascade
  damage maternal vascular endothelium

9. Preeclampsia – Pathology (2)
 Alloimmune Theory
 Sperm exposure
  mucous alloimmunization
  cascade (≈ classical inflammatory response)
  inhibition of placentation

10. Preeclampsia – Risk Factors
• Nulliparous • Chronic HTN • African American
• Previous preeclampsia • Chronic Renal Disease • Obesity
• Multiple Gestation • Collagen Vascular • 35 < Age < 20
• Abnormal Disease • New paternity
Placentation • Pregestational DM • Cohabiliation < 1 year
Immunogenic Disease Maternal
Related Related Related
• Relatives
• Mother-in-Law
Family
History

11. Preeclampsia - Complications
Maternal Fetal
CNS
• Seizures
Preterm Delivery
• Cerebral Edema
• Cerebral Hemorrhage
• Strokes (thrombosis)
Hepatic Stillbirth (IUFD)
• Hepatic Failure Intrapartum Fetal Distress
• Hepatic Rupture
• Subcapsular Hemorrhage
Heamatological
• DIC
Placental Abruption
• HELLP
Renal Uteroplacental Insufficency
• Renal Failure • Hypoxic Neurological Injury
• Oliguria
• Proteinuria >> Hypoproteinemia (Glomerular Injury) • IUGR
• Oligohydraminos
Lungs
• Pulmonary Edema

12. Preeclampsia - Classification
Mild Severe
Maternal Criteria Fetal Criteria
Oligohyd Abnormal
Clincal Criteria Labs IUGR -raminos Doppler
RUQ Oligo- Protein-
Pulmonary
HTN NS Edema Pain uria uria HELLP
(≤500ml) (≥5mg)
Hyperreflexia
Headache
Disturbances
Visual
SBP ≥ 160
DBP ≥110

13. Preeclampsia - Diagnosis
 Upon antenatal visits
 First visit
 Identify risk (Hx, PEx)
 BP + Urine protein test
 Following visits
 28/52 : Monthly BP + Urine protein test
 After 28/52 : More frequent BP + Urine protein tests
 2nd trimester : Uterine Artery Doppler (not sensitive)

14. Preeclampsia - Management
• Fetal: 2qw
• Close monitoring • CTG
• US
Admission
required Severity • US Doppler: Umbilical + Cerebral
Assessment • Liquor Assessment
• Bloods
IV Line • Infusions Stabilize
Patient
• Monitoring urine • Fluid Restriction (80ml/h)
output and ease of • Decision based on severity +
Urinary gestational age
Catheter 24h urine collection Therapy • Mother is concern
• Maternal
• PEx
• BP :15m, 30, 4qh
• 24/24 Urinary Collection • Decision on date required
Severity • 2qw: FBC, Coag. Delivery
Assessment Profile, LFT, serum(Cr), Uric
Acid

15. Preeclampsia – Treatment
 Curative Therapy: Delivery
 Balance maternal and fetal status
Severe Follow-Up
Mild Preeclampsia Seizure
Preeclampsia (44% PP  1/12)
•Expectant • Admission • A,B,C • Reassess.
•Admission • MgSO4 • Ox Stat Discharge when
•Betamethasone • Intrapartum • Oxygen stable  6/52
•MgSo4 4g.2g/h • Postpartum • MgSO4 4g.2g/h • MgSO4 1d
•RCOG: 1g/h 24h postpartum/post
• 2g bolus
last seizure
• IV Labetalol / IV • Left Lateral
Hydralizine / • PO Labetalol /
Position
Nifedipine PO Methyldopa /
• Prepare for Nifedipine:
• Decide on delivery CHTN
delivery
• Low dose Aspirin
/ LMWH
• Monitor HELLP
(LP:
corticosteroids)

16. Preeclampsia – Therapy (2)
 MgSO4  Antihypertensive
 Monitor  Monitor
 Ox Stat  BP
 Respiratory Rate  ≥ 130/80
 Replace Ca Gluconate 1g
 Only improves morbidity
infusion
 Deep tendon reflexes
 Urine Output  Aspirin
 Halt if less than 20 ml/h
 Inhibits thromboxane A2
 Recurrent Seizures synthesis
 MgSO4: 2g bolus (RCOG:   re-altering
increase infusion to 2g/h) TXA2/Prostacyclin balance

17. Preeclampsia – Delivery Indications
 Mild Preeclampsia  Severe Preeclampsia
 Expectant (Betamethasone +
 Expectant MgSO4)
 Stable  GA 24-32/52
 Deliver
 Preterm  GA > 32/52
 Deliver  Patient presenting with
 Uncontrollable BP
 Term  Symptoms
 Unstable preterm  Headache, RUQ, Visual
 Hyperreflexia
 Fetal compromise  Complications
 GR/OH/abnormal  HELLP or LP
 Renal Failure
Umbilical Doppler
 Hepatic Injury
Induced delivery  Pulmonary Edema
(PG, Oxytocin, Amniotomy) unless  DIC
obstetric indication

18. Androu Waheeb