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Aboubakr Elnashar

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  1. 1. PREECLAMPSIA‐ECLAMPSIA SPECTRUM Prof. Aboubakr elnashar Benha university Hospital, Egypt ABOUBAKR ELNASHAR INTRODUCTION HYPERTENSIVE DISORDERS OF PREGNANCY • Present in up to 10% of pregnancies ▪ In US: ▪ The 6 th leading cause of MM ▪ 9.9% of MM ▪ In Egypt: ▪ 2 nd leading cause of MM ▪ 15% of MM ▪ Leading cause of neonatal mortality/morbidity, primarily due to the effects of preterm delivery ABOUBAKR ELNASHAR
  2. 2. ABOUBAKR ELNASHAR Preeclampsia‐Eclampsia Spectrum • Greatest cause of maternal/perinatal morbidity& mortality • Includes: – Preeclampsia‐specify with or without severe features – Terminology change: mild preeclampsia is no longer used! – Preeclampsia superimposed on chronic HTN – Eclampsia – HELLP syndrome ABOUBAKR ELNASHAR
  3. 3. Eclampsia • Define: seizures in a patient with PET • Etiology: uncertain – ±cerebral edema, cerebral ischemia • BP: ▪ often significantly elevated ▪ 15% of cases BP may be normal (diastolic ≤90 mm Hg) ▪ Onset: Can occur before, during, or after delivery ABOUBAKR ELNASHAR HELLP Syndrome • A presentation of PET with severe features • HELLP acronym: – Hemolysis – Elevated Liver enzymes – Low Platelets ABOUBAKR ELNASHAR
  4. 4. 1. DEFINITION ❑ ACOG, 2013, 2015 ▪ Syndrome of new onset of Hypertension and either Proteinuria or End organ dysfunction after 20 w in a previously normotensive woman ABOUBAKR MOHAMED ELNASHAR ABOUBAKR ELNASHAR International Society for the Study of Hypertension Pregnancy (ISSHP).2018 Hypertension SBP at ≥140 mm Hg &/or DBP at ≥90 mm Hg on at least two occasions measured 4 hours apart in previously normotensive women accompanied by one or more of the following new- onset conditions at or after 20 w: 1. 2. 3. Proteinuria Maternal organ dysfunction Uteroplacental dysfunction ABOUBAKR MOHAMED ELNASHAR ABOUBAKR ELNASHAR
  5. 5. ❑Proteinuria: ▪No longer ▪Required alone in diagnosis ▪Useful in: ▪classifying PET as severe ▪deciding whether to induce {amount not shown to predict either maternal or fetal outcomes} (ACOG, 2013) ▪Heavy (5 g/24 h) has been eliminated as a criterion for diagnosing severe PET ▪Testing may be discontinued once significant proteinuria has been demonstrated ABOUBAKR ELNASHAR 2. PATHOGENESIS ▪2 STAGES: 1 &2 ▪3 TYPES: early, preterm, term ▪3 MECHANISMS: Vasospasm, capillary leak, activation of coagulation ▪4 THEORIES: ▪Multisystem disorder ABOUBAKR ELNASHAR
  6. 6. Stage I Impaired endothelization of cytotrophoblast Inadequate invasian of the spiral arteries in to myometrium Placental Ischemia Placental hypoxia ↓Production of Pro-angiogenic factors PLGF, VEGF Release of anti-angiogenic factors such as SFLT-1, PGs & Cytokines into the maternal circulation Stage II (fate in pregnancy) Oxidatively stressed placenta Systemic endothelial dysfunction & Inflam. response ↑systemic vascular resistance activation of coagulation cascade clinical manifestation like hypertension & proteinuria ABOUBAKR ELNASHAR hemoconcentration edema proteinuria thrombocytopenia oliguria HTN seizures abruption liver ischemia Endothelial activation Vasoactive agents: Prostaglandins nitric oxide endothelins Noxious agents: Cytokines Lipid peroxidases Vasospasm Capillary leak Activation of coagulation Reduced uteroplacental perfusion Maternal vascular disease Excessive trophoblast Faulty placentation Genetic, immunologic, inflammatory factors ABOUBAKR ELNASHAR
  7. 7. ▪ Classification according to onset *higher risk of short&long-term Morbidity & mortality. (Lisonkova et al, 2014) Preterm Term maternal& perinatal ABOUBAKR MOHAMED ELNASHAR <34 w 34-37 w ≥37 w Early* Preterm Term Preterm Term ABOUBAKR ELNASHAR ▪4 THEORIES 1. Impaired vascular remodeling of the fetal maternal interface 2. Excessive immune response to paternal antigen 3. Exaggerated systemic inflammatory response 4. Placental & endothelial dysfunction ABOUBAKR ELNASHAR
  8. 8. ABOUBAKR ELNASHAR 3. PREDICTION=SCREENING NICE: women should be considered to be at high risk of developing PE if they have any one high-risk factor hypertensive disease in previous pregnancy= 7X risk chronic hypertension chronic renal disease DM autoimmune disease any two moderate-risk factors nulliparity age ≥40 y BMI ≥35 kg/m 2 , family history of PE, or interpregnanc AB y OUB i A n KR t M e O r HA v M a ED l ELN > AS 1 HA 0 R y ABOUBAKR ELNASHAR
  9. 9. ACOG 2015 women with a history of early-onset PE: 7X risk preterm delivery ≤34 w, ≥one prior pregnancy complicated by PE ABOUBAKR MOHAMED ELNASHAR ABOUBAKR ELNASHAR F I G O , 2 0 1 9 : Criticism: 1. Each risk factor as a separate screening test with additive detection rate& screen-positive rate. 2. Maternal risk factors is not a sufficient tool for the effective prediction of PE. ABOUBAKR MOHAMED ELNASHAR Guidelines Detection rate of False+ve Preterm PE Term PE NICE 39% 34% 10% US preventive TF 90% 89% 64% ABOUBAKR ELNASHAR
  10. 10. Combined Risk Assessment Patient-specific risk for preterm PE is calculated using the Bayes-based method. The risk calculator available free of charge on the webpage https://fetalmedicine FMF mobile app. medical records software. ABOUBAKR MOHAMED ELNASHAR ABOUBAKR ELNASHAR 1. Risk Factors: Maternal Age, y Maternal Maternal Maternal Obstetric weight, kg height, cm ethnicity: white, Afro-Caribbean, South Asian, East Asian, Mixed Nulliparous, parous without prior PE, parous with prior PE Interpregnancy interval in years between the birth of the last child Gest age at delivery birth weight of previous pregnancy beyond 24 w Medical: Family history of PE (mother) Method of conception: spontaneous, ov induction, Smoking habit IVF History History History of of of chronic hypertension DM: type 1, type 2, insulin intake SLE or anti p hosol i p i d syndrome ABOUBAKR ELNASHAR
  11. 11. 2. Measurement Of Blood Pressure measured by validated automated&semiautomated devices The measured sBP and dBP will be automatically converted to MAP by the risk calculator. MAP=dBP+(sBP−dBP)∕3 MAP is converted to a multiple of median (MoM), adjusting for these associated maternal characteristics& gestational age will be used for calculation of patient-specific risk.ABOUBAKR MOHAMED ELNASHAR ABOUBAKR ELNASHAR 3. Measurement Of Uterine Artery Pulsatility TA US: done at 11+0 to 13+6 w corresponding to CRL 42–84 mm Index Gest age determined from measurement CRL. UTPI Abnormal if ≥90th percentile Is adjusted for associated maternal characteristics& gest age by converting it to a MoM ABOUBAKR ELNASHAR
  12. 12. Identification of the uterine artery at the level of the internal os (left) and typical waveforms of the uterine artery Doppler in the first trimester of pregnancy. ABOUBAKR MOHAMED ELNASHAR ABOUBAKR ELNASHAR 4. Measurement Of Biochemical Markers PLGF. The best biochemical marker PAPP-A if measurements of PLGF& UTPI are not available. ABOUBAKR MOHAMED ELNASHAR ABOUBAKR ELNASHAR
  14. 14. If Calculated risk: ≥1 in 100 A woman is at high risk The first-trimester combined test most predictive of preterm PE but not term PE. The best model is the one that combines 1. 2. 3. 4. Risk factors MAP UTPI. PLGF ABOUBAKR MOHAMED ELNASHAR ABOUBAKR ELNASHAR 4. PREVENTION FIGO, 2019 Women at high risk should receive aspirin prophylaxis Start at 11–14+6 w Dose: ~150 mg minimum: 100mg/d Every night Stop: ▪ 36 w, when delivery occurs, or ▪ PE is diagnosed. ABOUBAKR MOHAMED ELNASHAR ABOUBAKR ELNASHAR
  15. 15. In women with low calcium intake (<800 mg/d), either calcium replacement (≤1 g elemental calcium/d) or calcium supplementation (1.5–2 g elemental calcium/d) may reduce the burden of both early&late-onset PE. ABOUBAKR MOHAMED ELNASHAR ABOUBAKR ELNASHAR The benefit of other treatments, such as B e d r e s t ❑ Heparin Vit C& E Magnesium Folate Metformin, and Statin for prophylaxis of preterm PE not yet based on credible evidence their use solely is neither justified nor recommended. ABOUBAKR ELNASHAR
  16. 16. 5. DIAGNOSIS OF PREECLAMPSIA ▪ New onset hypertension after 20 weeks with proteinuria: ▪ Hypertension: – BP ≥140/90 mm Hg two times, taken 4 hours apart – BP ≥160/110 mm Hg once ▪ Proteinuria is defined by: – 24 hour protein ≥300 mg – Timed urine protein level extrapolated out to 24 hour value – Protein/creatinine ratio of ≥0.3 – Urine dip + 1 or more (only if other methods are not available) – Proteinuria is NOT required if the patient has new onset HTN with specified findings ABOUBAKR ELNASHAR ▪ Diagnosing Preeclampsia Without Proteinuria • New onset HTN with any of these findings: – Platelets <100,000/uL – Creatinine >1.1 mg/dL or doubled from baseline – Transaminases twice the normal levels – Pulmonary edema – Cerebral or visual symptoms ABOUBAKR ELNASHAR
  17. 17. ▪ Clinical features of severe PET ▪ In addition to hypertension & proteinuria: ▪ Severe headache ▪ Visual disturbance ▪ Papilloedema ▪ Liver tenderness ▪ Epigastric pain ▪ Vomiting ▪ Signs of clonus ▪ Platelet count <100 x 10 6 /l ▪ Abnormal liver enzymes (ALT or AST≥ 70 iu/l) ▪ HELLP syndrome. ABOUBAKR ELNASHAR ▪ Clinical Presentation of HELLP • Extremely variable presentation of symptoms • Common findings: – RUQ pain, epigastric pain, n&v – 85% hypertensive • DD: biliary colic, pancreatitis, fatty liver of pregnancy, GERD, hepatitis, idiopathic thrombocytopenic purpura (ITP), thrombotic thrombocytopenic purpura (TTP) • Timing of diagnosis: 30% of women are postpartum ABOUBAKR ELNASHAR
  18. 18. ▪ Laboratory Findings in HELLP • Hemolysis – Abnormal peripheral smear – LDH elevated • Liver enzymes – Transaminases > twice the normal • Platelet count – <100,000/uL ABOUBAKR ELNASHAR ▪ Management of HELLP • Similar to preeclampsia with severe features – Stabilize mother – Evaluate fetus for compromise – Determine optimal timing/route of delivery – Use continuous fetal monitoring – Manage BP and fluid status • All women should receive MgSO4 while symptomatic or in labor ABOUBAKR ELNASHAR
  19. 19. ❑Measurement of blood pressure 1. Patient: ▪ Rested ▪ Sitting at a 45-degree angle. 2. BP cuff: ▪ appropriate size ▪ placed at the level of the heart. 3. Readings: ▪ Multiple readings {confirm the diagnosis}. ▪ Korotkoff phase 5 for DBP. 4. The method: Automated: used with caution {underestimate particularly SBP} ABOUBAKR ELNASHAR 6. MANAGEMENT OF PREECLAMPSIA WITHOUT Severe Features • Expectant management before 37 w: • Mat: ▪ Closely watch for development of severe features ▪ CBC, transaminases, creatinine, LDH, uric acid ▪ Weekly labs – CBC, transaminases (AST, ALT) – No need to follow urine protein, as even >5 g is not considered a “severe feature” ▪ Foetal: Antepartum surveillance – NST’s, amniotic fluid measurement, biophysical profile – Growth ultrasound every 3 to 4 w • Delivery at 37 weeks ABOUBAKR ELNASHAR
  20. 20. WITH Severe Features • Admit to hospital & monitor closely on bedrest • Treatment goals: 1. Prevent seizures 2. Control BP to prevent cerebral hemorrhage 3. Expedite delivery, balancing maternal condition and fetal maturity ABOUBAKR ELNASHAR I. Maternal assessment & monitoring II. Foetal assessment III.Control BP IV.Prevention of seizures V. Control of seizures VI. Fluid balance VII.Delivery VIII. Postparum ABOUBAKR ELNASHAR
  21. 21. I. Maternal assessment and monitoring 1. Symptoms: ▪ Important components of worsening disease, particularly headache& abdominal pain. ▪ At least every 8 hours ▪ For ▪ Headache, visual changes, ▪ RUQ or epigastric pain, retrosternal pain or ▪ Convulsions ABOUBAKR ELNASHAR 2. Vital signs 1. BP: /15 m until the woman is stabilised and then /30 m in the initial phase of assessment. /4-h if a conservative management plan and the woman is stable and asymptomatic. 2. Maternal tendon reflexes: ▪ Assess Mg toxicity ▪ Assess risk of convulsion. ▪ Every 15 to 60 minutes until stable ABOUBAKR ELNASHAR
  22. 22. 3. Continuous oxygen saturation monitoring with a pulse oximeter: ▪ Valuable ▪ {give early signs of pulmonary oedema}. 4. Input & output ▪ Insert foley catheter if needed in acute situation , especially in the immediate postpartum period. ▪ Notify for <30 mL urine per hour ▪ Increasing oedema: Not in itself a sign that should determine management. ABOUBAKR ELNASHAR 3.Labs daily 1. CBC, liver function, renal function tests. ▪ At least daily when the results are normal ▪ More often if the clinical condition changes or if there are abnormalities. 2. Clotting studies ▪ Not required if the platelet count >100 x 10 6 /l. 3. Consider peripheral blood smear 4. Type & screen in labor ABOUBAKR ELNASHAR
  23. 23. ▪Uric acid: rise ▪ Correlates with poorer outcome for both mother& baby. ▪ Confirms the diagnosis of PET ▪ Should not be used for clinical decision-making. ▪Creatinine ▪ Elevated early in the disease process: underlying renal disease should be suspected. ▪ In severe disease: rise: worsening outcome ABOUBAKR ELNASHAR ▪Platelet count <100x10 6 : worsening disease coagulation abnormality consideration for delivery. ▪Platelet volume may be of benefit but are as yet unproven. ABOUBAKR ELNASHAR
  24. 24. ▪AST >75 iu/l or ALT >70 iu/l ▪ Significant ▪ >150 iu/l: increased maternal morbidity ▪Diagnosis of HELLP syndrome 1. Haemolysis: LDH levels, or blood film (fragmented red cells). 2. Platelet count: <100 x 10 6 ABOUBAKR ELNASHAR II. Foetal assessment 1. In the acute setting: ▪ CTG: assess fetal wellbeing at that time but does not give any predictive information. 2. In labour: continuous electronic fetal monitoring. 3. In Conservative management: Serial assessment will allow timing of delivery to be optimized. 1. US a. fetal size: IUGR 30% of PET usually asymmetrical: AC is the best for assessment b. liquor volume. ▪ Reduced: placental insufficiency and IUGR. ▪ Serial estimations: detect fetal compromise. ABOUBAKR ELNASHAR
  25. 25. III. Control BP ▪ Antihypertensive treatment ▪ Indications: 1. SBP> 160 mmHg or DBP>110 mmHg. 2. SBP <160 plus ▪ Severe disease ▪ Heavy proteinuria or ▪ Disordered liver or haematological test) {alarming rises in BP may be anticipated} ▪ Objective: ▪ There is an increasing trend toward tighter BP control ▪ SBP: below 150 mm Hg ▪ DBP: 80-100 mm Hg ABOUBAKR ELNASHAR ▪Drugs: ▪ Labetalol&hydralazine for acute&severe (ACOG, 2013) ▪ Labetalol [NICE, 2012] ▪ Acute, severe: ▪Nifedipine: oral not sublingually ▪ IR cap:10 mg initial; repeat after 30 m if necessary ▪ IR cap: 10-30 mg tid; not to exceed 120-180 mg/d ABOUBAKR ELNASHAR
  26. 26. ▪ Hydralazine: IV: ▪ Initial dose: 5 mg over 2 minutes ▪ After 20 minutes, if BP remains ≥160/110 mm Hg, repeat with 10 mg ▪ No more than 4 doses. ▪ If not give Labetalol or Nifidipine. ▪ Maintenance: 10 mg/h ▪ Add 2ml NS to reconstitute 20 mg hydralazine. Withdraw 0.5 ml hydralazine solution and add 9.5 ml NS to give total 10 ml solution. ABOUBAKR ELNASHAR ▪Labetalol: IV: ▪ Initial dose: 20 mg IV bolus over 2 minutes ▪ If BP remains ≥160/110 mm Hg, then repeat 10 minutes later with 40 mg IV, and 10 minutes later at 80 mg IV. If BP remains ≥160/110 mm Hg, switch to hydralazine ▪ Maximum daily IV dose of 300 mg ▪ Maintenance: 40 mg/h ABOUBAKR ELNASHAR
  28. 28. ▪ Chronic, moderate: ▪ Nifedipine: SR tab: 30-60 mg qd; not to exceed 90-120 mg/d ▪ Hydralazine: Oral: 25 mg tds ▪ Labetalol: ▪ 100 mg bid ▪ should be avoided in asthma. ▪ Methyldopa ▪ was the most commonly used therapies in UK. ▪ safe in long term follow-up of the delivered babies ▪ some studies have suggested some benefits of labetalol. ABOUBAKR ELNASHAR ▪Atenolol: increase in IUGR. ▪ACE inhibitors and ARBs: ▪contraindicated ▪{unacceptable fetal adverse effects}. ▪Diuretics ▪ relatively contraindicated for hypertension ▪ should be reserved for pulmonary oedema. ABOUBAKR ELNASHAR
  29. 29. IV. Prevention of seizures: Mg S ▪ Preferred anticonvulsant – Slows neuromuscular conduction& decreases CNS irritability – No significant effect on BP – Prevents seizures (NNT = 100 for all women with preeclampsia; NNT = 400 for preeclampsia without severe features ) – Decreases risk of placental abruption (NNT = 100) ABOUBAKR ELNASHAR ▪Indication: ▪ Severe PET: when? ▪ Once a delivery decision has been made & in the immediate postpartum period. ▪ When conservative management of a woman with severe hypertension and a premature fetus is made it would be reasonable not to treat until the decision to deliver has been made. ▪ Should be considered for women with PET for whom there is concern about the risk of E. ABOUBAKR ELNASHAR
  30. 30. ▪ Dosage ▪ Loading: 4 to 6 g IV over 15 to 20 min ▪ Maintenance: continuous infusion of 1-2 g/h ▪ Continued for ▪ 24 h following delivery or ▪ 24 h after the last seizure, whichever is the later, unless there is a clinical reason to continue. ▪ Regular assessment of: a. Urine output b. Maternal reflexes c. Respiratory rate d. Oxygen saturation . ABOUBAKR ELNASHAR ▪ Check magnesium level if: – Urine output <30 mL/hour – Elevated serum creatinine: MgSO4 toxicity is uncommon with normal renal function – Symptoms of MgSO4 toxicity – Loss of patellar reflexes ABOUBAKR ELNASHAR
  31. 31. V. Control of seizures • Avoid anticonvulsant polypharmacy • Protect airway to minimize aspiration • Prevent maternal injury • Administer MgSO4 to control convulsions • When stable, plan for delivery ABOUBAKR ELNASHAR I. 1. Do not leave the patient alone. 2. Prevent maternal injury during the convulsion. 3. Call for help& place a code blue call- Medical Emergency call. 4. Initiate resuscitation. 5. Turn the patient into left lateral position when able to do so. 6. Inform consultant obstetrician& anesthetist on call. ABOUBAKR ELNASHAR
  32. 32. II. AIRWAY 1. Assess & maintain patency, using oral suction if necessary. 2. Insert a plastic oral airway if possible 3. Administer oxygen therapy via face mask. III. BREATHING 1. Assess respiratory rate 2. Ambubag using facial mask/laryngeal mask or endotracheal tube if necessary. ABOUBAKR ELNASHAR IV. CIRCULATION 1. Evaluate Pulse & B P. If absent, initiate CPR. 2. Secure IV access as soon as possible ▪ with main line infusion ▪ with three-way tap attached ▪ Hartmann's Solution ▪ very slow rate, as fluid intake will be restricted to 1 ml/kg/h 3. Pulse oximetry is helpful. ABOUBAKR ELNASHAR
  33. 33. V. Mg SO4 ▪Therapy of choice to control seizures. ▪Loading dose: 4-6 g infusion pump over 5–10 min ▪Maintenance: 1-2 g/h for 24 h after the last seizure. ▪Recurrent seizures Further bolus of 2 g Mg SO4 or an increase in the infusion rate to 1.5 g or 2.0 g/h. ABOUBAKR ELNASHAR VI. Once stabilized ▪Plans should be made to deliver the woman ▪No particular hurry & a delay of several hours to make sure the correct care is in hand is acceptable, assuming that there is no acute fetal concern such as a fetal bradycardia. ▪The woman’s condition will always take priority over the fetal condition. ABOUBAKR ELNASHAR
  34. 34. VI. Fluid balance 1. Fluid restriction is advisable {reduce the risk of fluid overload in the intrapartum& postpartum periods} Total fluids should be limited to 80 ml/h or 1 ml/kg/h {a. pulmonary oedema has been a significant cause of maternal death. b. No evidence of the benefit of fluid expansion c. fluid restriction regimen is associated with good maternal outcome. d. No evidence that maintenance of a specific urine output is important to prevent renal failure, which is rare.}ABOUBAKR ELNASHAR 2. The regime of fluid restriction should be maintained until there is a postpartum diuresis, as oliguria is common with severe pre-eclampsia. 3. If there is associated maternal he: ▪ fluid balance is more difficult ▪ fluid restriction is inappropriate. ABOUBAKR ELNASHAR
  35. 35. VII. Delivery ▪When: •Once the woman is stable and with appropriate senior personnel present. •If the fetus is <34 w& delivery can be deferred: corticosteroids should be given, although after 24 h the benefits of conservative management should be reassessed. •Conservative management at very early gestations may improve the perinatal outcome but must be carefully balanced with maternal wellbeing. ABOUBAKR ELNASHAR ▪ Fetal indications ▪ Severe IUGR ▪ Nonreassuring fetal surveillance ▪ Oligohydramnios ▪ Maternal indications ▪ Gestational age of 37 w or greater* ▪ Severe PE: ▪ Platelet count below 100 × 10 3 per mm 3 (100 × 10 9 per L) ▪ Progressive deterioration of hepatic function ▪ Progressive deterioration of renal function ▪ Suspected placental abruption ▪ Persistent severe headache or visual changes ▪ Persistent severe epigastric pain, nausea, or vomiting ▪ Eclampsia ABOUBAKR ELNASHAR
  36. 36. ▪ Method: •Depend on 1. presentation 2. fetal condition 3. likelihood of success of induction of labour ▪ Vaginal delivery is preferred due to: – Lower risk of bleeding, infection, anesthesia reaction, and surgical complications – Quicker recovery ▪ CS is indicated for: – Continuous seizures or other emergent signs& symptoms – Fetal distress – Unfavorable cervix with severe prematurity(<30 w) ABOUBAKR ELNASHAR ▪ Anaethesia ▪ In the absence of contraindications, all of the following are acceptable for women undergoing CS: ▪ Epidural ▪ Spinal ▪ Combined spinal-epidural, and ▪ General anaesthesia. (A) ▪ Epidural/spinal preferred versus general ▪ General anesthesia is indicated if platelet count <50,000 ▪ Regional anaesthesia for women on LMWH: ▪ 12 h after a prophylactic dose ▪ 24 h after a therapeutic dose. (B) ABOUBAKR ELNASHAR
  37. 37. ▪The third stage: •5 u IM Syntocinon or 5 u IV Syntocinon given slowly. •Ergometrine or Syntometrine should not be given for prevention of hge {can further increase the blood pressure}. ABOUBAKR ELNASHAR VIII. Postpartum management ▪ Improvement is usually rapid after delivery – Risk of seizures are greatest in the first 24 hours after birth – Diuresis signals resolving of the disease process ▪ Women who develop hypertension or symptoms of PE postnatally (headaches, visual disturbances, n&v or epigastric pain): ▪ referred for a specialist opinion ▪ investigation to exclude PE. ABOUBAKR ELNASHAR
  38. 38. ▪ In Hospital 1. Close observation ▪ Postnatally for 4 days or more Women who deliver with severe PET (or E): ▪ BP and input &output ▪ If blood pressure remains elevated 24 hours postpartum, do not use NSAID’s for pain control ABOUBAKR ELNASHAR 2. Anti-hypertensive •Continued as dictated by BP. •BP should not exceed 160/110 mmHg •Reduction in anti-hypertensive therapy: in stepwise fashion. •Treat persistent HTN •If 2 values >150/100 mm Hg at least 4 to 6 hours apart •Persistent BP >160/110 mm Hg (goal is to treat within 1 h) •Avoid alpha methyldopa •In breastfeeding: labetalol, atenolol, nifedipine and enalapril can be given ABOUBAKR ELNASHAR
  39. 39. 3. Magnesium SO ▪ When already on MgSO4, continue until clinically stable: Usually 24 hours postpartum ▪ Women who have not required magnesium prior to delivery may require postpartum initiation of MgSO4 if the following occurs: • New onset of HTN with cerebral symptoms (headache or blurred vision) • PE with severe HTN (≥160/110 mm Hg) • Eclampsia ABOUBAKR ELNASHAR 4. Education: ▪ Signs/symptoms of postpartum PET at the time of discharge ▪ Understand PET may occur up to 4 w Postpartum ABOUBAKR ELNASHAR
  40. 40. ▪ Follow up: ▪ BP in 7 to 10 d ▪ BP and proteinuria at the 6 w. ▪ If hypertension or proteinuria persists then further investigation is recommended. ▪ Preconceptional counselling ABOUBAKR ELNASHAR Thank you ABOUBAKR ELNASHAR