Preeclampsia Revised

Preeclampsia Revised

Abo-Baker El-Nashar

Aboubakr Elnashar

Benha University Hospital, Egypt

Email: [email protected]

Preeclampsia

Revised

ABOUBAKR ELNASHAR


Abo-Baker El-Nashar

500 000 ladies are lost every year as a result of pregnancy and

its complications.

Preeclampsia is the third serious complication of pregnancy

after thrombo-embolism and obstetric hemorrhages.

PET is a syndrome characterized by the triad of:

Hypertension.

Proteinuria.

Edema.

It complicates 5-10% of all pregnancies, yet responsible for

20% of maternal mortalities

ABOUBAKR ELNASHAR


Abo-Baker El-Nashar

Usually presents

after 20 weeks except

Cases of multiple pregnancy.

Molar pregnancy

Lupus.

Usually affects

Primigravidas except

History of previous Preeclampsia.

On top of Hypertension.

Lupus.

It usually starts by Edema

Hypertension

Proteinuria.

Followed By

Then Followed By

ABOUBAKR ELNASHAR


Abo-Baker El-Nashar

Etiology is not Known

Many Explanations Suggested Non completely satisfactory.

Theories

Immunology:

Disturbance of the immune response of maternal tissue

to trophoblast is different in PET patients than in normal

pregnancy.

Patients with PET show more circulating TNF and

Interlukin-2 levels than normal pregnant patients.

Epidemiological studies showed that prior exposure to

paternal antigen makes the incidence of PET less.

If the immunological theory is true it is expected

that the condition will deteriorate .

ABOUBAKR ELNASHAR


Abo-Baker El-Nashar

Genetic Factors:

Genetic factor has been suggested:

Incidence is higher in daughters of mother with PET.

Incidence is higher between sisters.

Incidence is higher in certain races.

The precise pattern is not known:

A maternal dominant Gene model.

A maternal Fetal Gene model.

A maternal-fetal gene interaction model.

ABOUBAKR ELNASHAR


Abo-Baker El-Nashar

Prostacyclin & Thromboxane Disturbance:

Prostacyclin

A potent vasodilator and anti-

platelet aggregants produced by

vascular endothelium.

Thromboxane A2

A potent vasoconstrictor &

platelet aggregator, produced

by platelets & trophoblasts

i.e. More increase in favor of Prostacyclin

During normal pregnancy Production of Prostacyclin

Production of thromboxane A2

In cases of Preeclampsia Production of Prostacyclin

Production of thromboxane A2

Result in an thromboxane A2/prostacyclin ratio

Vascular Tone and Elevated Blood Pressure ABOUBAKR ELNASHAR


Abo-Baker El-Nashar

Hormonal Effects:

During normal pregnancy

There are refractoriness to the pressor

effect of the pressor hormones

In patients with PET or who are destined

to develop it later in pregnancy

Loss of refractoriness to

Angiotensin II precedes the

appearance of the clinical

manifestations of PIH by 8-12

weeks.

The bases for Angiotensin II screening test

Angiotensin II.

Catecholamine.

Vasopressin.

There are vascular

reactivity to these pressor

hormones

ABOUBAKR ELNASHAR


Abo-Baker El-Nashar

Classification

Mild

Severe

Severe PET:

Blood pressure > 160/110 mmHg.

Proteinuria 5gm/24hrs urine collection.

Oliguria.

Cerebral or visual disturbance

Headache Blurred vision.

Altered consciousness. Scotamata.

Pulmonary edema or cyanosis.

Epigastric or right upper quadrant pain.

ABOUBAKR ELNASHAR


Abo-Baker El-Nashar

Condition only improve after delivery of the

placenta.

It happen early and more severe in cases

with large placental volume, … twins,

molar pregnancy …

Placenta play

a key role

Kidney: Proteinuria, Oliguria, Creatinine,

Creatinine Clearance.

Liver: HELLP Syndrome.

Brain: Focal Patches, Hemorrhage.

Almost all

organs in the

body are

affected

Organ Affected

Pathophysiology

ABOUBAKR ELNASHAR


Abo-Baker El-Nashar

Renal Failure. Heart Failure.

HELLP Syndrome. Placental Abruption.

Eclampsia. Cerebral Hemorrhage.

High Incidence of Cesarean Section.

Maternal Complications

Preterm Labor.

Intrauterine Growth Restriction.

Intrauterine Fetal Death.

Fetal Complications

Complications

ABOUBAKR ELNASHAR


Abo-Baker El-Nashar

Prediction

Roll Over Test.

Cold Pressor test.

Angiotensin II Stimulation Test.

Plasma Cellular Fibronectin.

Doppler Velocimetry of the Uterine & Umbilical Artery.

Urinary Calcium Excretion.

Higher fasting Insulin Level.

All Proved To Be Unsuccessful.

ABOUBAKR ELNASHAR


Abo-Baker El-Nashar

Role of Aspirin

Low dose Aspirin (50-100mg/day).

In Low risk patients: No Role.

In High risk patients:

the incidence of early onset PET.

Effective in reducing the severity the disease..

No beneficial effect on decreasing IUGR & Preterm birth.

Prevention

Role of Aspirin.

Role of Calcium.

Role of Anti-oxidant.

ABOUBAKR ELNASHAR


Abo-Baker El-Nashar

Administration of Vitamin C & E to PET patients did not show much

effect.

When administrated as prophylaxis they show a significant reduction

in the incidence of preeclampsia.

Antioxidant also showed beneficial effect on:

Birth Weight Apgar Score

Preterm Labor Amount of liquor

Role of Antioxidants

Oxidative stress is currently a plausible hypothesis for the

mechanism of endothelial injury in preeclampsia

Role of Calcium

Calcium Supplementation (2g/day).

Only Beneficial in population with low Calcium supplementation.

No beneficial effect on population with normal calcium intake.

ABOUBAKR ELNASHAR


Abo-Baker El-Nashar

Depends on the Duration of Pregnancy & Severity of the condition

Termination of Pregnancy

Between 24 - 37

Weeks

Try to Postpone

delivery

Treatment

After 37 Weeks Before 24 Weeks

Further Management

According to

Severity

Mild PET

Severe PET ABOUBAKR ELNASHAR


Abo-Baker El-Nashar

Improving

Not-improving

Continue Ambulatory

Hospitalization

See patient twice weekly.

Fetal survey.

Maternal Survey.

Bed rest. ? Debatable.

Weigh daily.

BP monitoring.

Urine protein daily.

Fetal survey.

Maternal survey.

Bed rest. ? Debatable.

Regular diet.

Fluid Balance Chart.

weigh daily.

BP monitoring

Mild PET

Ambulatory

Expectant treatment

ABOUBAKR ELNASHAR


Abo-Baker El-Nashar

Fetal Surveillance

Fetal movement chart.

Contraction stress test.

Non-stress test.

Biophysical profiles.

Umbilical artery Doppler.

Ultrasound measurement of fetal growth.

Maternal Surveillance

Check for signs and symptoms of severity.

Renal function.

Liver function.

Coagulation status.

ABOUBAKR ELNASHAR


Abo-Baker El-Nashar ABOUBAKR ELNASHAR


Abo-Baker El-Nashar

Any deterioration

is an indication

for delivery

During

Conservative

Approach

Serial Evaluation

to The Following

Parameters

Parameter Indicating Delivery in a Patient with PET

General Mature gestation.

Blood

Pressure

>160/110 mmhg

despite therapy.

Platelets < 100 000/ml.

S. fibrinogen < 150 mg/dl.

SGPT SGOT Any elevation

BUN > 30mg/dl

Creatinine > 1.2 mg/dl

Creatinine

Clearance < 50 ml/min

NST

OCT

BPP

Acute compromise:

Non-reactive NST

Positive OCT

Abnormal BPP

Us.

Biometry

Umbilical

a. Doppler

Ch. Compromise

Severe IUGR

Abnormal Umbilical

artery Doppler

ABOUBAKR ELNASHAR


Abo-Baker El-Nashar

Management of Severe Preeclampsia

Deteriorating Maternal Condition or

Mature fetus or

Immature fetus Plus Acute or Chronic fetal compromise:

Definitive Management

Control blood pressure (Hydralazine)

Prevent convulsions (Magnesium Sulfate)

Deliver by vaginal or cesarean birth;

(Depending on fetal and maternal condition).

ABOUBAKR ELNASHAR


Abo-Baker El-Nashar

Drug Dose &

Route Onset of

Action

Adverse

Effects Comments

Hydralazine

5mg IV or IM

Then

5-10mg/20-40

min.

IV: 10min.

IM: 10-30

min.

Headache.

Flushing

Tachycardia.

Nausea.

Well

documented

safety &

efficiency

Labetalol 20mg IV

Then

20-80mg / 20-

30min. up to

300mg

5 -10 Min. Flushing.

Headache.

Vomiting

Tingling of

scalp

Hypotensive Drugs

ABOUBAKR ELNASHAR


Abo-Baker El-Nashar

Drug Dose &

Route

Onset of

Action

Adverse

Effects Comments

Nifedipine

5-10mg PO

Repeat in

10min

Sublingual not

recommended

Flushing.

Headache.

Tachycardia.

Nausea.

Inhibition of

labor.

May cause

abrupt drop in

blood

pressure.

May cause

hypotension if

MgSo4 is used

10 - 15

Min.

Diazoxide

30 -50mg

every

15min.

2 -5

Min.

Inhibit labor.

Hyper-

glycemia.

Fl. retention

Should be

used only in

refractory

cases.

Hypotensive Drugs

Contd.

ABOUBAKR ELNASHAR


Abo-Baker El-Nashar

HELLP SYNDROME

The syndrome of Hemolysis, Elevated Liver enzymes, and Low

Platelets

HELLP syndrome is a complication of severe PET.

Occurs in 10% of PET patients.

May develop before delivery in 70% of the patients and after delivery

in the remainder.

The criteria for the diagnosis of HELLP syndrome are based on

laboratory findings and include:

Hemolysis microangiopathic hemolytic anemia, characterized by

burr cells, schistocytes, and polychromasia on the peripheral

smear.

An increased bilirubin - most of it indirect - (above 1.2 mg/dl) and

increased LDH (above 600 IU/L) confirm the diagnosis. ABOUBAKR ELNASHAR


Abo-Baker El-Nashar

Elevated Liver Enzymes increased SGOT, SGPT and LDH.

Symptom of right upper quadrant pain may be associated with

hepatic cell damage, which also causes an elevation in liver

enzymes.

Low Platelet Count < 100 000 mm3.

THE SIGNS AND SYMPTOMS by incidence are:

Right upper quadrant or epigastric pain (86-90%).

Nausea and/or vomiting (45-84%).

Headache (50%).

Right upper quadrant tenderness on palpation (86%).

Diastolic blood pressure above 110 mmHg (67%).

Proteinuria above 2+ on dipstick (85-96%).

Demonstrable edema (55-67%).

ABOUBAKR ELNASHAR


Abo-Baker El-Nashar

MANAGEMENT OPTIONS

Management of the patient with HELLP syndrome includes the

same principles of treatment as that of severe PET.

This should start by assessing and correcting the maternal

coagulation abnormalities.

Platelets should be transfused when the platelets count is less

than 20 000/mm3.

Blood and blood products should be given if there is a need to

correct hypovolemia and coagulopathy.

Because of continued hemolysis in the postpartum period,

packed red blood cell transfusions are often necessary.

ABOUBAKR ELNASHAR


Abo-Baker El-Nashar

PE is still a serious complication during pregnancy.

It is a major cause of maternal & fetal complication.

Some of these complication are serious or even fatal for both

mother and fetus.

Early detection and proper management can result in

satisfactory outcome.

The role of antioxidant is promising.

Conclusions

ABOUBAKR ELNASHAR


Abo-Baker El-Nashar

Benha University Hospital, Egypt

Email: [email protected]

ABOUBAKR ELNASHAR

Health & Medicine

Preeclampsia Revised