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Pre-eclampsia

Dagnostic criteria for Preeclampsia

• Blood pressure :

  • Greater than equal to 140mmHg systolic or greater than or equal to 90mmHg diastolic on two occassions at least 4hrs apart after 20 weeks of gestation in a women with a previously normal blood pressure.

  • Greater than or equal to 160mmHg or greater than or equal to 110mmHg diastolic, hypertension can be confirmed within a short interval to faciitate timely antihypertensive therapy.

AND

• Proteinuria

1. Greater than or equal to 300mg per 24hr urine collection

2. Protein/ creatinine ration greater than or equal to 0.3

3. Dipstick reading of 1+ (Used only if other quantitative methods not available)

Or in the absence of proteinuria, new onset hypertension with the new onset of any of the following:

• Thrombocytopenia : Platelet count <1,00,000

• Renal failure :Serum Cr >1.1mg/dl or doubling of the serum creatinine inn the absence of other renal disease.

• Impaired liver function : Elevated blod concentration of liver transaminase to twice normal concentrations

• Pulmonary edema

• Cerebral or visual symptoms

Severe Pre-Eclampsia

• Systolic blood pressure of 160 mmHg or higher, or diastolic blood pressure of 110mmHg or higher on two occasions at least 4 hours apart while the patient is on bed rest.

• Thrombocytopenia (Platelet count <1,00,000)

• Impaired liver function as indicated by abnormally elevated blood concentrations of liver enzymes, severe persistent right upper quadrant or epigastric pain unresponsive to medication and not accounted for by alteranative diagnoses or both.

• Progressive renal insufficiency (serum creatinine concenttration greater than 1.1mg/dL or a doubling of serum creatinine in the absence of other renal disease).

• Pulmonary edema

• New onset cerebral or visual disturbances

Symptoms of preeclampsia

• Swelling of the face or hands

• Headache

• Blurring of vision

• Pain in the upper right quadrant or stoamch

• Nausea or vomiting

• Sudden weight gain

• Difficulty breathing

Risk factors for Preeclampsia

• Primiparity

• Previous preeclamptic pregnacy

• Chronic hypertension or chronic renal disease or both

• History of thrombophilia

• Multifetal pregnancy

• In vitro fertilization

• Family history of preeclampsia

• Type I diabetes mellitus or type II diabetes mellitus

• Obesity

• SLE

• Advanced maternal age (Older than 40 years)

Complication

• Pulmonary edema

• Myocardial infraction

• Stroke

• ARDS

• Coagulopathy

• Acute renal failure

• Retinal injury

Prevention of pre-eclampsia

• Bed Rest and salt restriction are not recommended for prevention of pre-eclampsia.

• Administration of vitamin C or Vitamin E to prevent preeclampsisa is not recommended.

• Calcium supplementation of 1.5 -2.0 g elemental calcium/day is recommended for prevention of pre eclampsia in women with low dietary intake of calcium.

• Low dose aspirin 75mg/day is recommended for prevention of pre-eclampsia in women with a medical history of early onset pre-eclampsia and preterm delivery at less than 34 weeks of gestation or preeclampsia in more than one pregancy. It is suggested to initiate aspirin during late first trimester.

Treatment of preeclampsia

• The close monitoring of women with gestational hypertension or preeclampsia without severe features with serial assessment of maternal and fetal movement and serial measurements off BP (Twice weekly) and assessment of platelet counts and liver enzymes is suggested.

Antihypertensive Therapy

• For women with mild gestational hypertension or preeclampsia with a persistent BP of less than 160mmHg systolic or 110mmHg diastolic, it is suggested that antihypertensive medications not be administrated.

• For women with preeclampsia with severe hypertension during pregnancy (sustained SBP of atleast 160 mmHg or diastolic BP of atleast 110mmHg), the use of antihypertensive therapy is recommended.

• For women with gestational hypertension or preeclampsia without severe features, it is suggested that strict bed rest not be prescribed. : Due to lack of evidence in study and increased risk of thromboembolism.

Fetal Monitoring

• For women with pereclampsia without severe features, use of ultrasonography to assess fetal growth and antenatal testing to assess fetal status is suggested.

• If evidence of fetal growth restriction is found in women with preeclampsia, fetoplacental assessment that includes umbilical artery doppler velocimetry as an adjunct antenatal test is recommended.

Management of Severe Preeclampsia

• For women with severe preeclampsia at or beyond 34 weeks of gestation and those with unstable maternal fetal conditions irrespective of gestational age, delivery soon after maternal stabilization is recommended.

   

• For women with severe preeclampsia at less than 34 weeks of gestation with stable maternal and fetal condition, it is recommended that continued pregnancy can be undertaken only at facilities with adequate maternal and neonatal intensive care resources.

• For women with severe eclampsia receiving expectant management at 34 weeks or less of gestation, the administration of corticosteroids for fetal lung ,maturity benefit is recommended.

   

• For women with preeclampsia, it is suggested that a delivery should not be based on the amount of proteinuria or change in the amount of proteinuria.

• For women with preeclampsia, it is suggested that the modes of delivery does not need to be cesarean delivery. The mode of delivery should be determined by fetal gestational age, fetal presentation, cervical status and maternal fetal condition.

Role of magnesium sulphate prophylaxsis

• Women with preeclampsia with systolic BP <160 mmHg and a diastolic BP <110 mmHg and no maternal symptoms, it is suggested that magnesium sulfate not be administrated universally for prevention of eclampsia.

• However certain signs and symptoms like headache, altered mental state, blurred vision, scotomata, clonus and right upper quadrant abdominal pain have traditionally been considered as a choice for initiation of magnesium sulfate therapy.

ECLAMPSIA

• Eclampsia is defined as the presence of new onset grand mal seizures in a woman with preeclampsia.

• Certain symptoms like persistent frontal or occipital headache, blurred vision, photophobia, epigastric or right upper quadrant pain or both and altered mental status are suggestive of impending eclampsia.

• Magnesium sulfate

• For women with eclampsia, the administration of parenteral magnesium sulfate is recommended.

• For women with severe preeclampsia, the administration of intrapartum-postpartum magnesium sulfate to prevent eclampsia is recommended.

• For women with preeclampsia undergoing cesarean delivery, the continued intraoperative administration of parenteral magnesium sulfate to prevent eclampsia is recommended.

• Dose

  • Continous IV infusion : 4 – 6 gm of Magnesium sulfate is diluted in 100ml NS and infused over 15 -20 min followed by 2gm/hr in 100 ml of IV maintence. Check magnesium level 6^th hrly to maintain as serum level of 4.8 -8.4 mg/dl.

• Intermittent IM regimen : Give loading dose of 4 gm of magnesium sulphate as 20% solution IV along with 10gm of 50% magnesium sulfate one half injected deeply in upper outer quadrant of both buttock. If convulsion still persists give upto 2gm IV as 20% solution. Followed by maintenance dose of 5 gm of 50% magnesium sulfate injected alternatively on both buttocks

• Collaborative Eclampsia Trial Regimen : Loading dose of 4gm IV Over 5min followed by infusion of 1gm/hr maintained for 24 hrs. Recurrent seizures should be treated with afurther dose of 2 -4 gm IV over 5min.

• It is discontinued after 24hrs of delivery.

Updated on 26/6/2014

Reference

• Hypertension in pregnancy ; The American college of Obstetricians and Gynecologist 2013