Preeclampsia resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rinky Agnes Botleroo, M.B.B.S.

Synonyms and keywords:

Overview

This section provides a short and straight to the point overview of the disease or symptom. The first sentence of the overview must contain the name of the disease.

Causes

The high risk factors of preeclampsia are

• History of any hypertensive disease during a previous pregnancy.
• Maternal disease such aschronic kidney disease, autoimmune diseases, diabetes, chronic hypertension.

Women are at moderate risk if they are

• Nulliparous
• ≥40 years of age
• Body mass index (BMI) ≥ 35 kg/m
• Family history of preeclampsia
• Multifetal pregnancy
• A pregnancy interval of more than 10 years

Additional clinical factors:

• Raised mean arterial blood pressure before 15 weeks’ gestation
• Polycystic ovarian syndrome
• Sleep disordered breathing
• Various infections such as periodontal disease, urinary tract infections and helicobacter pylori.
• Vaginal bleeding for at least five days during pregnancy increases preeclampsia risk
• Use of oocyte donation has a higher risk of preeclampsia than in vitro fertilization (IVF) without oocyte donation or natural conception.

Common Causes

Common cause of preeclampsia include uteroplacental ischemia and genetic predisposition due to the following:

• The formation of atheromatous plaques and fibrinoid necrosis of the spiral vessel walls
• Oxidative stress in trophoblast cells
• Apoptosis in trophoblast cells
• Systemic inflammatory response
• Vasospasm
• Platelet aggregation
• Thrombin formation
• Deposition of the fibrin in multiple organs

Diagnosis

Shown below is an algorithm summarizing the diagnosis of Pre-eclampsia.

Pregnant woman comes with Hypertension

Take complete history

Record the vitals: ❑ Blood pressure ❑ Temperature ❑ Respiratory rate ❑ Heart rate

Take obstetric history : ❑ Date of last menstrual period? ❑ Estimated date of delivery ❑ Confirm the gestational age, gravidity and parity. ❑ Check if this is a single or multiple gestation.

Ask about previous obstetric history if she was previous pregnant : ❑ Ask about previous pregnancies including miscarriages and terminations. ❑ Length of gestation. ❑ Ask about mode of delivery. ❑ Ask if there was similar complaints during previous pregnancy? ❑ Was there any complications throughout the pregnancy or during delivery such as shoulder dystocia, postpartum haemorrhage ?

Ask the following questions about menstrual history : ❑ Age of menarche ❑ Last menstrual period ❑ Is the menstrual flow normal? How many pads she has to use in a day? ❑ Is there any foul smell or colour change? ❑ How many days does the menstruation stay? ❑ Contraceptive history for example oral contraceptives, intrauterine device

See if following factors are present: ❑ History of hypertension ❑ Kidney disease ❑ Diabetes ❑ Hypertension with a previous pregnancy ❑ Mother's age younger than 20 or older than 40 ❑ Multiple fetuses (twins, triplets) ❑ African-American race

Do laboratory tests: ❑ Dipstick testing ❑ If dipstick test is positive (one protein or more), the use of either spot urine albumin to creatinine (A:Cr) or protein to creatinine (P:Cr) ratios are recommended to quantify proteinuria. ❑ Haemoglobin ❑ Platelet count ❑ Serum creatinine ❑ Liver enzymes ❑ Serum uric acid ❑ Use of PlGF or sFlt-1:PlGF ratio to help rule out preeclampsia in women between 20 and 34 + 6 weeks’ gestation in whom preeclampsia is suspected. ❑ Ultrasound assessment of fetal growth and umbilical artery doppler velocimetry or cerebroplacental ratio measurements to assess blood flow redistribution in placental insufficiency.

PRE-ECLAMPSIA:Preeclampsia is defined as Gestational Hypertension associated with new-onset maternal or uteroplacental dysfunction at or after 20 Weeks’ Gestation ❑ Gestational Hypertension : blood pressure higher than 140/90 measured on two separate occasions, more than 6 hours apart. Accompanied by at ≥1 of the following new-onset conditions: ❑ Proteinuria: automated dipstick urinalysis should be done. If not available, visual analysis can be used. If dipstick is positive (≥1+), confirmation is done with spot urine. Abnormal if Protein:Creatinine ≥ 30 mg/mmol or Albumin:Creatinine ≥ 8 mg/mmol. ❑ Renal complication: Acute Kidney Injury (creatinine ≥ 90 umol/L). ❑ Liver complications: Elevated transaminases, may be associated with right upper quadrant of epigastric abdominal pain. ❑ Neurological complications: Eclampsia, altered mental status, blindness, stroke, clonus, severe and persistent visual scotomata. ❑ Haematological complications: Thrombocytopenia (platelet count < 150000/µL, disseminated intravascular coagulation, hemolysis). ❑ Uteroplacental dysfunction: Fetal growth restriction, abnormal umbilical artery doppler wave form analysis, stillbirth.

Treatment

Shown below is an algorithm summarizing the treatment of mild hypertension and preeclampsia.

Woman with mild hypertension and preeclampsia

Evaluate maternal and fetal condition

❑ ≥40 weeks of gestation. ❑ ≥ 37 weeks of gestation, Bishop score ≥ 6, non-complaint patient ❑ ≥34 weeks gestation, Labor or rupture of membranes, Abnormal fetal testing, Intrauterine growth restriction

Yes

Delivery

No

↑

<37 weeks

37-39 weeks

→

Prostaglandin

❑ Fetal and maternal monitoring on a regular basis ❑ Inpatient and outpatient management

↑

❑ Worsening fetal and maternal condition ❑ ≥40 weeks of gestation ❑ Bishop score ≥ 6 at ≥ 37 weeks of gestation. ❑ Labor

→

Shown below is an algorithm summarizing the treatment of severe preeclampsia.

Woman with severe pre eclampsia

❑ Admit to the labor and delivery unit. ❑ Evaluate maternal and fetal condition for 24 hours. ❑ Administer Magnesium sulphate X 24 hours. ❑ Anti-hypertensives if systolic blood pressure ≥ 160mm Hg, diastolic blood pressure ≥110 mmHg and meant aretrial blood pressure ≥125 mmHg

Check if following are present: --- ❑ Maternal distress ❑ Non-reassuring fetal status. ❑ Labor or rupture of membranes. ❑ >34 weeks of gestation.

Yes

No

❑ Magnesium Sulphate ❑ Delivery.

↑

Severe intrauterine growth restriction

Yes

No

←

Steroids

↑

←

33-34 weeks of gestation

23-32 weeks of gestation

<23 weeks of gestation

❑ Steroids at 24-32 weeks ❑ Anti-hypertensives if required. ❑ Daily maternal and fetal evaluation. ❑ Delivery at 34 weeks.

termination of pregnancy

Drugs for urgent controlling of hypertension in preeclampsia	Dose	Specific considration	Onset of action
Labetalol	10–20 mg IV<br> then 20–80 mg every 10–30 minutes upto a maximum dosage of 300 mg;<br> or <br> infusion 1–2 mg/min IV	Contraindications: Asthma Decompensated heart failure, Heart block Bradycardia	1-2 minutes
Hydralazine	5 mg IV or IM, then 5–10 mg IV every 20–40 minutes upto a maximum dosage of 200 mg or keeping infusion of 0.5–10 mg/hr	Side effects in higher dosage: maternal hypotension Headaches Abnormal fetal heart rate tracings	10-20 minutes
Nifedipine	10–20 mg orally, repeat in 20 minutes if needed; then 10–20 mg every 2–6 hours, maximum daily dose is 180 mg	Side effect: Reflex tachycardia Headache	5-10 minutes

Do's

• Patient should start low-dose aspirin if she has two or more of the moderate-risk factors

Don'ts

• The content in this section is in bullet points.

References

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