PRE-ECLAMPSIA

REPRODUCTIVE HEALTH

1. PRE-ECLAMPSIA MR. JONES H.M-MBA 26-Aug-19 JONES H.M-MBA 1

2. PRE-ECLAMPSIA Pre- eclampsia is a condition specific to pregnancy occurring after the 20 th week of gestation characterised by hypertension, proteinuria and/or oedema. Pre- eclampsia is a complication of pregnancy in which a pregnant woman has high blood pressure, protein in urine and oedema, and may develop other symptoms and problems. 26-Aug-19 JONES H.M-MBA 2

3. The more severe the pre- eclampsia , the greater the risk of serious complications to both mother and baby. 26-Aug-19 JONES H.M-MBA 3

4. CLASSIFICATION MILD/ MODERATE PRE-ECLAMPSIA Blood pressure is 140/90mmHg to 150/100mmHg. Oedema up to 2+ (may be generalised). Proteinuria of up to 2+ (in the absence of UTI). SEVERE PRE-ECLAMPSIA Blood pressure exceeds 160/110mmHg Increase in proteinuria Oedema 3+ (generalised). Frontal headache and visual disturbances are usually present. Upper abdominal pain or epigastric pain with or without vomiting. 26-Aug-19 JONES H.M-MBA 4

5. RISK FACTORS Maternal personal risk factors for preeclampsia First pregnancy New partner/paternity Age younger than 18 years or older than 35 years History of preeclampsia Family history of preeclampsia Black race Obesity Interpregnancy interval less than 2 years or more than 10 years 26-Aug-19 JONES H.M-MBA 5

6. Maternal medical risk factors for preeclampsia Chronic hypertension, Preexisting diabetes (type 1 or type 2), Renal disease Systemic lupus erythematosus Obesity Thrombophilia 26-Aug-19 JONES H.M-MBA 6

7. Placental/fetal risk factors for preeclampsia Multiple gestations Hydrops fetalis Gestational trophoblastic disease 26-Aug-19 JONES H.M-MBA 7

8. PATHOPHYSIOLOGY Pre- eclampsia has been called a disease of theory because the true mechanism behind the pathogenesis is unknown. Women who develop pre- eclampsia become more sensitive to pressor agents (substances that increase blood pressure) rather than less sensitive to them as in normal pregnancy. This response has been linked to the ratio between prostacyclin , prostaglandins and thromboxane . 26-Aug-19 JONES H.M-MBA 8

9. Prostacyclin , a vasodilator produced by endothelial cells, decreases blood pressure, prevents platelet aggregation and promotes uterine blood flow. Thromboxane produced by platelets, causes vessels to constrict and platelets to clump together. In Pre- eclampsia , prostacyclin is decreased allowing the potent vaso -constrictor and platelet aggregating effects of thromboxane to dominate. 26-Aug-19 JONES H.M-MBA 9

10. These hormones are produced partially by the placenta which would help explain the reversal of the condition when the placenta is removed and why the incidence is increased when there is a larger than normal placental mass such as in hydrops , multiple pregnancy or hydatidiform mole. 26-Aug-19 JONES H.M-MBA 10

11. There is another theory which suggests that women who develop preeclampsia have been found to have an increased cardiac output and an associated endothelial damage. The vasodilation acts as a compensatory mechanism allowing a normal blood pressure in spite of the high cardiac output. The body responds to the endothelial damage with platelet aggregation and adherence to the damaged sites. 26-Aug-19 JONES H.M-MBA 11

12. The combination of these events will cause vaso -spasms and increased blood pressure, abnormal coagulation and thrombosis and increased permeability of the endothelium leading to oedema , proteinuria and hypovolaemia (blood seeps out in the tissue). 26-Aug-19 JONES H.M-MBA 12

13. PATHOLOGICAL CHANGES Blood; High blood pressure combined with endothelial cell damage affect capillary permeability leading to plasma proteins leak from the damaged blood vessels. This will cause decrease in the plasma colloid pressure and an increase in edema within the intracellular space. It will further cause hypovolemia and hemo concentration due to reduced intravascular plasma volume and this will be reflected in an elevated hematocrit level. 26-Aug-19 JONES H.M-MBA 13

14. Kidneys; Hypertensive disorders in pregnancy can also disrupt renal function. The detectable presence of proteins within the urine ( proteinuria ) may indicate that larger molecules than normal are being forced into the Bowman’s capsule. This is caused by increased blood pressure resulting in abnormal ultra filtration. As the condition worsens, oliguria develops as well signifying kidney damage and severe preeclampsia.  26-Aug-19 JONES H.M-MBA 14

15. Liver; There will be hypoxia and edema of the liver cells due to vasoconstriction of the hepatic vascular bed and this may lead to epigastric pain with intra capsular hemorrhages in severe cases. Rarely does rupture of the liver occur, however, there will be altered liver enzyme and albumin levels. 26-Aug-19 JONES H.M-MBA 15

16. Brain; The combination of hypertension and cerebral vascular endothelial dysfunction leads to increased permeability of the blood-brain barrier. This will result in cerebral edema and micro hemorrhaging leading to characteristics such as headaches, visual disturbances and convulsions. Excessive increase in blood pressure may lead to hypertensive encephalopathy.   26-Aug-19 JONES H.M-MBA 16

17. Fetal Placental; There will be vascular lesions in the placental bed due to reduced uterine blood flow and this may result in placental abruption. Blood flow to the chorio decidual spaces will also reduce thereby diminishing oxygen diffusion into the fetal circulation within the placenta leading to fetal growth restriction. Hormonal output is also impaired due to reduced placental function hence compromising survival of the fetus. 26-Aug-19 JONES H.M-MBA 17

18. SIGNS AND SYMPTOMS The signs of pre- eclampsia do not occur before the 20 th week of pregnancy and seldom after the 30 th week, however the earlier they occur the more serious the condition becomes. If the signs are found before 20 th week of pregnancy, it is usually an indication of the underlying pathological conditions e.g. trophoblastic diseases like hydatidiform mole or choriocarcinoma , chronic hypertension, chronic renal disease etc. 26-Aug-19 JONES H.M-MBA 18

19. Hypertension- a rise in blood pressure of above 140/90 or rise by 10-15 mmHg in two or more subsequent readings is suggestive of pre- eclampsia or PIH in a normo-tensive mother. Proteinuria - develops as reduced blood flow damages the kidneys. This damage allows the protein to leak into the urine. 26-Aug-19 JONES H.M-MBA 19

20. Oedema - occurs because the fluid leaves the blood vessels (due to hypoproteinaemia ) and enters the tissues. Sudden excessive weight gain is a first sign of fluid retention. Visible oedema of the legs and feet is common during pregnancy, but oedema above the waist is suggestive of pregnancy induced hypertension. 26-Aug-19 JONES H.M-MBA 20

21. GRADES OF OEDEMA: Grade 1 (1+) - Ankle oedema Grade 2 (2+) oedema of the lower limbs to knees Grade 3 (3+) Generalized oedema   26-Aug-19 JONES H.M-MBA 21

22. Visual disturbances -These disturbances are presumed to be due to cerebral vasospasm. Headache is of new onset and may be described as frontal, throbbing, or similar to a migraine headache. Epigastric pain is due to hepatic swelling and inflammation, with stretch of the liver capsule. Pain may be of sudden onset, is typically constant, and may be moderate-to-severe in intensity. 26-Aug-19 JONES H.M-MBA 22

23. INVESTIGATIONS Hypertension and proteinuria are not the only signs of pre- eclampsia , or necessarily the most important; they constitute evidence of end organ damage within on going process. 26-Aug-19 JONES H.M-MBA 23

24. Diagnostic tests to assess renal function, cardiovascular changes and liver enzymes are necessary to diagnose the extent to which the maternal system is affected. And these include: Blood urea and creatinine are raised, and a high level indicates a late stage of renal involvement. 26-Aug-19 JONES H.M-MBA 24

25. Platelet count is reduced Packed cell volume is increased Hb and haematocrit levels are raised Urinalysis-24 hour specimen will reveal protein > 0.3g Liver function test especially transaminase should be carried out to determine liver function 26-Aug-19 JONES H.M-MBA 25

26. Ultra sound scan- For the Bio-physical profile of the fetus and fetal movements, breathing and liquor volume Fetal maturity Test- Pulmonary surfactant (Lecithin sphingomyelin ratio, normal 2:1). 26-Aug-19 JONES H.M-MBA 26

27. MANAGEMENT OF PRE- ECLAMPSIA AIMS The ultimate aim is to prolong pregnancy until the baby is sufficiently mature to survive while safeguarding the mother’s life. To monitor the disease and prevent it from getting worse 26-Aug-19 JONES H.M-MBA 27

28. ANTENATALLY MILD PRE-ECLAMPSIA Treatment of pre- eclampsia is symptomatic because the cause is unknown. Usually the patient with mild pre- eclampsia will be nursed at home (Out patient). The patient is given the following advice; 26-Aug-19 JONES H.M-MBA 28

29. Rest - The patient should have adequate bed rest at home to ensure improved blood flow to the heart and therefore to the placenta. A doctor might order mild sedatives to promote restful sleep at home. Diet - The patient is advised to take diet rich in proteins and vitamins but low in carbohydrates and no extra salt. The patient is advised not to gain excess weight. The proteins and the vitamins are needed to nourish the growing foetus and prepare the woman for lactation. 26-Aug-19 JONES H.M-MBA 29

30. Antenatal visits - The woman is advised to make frequent visits to the health facility to ensure frequent monitoring of the condition. She is advised to report to the health facility if she is feeling very unwell (headache, oedema etc). Foetal well being –The patient is advised to maintain the “kick chart” to monitor any foetal movements. Usually the woman is admitted at 37 weeks if condition has remained stable so as to deliver in hospital. 26-Aug-19 JONES H.M-MBA 30

31. MODERATE TO SEVERE PRE-ECLAMPSIA Patients with moderate and severe pre- eclampsia need to be hospitalized till delivery. The patient should be admitted in the quiet room since she will be anxious about her condition 26-Aug-19 JONES H.M-MBA 31

32. Establish good midwife -patient relationship Explain condition to the patient to allay anxiety Allow significant others to visit when appropriate but give her time to rest Assign a nurse to attend to her constantly 26-Aug-19 JONES H.M-MBA 32

33. REDUCTION OF BLOOD PRESSURE The treatment is aimed at reducing blood pressure as soon as possible and this is achieved by the following: Putting the woman on bed rest in order to rest the heart, reduce demands of blood by other organs and improve placental perfusion. Record blood pressure 1 -2 hourly to detect any sudden rise or sudden drop which should be reported to the doctor. Give the ordered drugs Fluid intake and output is monitored and fluids may restricted if there is severe kidney damage. 26-Aug-19 JONES H.M-MBA 33

34. MONITORING OF OEDEMA Weigh patient daily Encourage bed rest Monitor fluid intake and output Do daily physical examinations to assess the amount of oedema present No extra salt is allowed 26-Aug-19 JONES H.M-MBA 34

35. DIET High protein and vitamins to nourish the growing foetus Low salt diet to avoid water retention Low carbohydrate diet to avoid gaining of excess weight 26-Aug-19 JONES H.M-MBA 35

36. OBSERVATIONS Since the foetus is at risk of intra uterine growth retardation because of placenta insufficiency, frequent and efficient monitoring is essential. The following should be done; Check the foetal heart rate 4 hourly depending on the condition of the mother 26-Aug-19 JONES H.M-MBA 36

37. Use cardiotocography machine. Continuously monitor the well being of the foetus especially if the patient is on antihypertensive drugs or where patient’s condition is not satisfactory. Ultra sound can be done to assess the foetal well being, the foetal movements, the amount of liquor and the foetal breathing pattern. 26-Aug-19 JONES H.M-MBA 37

38. Vital signs are done 4 hourly to monitor maternal well being. Abdominal examinations are done twice daily and in this case compare the height of fundus with the gestation age to rule out intrauterine growth retardation 26-Aug-19 JONES H.M-MBA 38

39. Note for any abdominal pains as presence of abdominal pains may denote abruptio placenta, onset of labour and deteriorating condition. Watch out for epigastric pain as this may be a sign of imminent eclampsia . Never leave the woman alone if shows signs of imminent eclampsia 26-Aug-19 JONES H.M-MBA 39

40. MEDICAL MANAGEMENT The following drugs may be ordered; Antihypertensives - May be ordered if B/P exceeds 150/100mmHg in an effort to reduce it, prevent CVA and eclampsia and therefore prolong pregnancy, maternal well being and foetal survival rate. When lowering blood pressure with medication it is vitally important to monitor the fetal heart in order to detect whether the lowered maternal BP is affecting the utero -placental blood flow and fetal oxygenation. 26-Aug-19 JONES H.M-MBA 40

41. Methyldopa ( Aldomet ) - 250-500mg 8hrly. It is a long term treatment until the fetus is more mature (35-36 weeks) This medication takes 24 hours to be effective 26-Aug-19 JONES H.M-MBA 41

42. Hydralizine Given when diastolic pressure is above 110 mmHg Given intravenously slowly 25mg 8hrly or 12hrly or 5mg iv bolus initially followed by an infusion of 2-20mg/hour according to the patient’s response.5 mg to 20 mg 26-Aug-19 JONES H.M-MBA 42

43. Neprosol - 6.25mg IV slowly over 4minutes for acute hypertension.  Nefidipine - 10-20mg subliqually used for acute lowering of B/P Steroids - When pre- eclampsia develops late in gestation, steroids maybe given to reduce the risk of RDS e.g. Dexamethasone 4 mg, 12 hourly for 48 hours. 26-Aug-19 JONES H.M-MBA 43

44. Aspirin- It is thought to inhibit production of platelet aggregating agent thromboxane A2, therefore low dose of aspirin maybe beneficial for women at high risk of pre- eclampsia . 26-Aug-19 JONES H.M-MBA 44

45. In imminent eclampsia , it is important to reduce the excitement of the central nervous system and the following measures should be taken: Phernobarbitone may be used in small amounts in mild eclampsia when patient is not going into labour early. Note that it has a depressive effect on the foetus and the maternal respiration system. Magnesuim Sulphate 5g (mgSo4) in 200mls of 5% dextrose over 20minutes and then 5mg i.m start 6hrly for 2/7 only if diastolic pressure is above 90mmHg. 26-Aug-19 JONES H.M-MBA 45

46. Diazepam can be used for transporting the patient with imminent eclampsia Diuretics are not used as they aggravate haemoconcentration and may lead to haemorrhagic pancreatitis in the mother. Manitol 200mls iv 6hrly can only be used when there is cerebral oedema and mainly this is in eclempsia . 26-Aug-19 JONES H.M-MBA 46

47. OBSTETRIC MANAGEMENT The obstetrician decides the optimum time for the delivery of the baby. This depends on the maternal and foetal well being and not on the period of gestation. If patient responds well to treatment in mild and moderate pre- eclampsia the pregnancy is usually allowed to continue and usually labour is induced before term to reduce effects of placental insufficiency. 26-Aug-19 JONES H.M-MBA 47

48. If patient does not respond to treatment and has moderate or severe pre- eclampsia , then an induction of labour is usually commenced after 24hrs Indications for induction are: Foetal intrauterine growth retardation Uncontrolled rising blood pressure Poor renal function 26-Aug-19 JONES H.M-MBA 48

49. NURSING CARE DURING LABOUR Labour is induced by an IV oxytocics being administered together with the rupture of membranes. Episiotomy and forceps or vacuum extraction is frequently used to prevent exhaustion by the patient as this may lead to eclampsia . Caesarian section may be performed where labour is detrimental to the maternal and foetal condition. 26-Aug-19 JONES H.M-MBA 49

50. The following measures should be done: Do not leave patient alone Inform the doctor immediately of any change in the patients condition Check blood pressure half hourly or quarter hourly and foetal heart rate quarter hourly or CTC machine can be useful to monitor the foetal heart 26-Aug-19 JONES H.M-MBA 50

51. When necessary put up intravenous fluid line but careful not to overload the patient Keep the patient sedated and you can even give her epidural anesthesia Continue with medication the patient is on Keep a record of all drugs during labour and delivery to be reported to a pediatrician 26-Aug-19 JONES H.M-MBA 51

52. Prepare the patient for episiotomy/forceps delivery/vacuum extraction Note: Ergometrine and syntometrine are never useful in the third stage of labour . These cause peripheral vascular spasms and increase the blood pressure   26-Aug-19 JONES H.M-MBA 52

53. NURSING CARE DURING PUERPERIUM Convulsions can occur soon after delivery for the first time and therefore, the first 24 hours is the most critical period. The patient should be nursed as follows: Continue with the sedation of the patient Constantly monitor the patient’s condition from delivery to 24 hours. 26-Aug-19 JONES H.M-MBA 53

54. Check the blood pressure hourly for 6 hours and then if decreasing 4 hourly for 24 hours and if stable blood pressure can be done twice daily. Monitor fluid balance until it is normal Continue with urinalysis for proteins till negative and repeat on disc 26-Aug-19 JONES H.M-MBA 54

55. Continue with urinalysis for proteins till negative and repeat on discharge Note: Patient will only be discharged when blood pressure is normal and urine is free of proteins. NEONATAL CARE These babies are always small for dates and premature, therefore give them care accordingly. 26-Aug-19 JONES H.M-MBA 55

56. COMPLICATIONS Eclampsia Placenta abruptio Renal failure Subcapsular hemorrhage or rapture of the liver Disseminated intravascular coagulation (DIC) Cardiovascular accident 26-Aug-19 JONES H.M-MBA 56

57. HELLP syndrome- a syndrome of H aemolysis E levated L iver enzyme and L ow P latelet count. It represents a variant of pre- eclampsia / eclampsia syndrome. Pregnancies complicated with this syndrome have been associated with significant maternal and perinatal morbidity and mortality. 26-Aug-19 JONES H.M-MBA 57

58. THE END 26-Aug-19 JONES H.M-MBA 58