Preeclampsia Revised

Preeclampsia
Revised

1. Preeclampsia Revised
Abo-Baker El-Nashar
Aboubakr Elnashar
Benha University Hospital, Egypt
Email: [email protected]

Preeclampsia
Revised
ABOUBAKR ELNASHAR

2. Preeclampsia Revised
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

3. Preeclampsia Revised
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

4. Preeclampsia Revised
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

5. Preeclampsia Revised
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

6. Preeclampsia Revised
Abo-Baker El-Nashar
Prostacyclin & Thromboxane Disturbance:
Prostacyclin
A potent vasodilator and anti-
platelet aggregants produced by
vascular endothelium.
Thromboxane A
2
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 A
2
 In cases of Preeclampsia
 Production of Prostacyclin
 Production of thromboxane A
2
Result in an  thromboxane A
2/prostacyclin ratio
Vascular Tone and Elevated Blood Pressure
ABOUBAKR ELNASHAR

7. Preeclampsia Revised
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

8. Preeclampsia Revised
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

9. Preeclampsia Revised
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

10. Preeclampsia Revised
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

11. Preeclampsia Revised
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

12. Preeclampsia Revised
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

13. Preeclampsia Revised
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

14. Preeclampsia Revised
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

15. Preeclampsia Revised
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

16. Preeclampsia Revised
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

17. Preeclampsia Revised
Abo-Baker El-Nashar
ABOUBAKR ELNASHAR

18. Preeclampsia Revised
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

19. Preeclampsia Revised
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

20. Preeclampsia Revised
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

21. Preeclampsia Revised
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
MgSo
4 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

22. Preeclampsia Revised
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

23. Preeclampsia Revised
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 mm
3
.
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

24. Preeclampsia Revised
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

25. Preeclampsia Revised
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

26. Preeclampsia Revised
Abo-Baker El-Nashar
Benha University Hospital, Egypt
Email: [email protected]

ABOUBAKR ELNASHAR