Pre Eclampsia

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Pre Eclampsia

• S Rajendran

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Pre eclampsia (PET)

• Disorder of the epithelium
• Peculiar to pregnancy - arising from the failure
  of maternal adaptation to pregnancy
• Multisystemic
• Manifested by
• Hypertension
• Renal impairment - accompanied by proteinuria
• Fluid retention
• Intravascular coagulation

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Pre eclampsia

• Impact
• 2 pregnancies
• Significant maternal morbidity mortality (40
  000 deaths worldwide, 14 in UK (2004 CEMD)
• Significant neonatal morbidity mortality
• 20 of SCBU/NNU occupancy
• 15 of iatrogenic preterm deliveries
• Long term development of hypertension, Diabetes
  , IHD

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Risk Factors

• 1. Socio demographic
• Agegt40
• SE status
• Ethnic groups
• 2. Genetic
• Mother/ sister with PET
• 3. Pregnancy factors
• Multiple pregnancy
• Primipara
• Previous early onset severe PET
• 4. PMH
• Obesity
• Chronic renal disease
• Chronic hypertension
• Diabetes
• Thrombophilia
• SLE

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Pathogenesis

• Theories
• Various
• Reduction in placental blood flow
• Either due to abnormal placentation
• Maternal microvascular disease
• Release of circulating factors target maternal
  vascular endothelial cells

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Pathogenesis - cont

• Early pregnancy
• Failure of communication between mother - fetal
  systems
• Failure of physiological adaptation
• Therefore - failed trophoblastic invasion of
  maternal spiral arterioles
• Thomboxane (vasosonstrictors) increase rel to
  PGI2 and NO (Vasodilators)
• Failure of plasma volume expansion
• Development of high pressure system

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Pathogenesis - cont

• Placenta perfused under high pressure
• Endothelial damage
• Microthrombi formation
• Placetal size reduced
• IUGR

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Pathogenesis - clinical syndrome

• 1. CVS/ Pulm
• High CO state
• High PVR
• LVF
• Pulmonary odema - leaky endothelium
• ARDS

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Pathogenesis - clinical syndrome

• 2. Kidneys
• Glomerular endothelial cells swell
• Block capillaries
• leaking - proteinuria (gt300mg/24hrs)
• Impaired renal function tests

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Pathogenesis - clinical syndrome

• 3. Liver
• Fibrin deposits - hepatocellular damage
• Distension, odema - epigastric pain
• Subcapsular haemorrhage
• DIC - abnormal LFTs
• HEELP

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Pathogenesis - clinical syndrome

• 4. CNS
• Vasoconstriction as a protective response -
  headaches. Visual disturbance
• Hyperreflexia
• Small vessel damage - infarcts, haemorrhages -
  Eclampsia , CVA

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Diagnosis

• Hypertension gt 160/90 on two occasions
• Proteinuria gt 300 mg/24
• Altered renal function tests
• Raised UA
• Raised serum Cr
• Altered LFTs
• Raised AST/ALT
• Derranged clotting factors
• Coagulation
• Platelet consumption - DIC

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Management

• 1. Treat blood pressure
• To prevent CVA
• To allow fetal maturity
• 2. monitor maternal well being
• BP, 24 urine protein
• Biochemistry
• Symptoms
• 3. monitor fetal wellbeing
• USS for growth
• Doppler
• CTG
• Steroids (if preterm delivery envisaged)

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Management

• Delivery is the only cure!!
• So management relies on delivery as soon as
  practically possible in the most suitable way
  possible
• Balance between maternal and fetal risks

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Treatment

• 1. Antihypertensives
• Long term - methyl dopa safest
• But - slow acting . Poor antihypertensive
• Other SE
• Labetalol - good effective in acute management of
  severe hypertension (IV and Oral )
• But placental hypoperfusion
• Nifedipine - good in acute management
• But - placental hypoperfusion
• Hydralazine - IV only useful in acute management

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Eclampsia

• Fitting !!
• Grand mal
• Self limiting
• BP can be normal
• Any woman in pregnancy who fits should have
  eclampsia management until proven otherwise
• Management
• Treat fit - Mg SO4
• Prevent further fitting - Mg SO4
• Stabilise mother BP
• Deliver