PREECLAMPSIA & ECLAMPSIAPREECLAMPSIA & ECLAMPSIA

ObjectiveObjective-:-: A unique disease A unique disease ((syndromesyndrome)) of pregnant of pregnant

woman in the second half of pregnancy. woman in the second half of pregnancy. Carries significant maternal & fetal morbidity Carries significant maternal & fetal morbidity

and mortality.and mortality. Two criteria for diagnosing preeclampsia Two criteria for diagnosing preeclampsia

hypertension & proteinuria, in eclampsia hypertension & proteinuria, in eclampsia

tonic and clonic convulsions.tonic and clonic convulsions. The definite cure of preeclamsia & The definite cure of preeclamsia &

eclampsia is delivery.eclampsia is delivery.

Defenition of preeclampsiaDefenition of preeclampsia-:-:

The presence of hypertension of at least The presence of hypertension of at least

140140//9090 mm Hg recorded on two separate mm Hg recorded on two separate

occasions at least occasions at least 4 4 hours apart and in the hours apart and in the

presence of at least presence of at least 300300 mg protein in a mg protein in a

2424 hours collection of urine arrising de novo hours collection of urine arrising de novo

after the after the 2020thth week gestation in a previously week gestation in a previously

normotensive women and resolving normotensive women and resolving

completetly by the sixth postpartum weekcompletetly by the sixth postpartum week..

Classification of Classification of hypertensive hypertensive disorders of pregnancydisorders of pregnancy

Preeclampsia Preeclampsia // eclampsia eclampsia Chronic hypertensionChronic hypertension Chronic hypertension with Chronic hypertension with

superimposedsuperimposed

preeclampsiapreeclampsia Gestational or transient hypertensionGestational or transient hypertension

Aetiology of preeclampsiaAetiology of preeclampsia-:-:

))Genetic predispositionGenetic predisposition((

))Abnormal immunological responseAbnormal immunological response((

))Deficient trophoplast invasionDeficient trophoplast invasion((

))Hypoperfused placentaHypoperfused placenta((

))Circulating factorsCirculating factors((

))Vascular endothelial cell activationVascular endothelial cell activation((

))Clinical manifestations of the diseaseClinical manifestations of the disease((

IncidenceIncidence

3%3% of pregnancies. of pregnancies.

EpidemiologyEpidemiology More common in primigravidMore common in primigravid There is There is 3-43-4 fold increase in first degree fold increase in first degree

relatives of affected women.relatives of affected women.

Risk Factors for preeclampsiaRisk Factors for preeclampsia Condition in which the placenta is Condition in which the placenta is

enlarged enlarged ((DM,MP,hydropsDM,MP,hydrops)) Pre-existing hyertension or renal diseasesPre-existing hyertension or renal diseases.. Pre-existing vascular disease Pre-existing vascular disease

((diabetesdiabetes,,autoimmune vasculitisautoimmune vasculitis))

PathophisiologyPathophisiology-:-:

Defective trophoplast invasion hypoperfused Defective trophoplast invasion hypoperfused placenta release factorsplacenta release factors ( (growth factors,growth factors,

CytokinesCytokines)) vascular endothelial cell vascular endothelial cell

activation.activation. VasospasmVasospasm hypertension hypertension Endothelial cell damage oedema, Endothelial cell damage oedema,

hemoconcentrationhemoconcentration Kidneys,glomeruloendotheliosis Kidneys,glomeruloendotheliosis

proteinuria,reduced uric excretion and oligouria.proteinuria,reduced uric excretion and oligouria.

Liver,subendothelial fibrin depositionLiver,subendothelial fibrin deposition

elevated liver,hemorrhage,infarction,liver elevated liver,hemorrhage,infarction,liver rupture and epigastric pain.rupture and epigastric pain.

BloodBlood thrombocytopenia,DIC,HELLP thrombocytopenia,DIC,HELLP syndrome.syndrome.

Placental vasospasm placental Placental vasospasm placental infarction,placental abruptio& infarction,placental abruptio& uteroplacental perfusion IUGR.uteroplacental perfusion IUGR.

CNS vasospasm&oedemaCNS vasospasm&oedema headache, headache,

visual symptonsvisual symptons((blurred vision,spots, blurred vision,spots,

scotomascotoma)) hyperreflexia and convulsions hyperreflexia and convulsions.

Symptoms of preeclampsiaSymptoms of preeclampsia

1.1. HeadacheHeadache

2.2. May be symptomlessMay be symptomless

3.3. Visual symptomsVisual symptoms

4.4. Epigastric and right abdominal painEpigastric and right abdominal pain

Signs of preeclampsiaSigns of preeclampsia

1.1. HypertensionHypertension

2.2. Non dependent oedemaNon dependent oedema

3.3. Brisk reflexesBrisk reflexes

4.4. Ankle clonusAnkle clonus((more than more than 33 beats beats))

5.5. Fundal heightFundal height

InvestigationsInvestigations

MaternalMaternal Urinalysis by dipstickUrinalysis by dipstick 2424hours urine collectionhours urine collection Full blood countFull blood count((platelets&haematocritplatelets&haematocrit)) Renal functionRenal function((uric acid,s.creatinine,ureauric acid,s.creatinine,urea)) Liver function testsLiver function tests Coagulation profileCoagulation profile

FetalFetal1.1. Uss(growth parameters,fetal size,AF)Uss(growth parameters,fetal size,AF)2.2. CTGCTG3.3. BPPBPP4.4. DopplerDoppler

Management of preeclampsiaManagement of preeclampsiaPrinciplesPrinciples Early recognition of the syndromeEarly recognition of the syndrome Awarness of the serious nature of the conditionAwarness of the serious nature of the condition Adherence to agreed guidelines(protocol)Adherence to agreed guidelines(protocol) Well timed deliveryWell timed delivery Postnatal follow up and counselling for future pregnancyPostnatal follow up and counselling for future pregnancy REMEMBER: Delivery is the only cure for preeclampsiaREMEMBER: Delivery is the only cure for preeclampsia

A Mild preeclampsiaA Mild preeclampsia Diastolic blood pressure 90-95mmhgDiastolic blood pressure 90-95mmhg

minimal proteinurea,normal heamatologicalminimal proteinurea,normal heamatological and biochemical parameters,no fetaland biochemical parameters,no fetal

compromise.Deliver at termcompromise.Deliver at term..B severe preeclampsia (BP>160/110MMHGB severe preeclampsia (BP>160/110MMHG,,

urine protein 5grams 3urine protein 5grams 3( +( + Abnormal haematological and biochemicalAbnormal haematological and biochemical

parameters,abnormal fetal findingsparameters,abnormal fetal findings 11 . .Control blood pressure(aim to keepControl blood pressure(aim to keep

BP 90-95mmghBP 90-95mmgh ( (

DrugsDrugs-:-:agentagentactionactiondosedoseSide effectSide effectcommentcomment

Methyl Methyl dopadopa

centralcentral500-4000500-4000 mgmg

dpressiondpressionLate onset Late onset 24hours24hours

hydralazinehydralazineDirect Direct vasodilatorvasodilator

5mg…10mg5mg…10mgHeadacheHeadache,,

FlushingFlushing

palpitationpalpitation

Drug of Drug of emergencyemergency

labetalollabetalolBeta&alpha Beta&alpha blockerblocker

20mg…20mg…40mg every 40mg every 10m10m

NauseaNausea

VomitingVomiting

h.blockh.block

Avoid inAvoid in

h.Failureh.Failure

b.asthmab.asthma

nifedipinenifedipineCa.channelCa.channel

blockerblocker

5mg sub5mg sub..SevereSevere

headacheheadache

ForFor

emergencyemergency

DeliveryDelivery-:-:Transfer patient to tertiary center if herTransfer patient to tertiary center if her

Condition permitsCondition permits..

If fetus is preterm give mother If fetus is preterm give mother 12mg12mg

Dexamethasone im twice Dexamethasone im twice 12hs12hs apart to apart to enhance lung maturityenhance lung maturity..

Deliver cDeliver c//s or vaginals or vaginal..

Avoid ergometrine in Avoid ergometrine in 33rdrd stage stage..

Give anticoagulantGive anticoagulant..

Complications of preeclampsiaComplications of preeclampsia-:-: ECLAMPSIAECLAMPSIAMaternalMaternal CVACVA HEELP syndromeHEELP syndrome Pulmonary oedemaPulmonary oedema Adult RDSAdult RDS Renal failureRenal failureFetalFetal IUGRIUGR IUFDIUFD Abruptio placentaAbruptio placentaProphylaxis(aspirin,antioxidant)Prophylaxis(aspirin,antioxidant)

EclampsiaEclampsia-:-: Is a life threatening complications of Is a life threatening complications of

preeclampsia,defined as tonic,clonic preeclampsia,defined as tonic,clonic convulsions in a pregnant woman in the convulsions in a pregnant woman in the absence of any other neurological or absence of any other neurological or metabolic causes.It is an obstetric metabolic causes.It is an obstetric emergency.emergency.

It occurs antenatal,intrapartum,postpartumIt occurs antenatal,intrapartum,postpartum

))after delivery after delivery 24-48hs24-48hs((

ManagementManagement((carried out by a teamcarried out by a team)) 1.1.Turn the patient on her sideTurn the patient on her side 2.2.Ensure clear airwayEnsure clear airway((suction,mouth gagsuction,mouth gag)) 3.3.Maintain iv accessMaintain iv access 4.4.Stop fitsStop fits((mag.sul,diazepammag.sul,diazepam)) 5.5.Control BPControl BP((hydralazine,labetalolhydralazine,labetalol)) 6.6.Intake & output chartIntake & output chart 7.7.InvestigationsInvestigations((urine,urine,FBCFBC,,RFTRFT,,LFTLFT,, clotting profile,cross matchclotting profile,cross match)) 8.8.Monitor patient and her fetusMonitor patient and her fetus 9.9.After stabilizationAfter stabilization((BPcontrolled,no BPcontrolled,no convulsions,hypoxia controlledconvulsions,hypoxia controlled)) deliver deliver

Mag.sulphate:-Mag.sulphate:- Drug of choice in ecclampsiaDrug of choice in ecclampsia Given iv,imGiven iv,im((4-6gr4-6gr bolus dose, bolus dose,1-2gr1-2gr

maintenancemaintenance)) Acts as cerebral vasodilator and Acts as cerebral vasodilator and

menbrane stabilizermenbrane stabilizer Over dose lead to respiratory depression Over dose lead to respiratory depression

and cardiac arrestand cardiac arrest Monitor patientMonitor patient((reflexes,reflexes,RRRR,urine output,urine output)) Antidote cal.gluconate Antidote cal.gluconate 10ml 10%.10ml 10%.

Dr.Ghada Abed AlmalkiDr.Ghada Abed Almalki

Ob/Gyne demonstratorOb/Gyne demonstrator

KAUKAU