Makindo Medical Notes.com

Patients with resistant severe hypertension despite or persistent cerebral symptoms while on magnesium sulfate are delivered irrespective of fetal gestational age. About 5% of women with preeclampsia first manifest signs and symptoms after deliver

About

• Hypertensive disorders affect 7-10% of all pregnant women
• May be associated with fetal Long chain acyl-CoA dehydrogenase deficiency

Preeclampsia (HTN + protein in urine)

• Hypertension that begins after week 20 of pregnancy
• With significant proteinuria that disappears at 12 weeks after the labour.
• Proteinuria = 300mg per 24-hour timed collection
• Proteinuria is 1+ on dipstick on at least two occasions at least 4 hours apart
• Severe Eclampsia the Proteinuria is 3+

Effects

• The mother's high blood pressure reduces the blood supply to the fetus
• Fetus may get less oxygen and fewer nutrients
• May show abnormal development

Eclampsia (Grand mal seizure)

• Grand mal seizures during pregnancy or during/after delivery
• In a woman with preeclampsia, not attributable to other causes.
• Most occur in the third trimester after 28 weeks of pregnancy

Severe pre-eclampsia

• This is defined as pre-eclampsia with DBP = 110 mmHg, SBP;160 mmHg
• and/or with symptoms, and/or biochemical and/or haematological impairment

HELLP syndrome (Severe form)

• Pregnancy, Haemolysis
• Elevated liver enzymes
• Low platelets. Severe HTN

Clinical

• Severe headache
• Sudden swelling of face, hands, feet
• Visual disturbance such as blurring or flashing before eyes
• Epigastric pain and/or vomiting
• Signs of clonus
• Papilloedema, liver tenderness
• Platelet count falling to below 100 x 106/l 6
• LFTS (ALT or AST rising to above 70iu/l)
• HELLP syndrome

Complications

• Eclamptic seizures can develop (even before proteinuria is identified)
• Cerebral haemorrhage, stroke, seizures, cardiopulmonary compromise
• Renal failure, liver hematoma or rupture, placental abruption
• Preterm delivery and death.
• Preeclampsia may come on after deliver

Investigations

• FBC, U&E, LFTs, Urate, Creatinine
• Coagulation screen if platelet count < 100
• ECG and CT head may be needed to exclude bleed/stroke
• Group and hold serum

Assessment

• Test all urine specimens for protein
• Measure and record all fluid intake and urinary output
• MEOWS chart
• Fetal cardiotocograph (continuous if in labour)
• Fetal ultrasound scan for EFW, AFV, placental maturity,
• Fetal Umbilical Artery Doppler studies
• Middle Cerebral Artery Doppler studies if fetal umbilical artery doppler studies are abnormal or there is other concern about fetus e.g. IUGR or reduced fetal activity

Urine 24-hour urine collections for:

• i. Total protein and creatinine clearance
• ii. Catecholamines

Management Seizure

• ABCDE. Involve Obgyn immediately
• Magnesium sulfate Loading dose IV 4-6 g over 20 minutes
• Magnesium sulfate Maintenance dose IV 1-2 g per hour for at least 24-48 h

Management BP

• Hydralazine 5 or 10 mg dose slowly IV
• Labetalol 20 to 40mg IV every 15 minutes as needed

Materno-Fetal Health

• Maternal and fetal conditions are assessed, and a decision is made regarding the need for delivery.
• Those with a gestational age of 24 to 34 weeks are given corticosteroids to accelerate fetal lung maturity
• Fetal evaluation required
• Patients with resistant severe hypertension despite or persistent cerebral symptoms while on magnesium sulfate are delivered irrespective of fetal gestational age

References

• Eclampsia: an overview clinical presentation, diagnosis and management
• MANAGEMENT OF SEVERE PRE-ECLAMPSIA AND ECLAMPSIA