What is the biggest indicator for pre-eclampsia

1biggest indicator for pre-eclampsia
2What are the Risk factors of pre-eclampsia
3Type of Pre-eclampsia
4Treatment of Mild and severe Pre-eclampsia
5Cause of Maternal Death in pre-eclampsia

Ominous/Impending signs of pre-eclampsia/ Biggest indicator for pre-eclampsia:

1.Headache- The patient is sufferning from severe headache from the very begaing of pre-eclampsia
2.Blurring of vision- With severe headache patient also complaints that she is unclear vision.
3.Insomnia- diffuclty in falling sleep at night.
4.Oliguria- severly decrease urine output.
5.Epigastric pain- pain feel in the upper abdomen

Pre-eclampsia: is a multi-system disorder of unknown ideology characterized by the new onset of hypertension to the extent of equal or more than 140/90 mmH after 20 weeks of pregnancy with proteinuria in previously normotensive and nonproteinuric women, or absence of proteinuria, presence of any end organ damage.

                                                                                    Or

Rise of blood pressure more than or equal to 160 mmH of systolic and 100 mmHg of diastolic measuring on 2 occasions at least 4 hours apart in previously normotensive women after 20 weeks of pregnancy with proteinuria.

What are the examples of end organ damage:

  1. Neurological Disorder:

-Severe headache

-Blurring of vision

-Blindness

-Mental disorder

-Stroke

  1. Hematological Disorder:

-Thrombocytopenia (less than 1 lac platelet count)

-DIC

  1. Renal Impairment:

-Oliguria (less than 400 ml of urine pass  in 24 Hours)

-Serum creatinine [ more than  1.1 mg/dl or Double of Normal level (0.6-1.2 mg/dl)]

-Serum Uric acid (more than 4.5mg/dl)

4.Hepatic Impairment:

-ALT and AST enzyme level are rise.

-Abdominal pain in Epigastric area.

-Foetal Growth retardation occure.

-Pulmonary edema delvoped.

What are the Risk factors of pre-eclampsia:

-Young primigravida, which is considered women who are less than 19 years old.

-Elderly primigravida which is consider women who is more than 30 year

-Previous history of Pre-eclampsia

-Obesity, BMI is more than 30

-Family History of Hypertensoin or Pre-eclampsia

-Pregnancy following ART (Artificial Reproductive Technique)

-Patient is suffering from  other medical disorders, such as:

=HTN

= Hypothyroidism

=Gestational diabetes mallitus

= Uncontrolled diabetes mallitus

= Anemia

= Molar Pregnancy

= Multiple Pregnancy

= Pregnancy interval more than 5 years

= PCOS before Pregnancy

= Dyslipidemia

= Thrombophilia

= Connective Tissue Disorder:( SLE, Antiphospholipid antibody syndrome)

Pathophysiology/Pathogenesis of pre-eclampsia:

  1. Endothelial Dysfunction: It is due to Oxidative Stress, Inflammatory Mediator, Failure of Trophoblastic invasion
  2. Intense Vasospasm: Due to Increase Vasoconstrictor (Thromboxane A2, Endothelin, Angiotensin and Decrease Vasodilator (Nitric Oxide, PG 12)

Type of Pre-eclampsia:

1)Mild Pre eclamosia

2)Severe Pre-eclampsia

1) Mid Pro-eclampsia: Patients does not comes to you with any Symptoms. It is diagnosed in  Routine Antenatal check-up. The Only presentation  Leg Oedema, Rapid Weight gain( more than 4 pound weight gain in 1 week). Blood Pressure is more than 140/90 mmHg but less than 160/100 mmHg.

2) Severe Pre-eclampsia: BP => 160/100 mmHg along with Feature of  End Organ damage such as Blurring of vision, oliguria. Headache, Blindness, Pulmonary Oedema, epigastric pain. If those feature present ,this also can be known as impending eclampsia.

Impending Eclampsia: Eminent to develop eclampsia

Why leg oedema occure in Pre-eclampsia?

Due to Endothelial Dysfunction (Glomerular endothelium) which  Increase Capillary Permeability.

Investigation of Pre-eclampsia:

-Blood grouping if not done

-RH typing if not done

-Complete blood count

-Urine R/M/E

-24-hour urinary protein level

-PCR

-Urinary dipstick (Bed Side 9 PA1 413)

-Renal function test

-ALT, AST level

-USG for pregnancy profile

USG finding in fatal Associated with Pre-eclampsia:

-Foetal Growth Retardation

-Oligohydramnios

Why IUGR/ Oligohydramnios occur in Pre-eclampsia?

> Due to Placental Insufficiency [(Note): Pre-eclampsia is a high-risk pregnancy. A minimum of 4 antenatal visits is not enough, Patient have to visit every 2 weeks interval for an antenatal check-up before 28 weeks of pregnancy. After 28 weeks of pregnancy, a Weekly visit is needed until delivery.]

Treatment of Mild Pre-eclampsia:

-Bed Rest in the Left lateral position (Bed rest in the left lateral position will improve renal and uterine circulation. improved renal blood flow – diuresis-decreased blood pressure, increased uterine blood flow – improved placental perfusion).

-Salt Restricted Diet.

-Sedative at night ( Diazepam 5mg)

-Anti-hypertensive Drugs

1)1st-line Anti-hypertensive Drug

-Labetalol: [highest (Dose: 100- 2400 mg) . If not control then Methyl-Dopa is given]

-Alpha Methyl-dopa (Maximum Dose:2000 mg QDS)

2)2nd-line Anti-hypertensive Drugs

-Calcium Channel Blocker: Nifedipine

-Hydralazine

3)3rd-line Anti-hypertensive Drugs:

-Beta Blocker

-Diuretics

Treatment of Severe Pre-eclampsia:

1)Hospitalization

2)Control BP with antihypertensive drugs.[If Feature of impending eclampsia appears, give a prophylactic dose(10 gm) of Mgso4 to prevent eclampsia(Convulsion)]

3)Maintenance Dose of MgSo4 is 2.5 gm every 4 hourly on each buttock up to 24 hour

4)Steroid dexamethasone (6 mg IM,4 Dose 12 hourly) for lung maturation of the fetus. Because premature termination may occure at anytime.

5)If blood pressure becomes controlled, edema subsides, proteinuria becomes insignificant, and good fatal condition pregnancy can be continued till 37th weeks and then termination Is to be done. In the case of Severe Pre-eclampsia, we would prefer the termination by at least 34th completed weeks.

6)The mood of delivery depends on the mother, fetus, and condition of the cervix. I BP is under control, no future of impending eclampsia, no fetal distress, and the cervix is favorable then we can approach vaginal delivery with oxytocin drip when labor is active, and ARM is to be done.

In which condition we can do termination of pre-eclampsia patient in 34th of pregency:

-Severe Pre-eclampsia with impending signs of eclampsia.

-If Pre-eclampsia is not controlled with 3 antihypertensive drugs on a Maximum dose of that drug.

      > Labetalol

      >Alpha methyl dopa

      >Nifedipine

      >Hydralazine

-If the patient develops eclampsia.

-Biochemical para meter abnormality.

-Any fetal Complications.

       >Fetal Distress

       >Congenital Abnormality

Dose of antihypertensive in Pre-eclampsia:

Alpha methyl dopa: 500 mg BT [severe cases -Maximum dose 2000 mg per day]

Labetalol: 200 mg BT [ Maximum dose: 2400 mg per day]

Nifedipine: initially started with 10-20 mg extended maximum of 40 mg per day

Pre-requisition of giving MgSo4:

-Respiratory rate >16 breaths/minute [ RR > 12 breaths/min)

-Urine output >30 ml/Hour

-Patellar jerk must be present.

If MgSo4 is given to a person having absent patellar jerk there will be toxicity of MgSo4, then immediately stop MgSo4 and treat with 10 ml 10% Calcium gluconate.

Contraindication of MgSo4:

-In patients with myasthenia gravis

-If patellar reflexes are absence

-If the urinary output is less than 30 ml/hour

-If the respiratory rate is less than 16 breaths/min

Complications of Pre-eclampsia:

  1. Immediate complications:
  2. Maternal complication:

>During pregnancy

-Eclampsia

-Preterm labor

-Abruptio placenta

-HELLP syndrome[H= haemolysis EL= Elevated liver enzyme LP= Low platelet count]

-DIC

-Renal Failure

-Acute LVF

– Pulmonary edema ix. Cerebral hemorrhage

– Dimness of vision and even blindness

> During labour

-Eclampsia

-PPH

> During puerperium

-Eclampsia (usually within 48 hours)

-Shock

-Puerperal sepsis

  1. Fetal complication:

-IUFD

-IUGR

-Asphyxia

-Prematurity

  1. Remote complications:

-Residual hypertension may persist even after 6 months following delivery in about 50% of cases

-Recurrent pre-eclampsia (25% cases of recurrence in subsequent pregnancies)

-Chronic renal disease

– Placenta abruption

Cause of Maternal Death in pre-eclampsia:

-Eclampsia

-Accidental hemorrhage

-HELLP syndrome

-Oliguria

-Anuria

-Pulmonary Oedema

-Acute Renal Failure

FAQ

Scenario: A lady 28 years old with the complaint of amenorrhea for 36 weeks with BP more than or equal to 160/90 mmHg with the feature of impending eclampsia / with the blurring of vision, headache, and epigastric pain.
Q. What is your diagnosis?
>Diagnosis: 36th week of pregnancy with signs of impending eclampsia Or Preeclampsia with severe features.

What is HELLP syndrome and what is its clinical feature?
HELLP syndrome is a rare complication of pre-eclampsia (10-15%) and is an acronym for
-Ha=Hemolysis
-EL= Elevated Liver enzyme
-LP= Low platelet count (< 100000/mm/l”)
HELLP syndrome can even develop without maternal hypertention.

Clinical Features:
-Nausea
-Vomiting
-Epigastric pain

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