REPRODUCTIVE HEALTH

1. PRE-ECLAMPSIA
MR. JONES H.M-MBA
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2. PRE-ECLAMPSIA
 Pre-eclampsia is a condition specific to pregnancy occurring
after the 20th week of gestation characterised by hypertension,
proteinuria and/or oedema.
 Pre-eclampsia is a complication of pregnancy in which a
pregnant woman has high blood pressure, protein in urine and
oedema, and may develop other symptoms and problems.
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3.  The more severe the pre-eclampsia, the greater the risk of
serious complications to both mother and baby.
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4. CLASSIFICATION
 MILD/ MODERATE PRE-ECLAMPSIA
 Blood pressure is 140/90mmHg to 150/100mmHg.
 Oedema up to 2+ (may be generalised).
 Proteinuria of up to 2+ (in the absence of UTI).
 SEVERE PRE-ECLAMPSIA
 Blood pressure exceeds 160/110mmHg
 Increase in proteinuria
 Oedema 3+ (generalised).
 Frontal headache and visual disturbances are usually present.
 Upper abdominal pain or epigastric pain with or without vomiting.
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5. RISK FACTORS
 Maternal personal risk factors for preeclampsia
 First pregnancy
 New partner/paternity
 Age younger than 18 years or older than 35 years
 History of preeclampsia
 Family history of preeclampsia
 Black race
 Obesity
 Interpregnancy interval less than 2 years or more than 10 years
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6.  Maternal medical risk factors for preeclampsia
 Chronic hypertension,
 Preexisting diabetes (type 1 or type 2),
 Renal disease
 Systemic lupus erythematosus
 Obesity
 Thrombophilia
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7.  Placental/fetal risk factors for preeclampsia
 Multiple gestations
 Hydrops fetalis
 Gestational trophoblastic disease
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8. PATHOPHYSIOLOGY
 Pre-eclampsia has been called a disease of theory because the
true mechanism behind the pathogenesis is unknown.
 Women who develop pre-eclampsia become more sensitive to
pressor agents (substances that increase blood pressure) rather
than less sensitive to them as in normal pregnancy.
 This response has been linked to the ratio between prostacyclin,
prostaglandins and thromboxane.
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9.  Prostacyclin, a vasodilator produced by endothelial cells,
decreases blood pressure, prevents platelet aggregation and
promotes uterine blood flow.
 Thromboxane produced by platelets, causes vessels to constrict
and platelets to clump together.
 In Pre-eclampsia, prostacyclin is decreased allowing the potent
vaso-constrictor and platelet aggregating effects of
thromboxane to dominate.
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10.  These hormones are produced partially by the placenta which
would help explain the reversal of the condition when the
placenta is removed and why the incidence is increased when
there is a larger than normal placental mass such as in hydrops,
multiple pregnancy or hydatidiform mole.
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11.  There is another theory which suggests that women who
develop preeclampsia have been found to have an increased
cardiac output and an associated endothelial damage.
 The vasodilation acts as a compensatory mechanism allowing a
normal blood pressure in spite of the high cardiac output.
 The body responds to the endothelial damage with platelet
aggregation and adherence to the damaged sites.
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12.  The combination of these events will cause vaso-spasms and
increased blood pressure, abnormal coagulation and thrombosis
and increased permeability of the endothelium leading to
oedema, proteinuria and hypovolaemia (blood seeps out in the
tissue).
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13. PATHOLOGICAL CHANGES
 Blood; High blood pressure combined with endothelial cell
damage affect capillary permeability leading to plasma proteins
leak from the damaged blood vessels.
 This will cause decrease in the plasma colloid pressure and an
increase in edema within the intracellular space.
 It will further cause hypovolemia and hemo concentration due
to reduced intravascular plasma volume and this will be
reflected in an elevated hematocrit level.
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14.  Kidneys; Hypertensive disorders in pregnancy can also disrupt
renal function.
 The detectable presence of proteins within the urine
(proteinuria) may indicate that larger molecules than normal are
being forced into the Bowman’s capsule.
 This is caused by increased blood pressure resulting in abnormal
ultra filtration.
 As the condition worsens, oliguria develops as well signifying
kidney damage and severe preeclampsia.
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15.  Liver; There will be hypoxia and edema of the liver cells due to
vasoconstriction of the hepatic vascular bed and this may lead
to epigastric pain with intra capsular hemorrhages in severe
cases.
 Rarely does rupture of the liver occur, however, there will be
altered liver enzyme and albumin levels.
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16.  Brain; The combination of hypertension and cerebral vascular
endothelial dysfunction leads to increased permeability of the
blood-brain barrier.
 This will result in cerebral edema and micro hemorrhaging
leading to characteristics such as headaches, visual disturbances
and convulsions. Excessive increase in blood pressure may lead
to hypertensive encephalopathy.
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17.  Fetal Placental; There will be vascular lesions in the placental
bed due to reduced uterine blood flow and this may result in
placental abruption.
 Blood flow to the chorio decidual spaces will also reduce thereby
diminishing oxygen diffusion into the fetal circulation within the
placenta leading to fetal growth restriction.
 Hormonal output is also impaired due to reduced placental
function hence compromising survival of the fetus.
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18. SIGNS AND SYMPTOMS
 The signs of pre-eclampsia do not occur before the 20th week of
pregnancy and seldom after the 30th week, however the earlier
they occur the more serious the condition becomes.
 If the signs are found before 20th week of pregnancy, it is usually
an indication of the underlying pathological conditions e.g.
trophoblastic diseases like hydatidiform mole or
choriocarcinoma, chronic hypertension, chronic renal disease
etc.
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19.  Hypertension- a rise in blood pressure of above 140/90 or rise by
10-15 mmHg in two or more subsequent readings is suggestive
of pre-eclampsia or PIH in a normo-tensive mother.
 Proteinuria- develops as reduced blood flow damages the
kidneys.This damage allows the protein to leak into the urine.
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20.  Oedema- occurs because the fluid leaves the blood vessels (due
to hypoproteinaemia) and enters the tissues.
 Sudden excessive weight gain is a first sign of fluid retention.
 Visible oedema of the legs and feet is common during
pregnancy, but oedema above the waist is suggestive of
pregnancy induced hypertension.
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21. GRADES OF OEDEMA:
 Grade 1 (1+) - Ankle oedema
 Grade 2 (2+) oedema of the lower limbs to knees
 Grade 3 (3+) Generalized oedema
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22. • Visual disturbances -These disturbances are presumed to be due to
cerebral vasospasm.
• Headache is of new onset and may be described as frontal,
throbbing, or similar to a migraine headache.
• Epigastric pain is due to hepatic swelling and inflammation, with
stretch of the liver capsule.
• Pain may be of sudden onset, is typically constant, and may be
moderate-to-severe in intensity.
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23. INVESTIGATIONS
 Hypertension and proteinuria are not the only signs of pre-
eclampsia, or necessarily the most important; they constitute
evidence of end organ damage within on going process.
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24.  Diagnostic tests to assess renal function, cardiovascular changes
and liver enzymes are necessary to diagnose the extent to which
the maternal system is affected. And these include:
 Blood urea and creatinine are raised, and a high level indicates a
late stage of renal involvement.
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25.  Platelet count is reduced
 Packed cell volume is increased
 Hb and haematocrit levels are raised
 Urinalysis-24 hour specimen will reveal protein > 0.3g
 Liver function test especially transaminase should be carried out
to determine liver function
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26.  Ultra sound scan- For the Bio-physical profile of the fetus and
fetal movements, breathing and liquor volume
 Fetal maturity Test- Pulmonary surfactant (Lecithin
sphingomyelin ratio, normal 2:1).
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27. MANAGEMENT OF PRE- ECLAMPSIA
AIMS
 The ultimate aim is to prolong pregnancy until the baby is
sufficiently mature to survive while safeguarding the mother’s
life.
 To monitor the disease and prevent it from getting worse
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28. ANTENATALLY
MILD PRE-ECLAMPSIA
 Treatment of pre-eclampsia is symptomatic because the cause is
unknown.
 Usually the patient with mild pre-eclampsia will be nursed at
home (Out patient).
 The patient is given the following advice;
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29. Rest- The patient should have adequate bed rest at home to
ensure improved blood flow to the heart and therefore to the
placenta.
 A doctor might order mild sedatives to promote restful sleep at
home.
Diet- The patient is advised to take diet rich in proteins and
vitamins but low in carbohydrates and no extra salt.
 The patient is advised not to gain excess weight.
 The proteins and the vitamins are needed to nourish the
growing foetus and prepare the woman for lactation.
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30. Antenatal visits- The woman is advised to make frequent visits to
the health facility to ensure frequent monitoring of the
condition.
 She is advised to report to the health facility if she is feeling very
unwell (headache, oedema etc).
Foetal well being –The patient is advised to maintain the “kick
chart” to monitor any foetal movements.
 Usually the woman is admitted at 37 weeks if condition has
remained stable so as to deliver in hospital.
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31. MODERATE TO SEVERE PRE-ECLAMPSIA
 Patients with moderate and severe pre-eclampsia need to be
hospitalized till delivery.
 The patient should be admitted in the quiet room since she will
be anxious about her condition
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32.  Establish good midwife -patient relationship
 Explain condition to the patient to allay anxiety
 Allow significant others to visit when appropriate but give her
time to rest
 Assign a nurse to attend to her constantly
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33. REDUCTION OF BLOOD PRESSURE
 The treatment is aimed at reducing blood pressure as soon as
possible and this is achieved by the following:
 Putting the woman on bed rest in order to rest the heart, reduce
demands of blood by other organs and improve placental
perfusion.
 Record blood pressure 1 -2 hourly to detect any sudden rise or
sudden drop which should be reported to the doctor.
 Give the ordered drugs
 Fluid intake and output is monitored and fluids may restricted if
there is severe kidney damage.
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34. MONITORING OF OEDEMA
 Weigh patient daily
 Encourage bed rest
 Monitor fluid intake and output
 Do daily physical examinations to assess the amount of oedema
present
 No extra salt is allowed
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35. DIET
 High protein and vitamins to nourish the growing foetus
 Low salt diet to avoid water retention
 Low carbohydrate diet to avoid gaining of excess weight
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36. OBSERVATIONS
 Since the foetus is at risk of intra uterine growth retardation
because of placenta insufficiency, frequent and efficient
monitoring is essential.The following should be done;
 Check the foetal heart rate 4 hourly depending on the condition
of the mother
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37.  Use cardiotocography machine.
 Continuously monitor the well being of the foetus especially if
the patient is on antihypertensive drugs or where patient’s
condition is not satisfactory.
 Ultra sound can be done to assess the foetal well being, the
foetal movements, the amount of liquor and the foetal
breathing pattern.
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38.  Vital signs are done 4 hourly to monitor maternal well being.
 Abdominal examinations are done twice daily and in this case
compare the height of fundus with the gestation age to rule out
intrauterine growth retardation
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39.  Note for any abdominal pains as presence of abdominal pains
may denote abruptio placenta, onset of labour and deteriorating
condition.
 Watch out for epigastric pain as this may be a sign of imminent
eclampsia.
 Never leave the woman alone if shows signs of imminent
eclampsia
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40. MEDICAL MANAGEMENT
The following drugs may be ordered;
 Antihypertensives - May be ordered if B/P exceeds
150/100mmHg in an effort to reduce it, prevent CVA and
eclampsia and therefore prolong pregnancy, maternal well
being and foetal survival rate.
 When lowering blood pressure with medication it is vitally
important to monitor the fetal heart in order to detect whether
the lowered maternal BP is affecting the utero-placental blood
flow and fetal oxygenation.
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41. Methyldopa (Aldomet) - 250-500mg 8hrly.
 It is a long term treatment until the fetus is more mature (35-36
weeks)
 This medication takes 24 hours to be effective
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42. Hydralizine
 Given when diastolic pressure is above 110 mmHg
 Given intravenously slowly
 25mg 8hrly or 12hrly or 5mg iv bolus initially followed by an
infusion of 2-20mg/hour according to the patient’s response.5
mg to 20 mg
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43.  Neprosol - 6.25mg IV slowly over 4minutes for acute
hypertension.
 Nefidipine - 10-20mg subliqually used for acute lowering of B/P
 Steroids- When pre-eclampsia develops late in gestation,
steroids maybe given to reduce the risk of RDS e.g.
Dexamethasone 4 mg, 12 hourly for 48 hours.
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44.  Aspirin- It is thought to inhibit production of platelet
aggregating agent thromboxane A2, therefore low dose of
aspirin maybe beneficial for women at high risk of pre-
eclampsia.
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45.  In imminent eclampsia, it is important to reduce the excitement
of the central nervous system and the following measures
should be taken:
 Phernobarbitone may be used in small amounts in mild
eclampsia when patient is not going into labour early.
 Note that it has a depressive effect on the foetus and the
maternal respiration system.
 Magnesuim Sulphate 5g (mgSo4) in 200mls of 5% dextrose
over 20minutes and then 5mg i.m start 6hrly for 2/7 only if
diastolic pressure is above 90mmHg.
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46.  Diazepam can be used for transporting the patient with
imminent eclampsia
 Diuretics are not used as they aggravate haemoconcentration
and may lead to haemorrhagic pancreatitis in the mother.
 Manitol 200mls iv 6hrly can only be used when there is cerebral
oedema and mainly this is in eclempsia.
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47. OBSTETRIC MANAGEMENT
 The obstetrician decides the optimum time for the delivery of
the baby.
 This depends on the maternal and foetal well being and not on
the period of gestation.
 If patient responds well to treatment in mild and moderate pre-
eclampsia the pregnancy is usually allowed to continue and
usually labour is induced before term to reduce effects of
placental insufficiency.
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48.  If patient does not respond to treatment and has moderate or
severe pre-eclampsia, then an induction of labour is usually
commenced after 24hrs
 Indications for induction are:
 Foetal intrauterine growth retardation
 Uncontrolled rising blood pressure
 Poor renal function
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49. NURSING CARE DURING LABOUR
 Labour is induced by an IV oxytocics being administered
together with the rupture of membranes.
 Episiotomy and forceps or vacuum extraction is frequently used
to prevent exhaustion by the patient as this may lead to
eclampsia.
 Caesarian section may be performed where labour is
detrimental to the maternal and foetal condition.
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50. The following measures should be done:
 Do not leave patient alone
 Inform the doctor immediately of any change in the patients
condition
 Check blood pressure half hourly or quarter hourly and foetal
heart rate quarter hourly or CTC machine can be useful to
monitor the foetal heart
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51.  When necessary put up intravenous fluid line but careful not to
overload the patient
 Keep the patient sedated and you can even give her epidural
anesthesia
 Continue with medication the patient is on
 Keep a record of all drugs during labour and delivery to be
reported to a pediatrician
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52.  Prepare the patient for episiotomy/forceps delivery/vacuum
extraction
 Note: Ergometrine and syntometrine are never useful in the
third stage of labour.These cause peripheral vascular spasms
and increase the blood pressure
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53. NURSING CARE DURING
PUERPERIUM
 Convulsions can occur soon after delivery for the first time and
therefore, the first 24 hours is the most critical period. The
patient should be nursed as follows:
 Continue with the sedation of the patient
 Constantly monitor the patient’s condition from delivery to 24
hours.
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54.  Check the blood pressure hourly for 6 hours and then if
decreasing 4 hourly for 24 hours and if stable blood pressure can
be done twice daily.
 Monitor fluid balance until it is normal
 Continue with urinalysis for proteins till negative and repeat on
disc
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55.  Continue with urinalysis for proteins till negative and repeat on
discharge
 Note: Patient will only be discharged when blood pressure is
normal and urine is free of proteins.
NEONATAL CARE
 These babies are always small for dates and premature,
therefore give them care accordingly.
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56. COMPLICATIONS
 Eclampsia
 Placenta abruptio
 Renal failure
 Subcapsular hemorrhage or rapture of the liver
 Disseminated intravascular coagulation (DIC)
 Cardiovascular accident
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57.  HELLP syndrome- a syndrome of Haemolysis Elevated Liver
enzyme and Low Platelet count. It represents a variant of pre-
eclampsia/eclampsia syndrome.
 Pregnancies complicated with this syndrome have been
associated with significant maternal and perinatal morbidity and
mortality.
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58. THE END
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