aboubakr elnashar

1. THE
MANAGEMENT
OF
SEVERE
PET/ECLAMPSIA
Prof.Aboubakr
elnashar
Benha
university
Hospital,
Egypt
ABOUBAKR
ELNASHAR
Introduction
ABOUBAKR
ELNASHAR

2. ABOUBAKR
ELNASHAR
❑Eclampsia
(E):
convulsions
superimposed
on
PET.
❑Preeclampsia
(PET):
PIH
in
association
with
proteinuria
(>
0.3
g/24
h)
±
oedema
❑Severe
PET
▪
DBP
≥
110
mmHg
on
2
occasions
or
▪
SBP
≥
170
mmHg
on
2
occasions
and
that,
together
with
significant
proteinuria
(1
g/litre)
▪
DBP
≥
100
mmHg
on
2
occasions
&
significant
proteinuria
with
at
least
2
S
or
S
of
imminent
E.
❑HELLP
syndrome:
▪
Variant
of
severe
PET
▪
Haemolysis,
Elevated
liver
enzymes,
Low
platelet
count
ABOUBAKR
ELNASHAR

3. 1.
DEFINITION
❑Syndrome
of
new
onset
of
Hypertension
and
either
Proteinuria
or
End
organ
dysfunction
after
20
w
in
a
previously
normotensive
woman
(ACOG,
2013)
ABOUBAKR
ELNASHAR
❑Proteinuria:
▪No
longer
▪Required
alone
in
diagnosis
▪Useful
in:
▪classifying
PET
as
severe
▪deciding
whether
to
induce
{amount
not
shown
to
predict
either
maternal
or
fetal
outcomes}
(ACOG,
2013)
▪Heavy
(5
g/24
h)
has
been
eliminated
as
a
criterion
for
diagnosing
severe
PET
▪Testing
may
be
discontinued
once
significant
proteinuria
has
been
demonstrated
ABOUBAKR
ELNASHAR

4. ❑Diagnosis
of
PET
(ACOG
,
2015)
New-onset
hypertension
without
proteinuria
plus
1
of
the
following:
1.
Platelet
count
below
100,000/μL
2.
Serum
creatinine
level
above
1.1
mg/dL
3.
Doubling
of
serum
creatinine
in
the
absence
of
other
renal
disease
4.
Liver
transaminase
levels
at
least
twice
the
normal
5.
Pulmonary
edema
6.
Cerebral
or
visual
symptoms
ABOUBAKR
ELNASHAR
William,
2016
ABOUBAKR
ELNASHAR

5. ❑Clinical
features
of
severe
PET
▪
In
addition
to
hypertension
&
proteinuria:
▪
Severe
headache
▪
Visual
disturbance
▪
Papilloedema
▪
Liver
tenderness
▪
Epigastric
pain
▪
Vomiting
▪
Signs
of
clonus
▪
Platelet
count
<100
x
10
6
/l
▪
Abnormal
liver
enzymes
(ALT
or
AST≥
70
iu/l)
▪
HELLP
syndrome.
ABOUBAKR
ELNASHAR
❑
Maternal
assessment
1.
Symptoms:
1.
Convulsions,
abdominal
pain
or
general
malaise:
PET
should
be
considered:
BP&
urine
analysis.
2.
Symptoms
are
important
components
of
worsening
disease,
particularly
headache&
abdominal
pain.
ABOUBAKR
ELNASHAR

6. 2.
Signs:
1.
Increasing
oedema:
Not
in
itself
a
sign
that
should
determine
management.
2.
Maternal
tendon
reflexes:
▪
Assess
Mg
toxicity
▪
Assess
risk
of
convulsion.
3.
Continuous
oxygen
saturation
monitoring
with
a
pulse
oximeter:
▪
Valuable
▪
{give
early
signs
of
pulmonary
oedema}.
ABOUBAKR
ELNASHAR
❑Measurement
of
blood
pressure
1.
Patient:
▪
Rested
▪
Sitting
at
a
45-degree
angle.
2.
BP
cuff:
▪
appropriate
size
▪
placed
at
the
level
of
the
heart.
3.
Readings:
▪
Multiple
readings
{confirm
the
diagnosis}.
▪
Korotkoff
phase
5
for
DBP.
4.
The
method:
Automated:
used
with
caution
{underestimate
particularly
SBP}
ABOUBAKR
ELNASHAR

7. ❑High
blood
pressure:
▪≥140
mm
Hg
systolic
or
≥90
mm
Hg
diastolic
on
2
occasions,
4
h
apart
after20
w
▪Either
▪high
systolic
or
▪high
diastolic
is
sufficient
▪Systolic
BP:
▪as
important
as
diastolic
blood
pressure
in
diagnosis
▪Persistent,
severe
(≥
160
mmHg)
should
be
treated
promptly.
ABOUBAKR
ELNASHAR
❑Measurement
of
proteinuria
1.
Visual
dipstick
assessment:
▪
2+
dipstick
▪
1+
=
0.3
g/l
▪
2+
=
1
g/l
▪
3+
=
3
g/l.
▪
Poor
predictive
value
▪
False
negative
as
well
as
false
positive
rates.
ABOUBAKR
ELNASHAR

8. 2.
24-h
protein
urine
collection.
▪High
false
positive
rates
with
dipsticks:
confirm
significant
proteinuria,
unless
the
clinical
urgency
dictates
immediate
delivery.
▪Inconvenient
▪Sometimes
inaccurate
{improper
collection}.
▪Excellent
correlation
with
ratio
of
protein
to
creatinine
concentrations
in
a
random
urine
sample
ABOUBAKR
ELNASHAR
3
.
Spot
protein
creatinine
ratio
±valid
alternative.
0.03
g/mmol
equivalent
to
0.3
g/24
h.
ABOUBAKR
ELNASHAR

9. ▪
Creatinine
excretion/d
▪
15-20mg/Kg=
1000-1500mg
▪
constant
throughout
the
day
regardless
of
changes
in
urine
flow
rate.
▪
Protein
excretion/d:
<
100
-
150mg.
▪
Normal
protein-to-creatinine
ratio:
100-150mg
protein/
1000-
1500mg
creatinine=
<
0.1
▪
Protein-to
creatinine
ratio
in
a
random
sample
(in
mg/mg)
is
roughly
equal
to
24-hour
urine
protein
excretion
in
grams/day
▪
Reasonable
“rule-out”
test
for
detecting
proteinuria
of
0.3
g/day
or
more
in
hypertensive
pregnancy.ABOUBAKR
ELNASHAR
ACOG,
2013
Proteinuria
▪≥300
mg/dL
on
a
24-h
urine
▪PCR:
≥0.3
or
▪Protein
dipstick
reading
of
>1
if
quantitative
analysis
is
not
available
ABOUBAKR
ELNASHAR

10. I.
Maternal
monitoring
II.
Foetal
assessment
III.Control
BP
IV.Prevention
of
seizures
V.
Control
of
seizures
VI.
Fluid
balance
VII.Delivery
VIII.
Postparum
ABOUBAKR
ELNASHAR
I.
Maternal
monitoring
1.
BP:
/15
m
until
the
woman
is
stabilised
and
then
/30
m
in
the
initial
phase
of
assessment.
/4-h
if
a
conservative
management
plan
and
the
woman
is
stable
and
asymptomatic.
2.
CBC,
liver
function,
renal
function
tests.
▪
Repeated
at
least
daily
when
the
results
are
normal
▪
more
often
if
the
clinical
condition
changes
or
if
there
are
abnormalities.
ABOUBAKR
ELNASHAR

11. 3.
Clotting
studies
▪
not
required
if
the
platelet
count
>100
x
10
6
/l.
4.
Input
and
output
chart.
▪
A
catheter
with
an
hourly
urometer
in
the
acute
situation,
especially
in
the
immediate
postpartum
period.
ABOUBAKR
ELNASHAR
▪Uric
acid:
rise
▪
correlates
with
poorer
outcome
for
both
mother
and
baby.
▪
confirms
the
diagnosis
of
PET
▪
levels
should
not
be
used
for
clinical
decision-
making.
▪Creatinine
▪
elevated
early
in
the
disease
process:
underlying
renal
disease
should
be
suspected.
▪
In
severe
disease:
rise:
worsening
outcome
ABOUBAKR
ELNASHAR

12. ▪Platelet
count
<100x10
6
:
worsening
disease
coagulation
abnormality
consideration
for
delivery.
▪Platelet
volume
may
be
of
benefit
but
are
as
yet
unproven.
ABOUBAKR
ELNASHAR
▪AST
>75
iu/l
or
ALT
>70
iu/l
▪
Significant
▪
>150
iu/l:
increased
maternal
morbidity
▪Diagnosis
of
HELLP
syndrome
1.
Haemolysis:
LDH
levels,
or
blood
film
(fragmented
red
cells).
2.
Platelet
count:
<100
x
10
6
ABOUBAKR
ELNASHAR

13. II.
Foetal
assessment
1.
In
the
acute
setting:
CTG:
assess
fetal
wellbeing
at
that
time
but
does
not
give
any
predictive
information.
2.
In
labour:
continuous
electronic
fetal
monitoring.
ABOUBAKR
ELNASHAR
3.
In
Conservative
management:
Serial
assessment
will
allow
timing
of
delivery
to
be
optimised.
1.
US
a.
fetal
size:
IUGR30%
of
PET
usually
asymmetrical:
AC
is
the
best
for
assessment.
b.
liquor
volume.
▪
Reduced:
placental
insufficiency
and
IUGR.
▪
Serial
estimations:
detect
fetal
compromise.
2.
Umbilical
artery
Doppler:
▪
Absent
or
reversed-end
diastolic
flow
▪
improves
neonatal
outcome
▪
used
to
follow
pregnancies
and
optimise
delivery.
ABOUBAKR
ELNASHAR

14. 3.
CTG:
▪
Repeated
regularly
and
easily
▪
No
need
of
expensive
equipment
or
highly
skilled
personnel.
ABOUBAKR
ELNASHAR
III.
Control
BP
Antihypertensive
treatment
▪
Indications:
1.
SBP>
160
mmHg
or
DBP>110
mmHg.
2.
SBP
<160
plus
▪
severe
disease
▪
heavy
proteinuria
or
▪
disordered
liver
or
haematological
test)
{alarming
rises
in
BP
may
be
anticipated}.
ABOUBAKR
ELNASHAR

15. 3.
DBP
between
100
mmHg
and
110
mmHg
Continuing
debate
{treatment
a.
Reduction
of
severe
hypertensive
crises
b.
Reduction
in
the
need
for
further
antihypertensive
therapy
c.
Small
reduction
in
infant
birth
weight.
d.
Prolongation
of
pregnancy
of
an
average
of
15
days}.
ABOUBAKR
ELNASHAR
❑Indication
of
antihypertensive:
❑BP:
more
than
160/110
mm
Hg
(ACOG,
2013)
❑SBP:
over
170
mm
Hg.
(WHO)
ABOUBAKR
ELNASHAR

16. 6.
MANAGEMENT
I.
Antihypertensive
❑There
is
an
increasing
trend
toward
tighter
blood
pressure
control
❑keeping
▪SBP:
below
150
mm
Hg
▪DBP:
80-100
mm
Hg
❑First-line
treatment
▪labetalol
and
hydralazine
for
acute
and
severe
(ACOG,
2013)
▪Labetalol
[NICE,
2012]
ABOUBAKR
ELNASHAR
▪Drugs:
•Acute,
severe:
▪Nifedipine:
oral
not
sublingually
▪
IR
cap:10
mg
initial;
repeat
after
30
m
if
necessary
▪
IR
cap:
10-30
mg
tid;
not
to
exceed
120-180
mg/d
ABOUBAKR
ELNASHAR

17. ▪
Hydralazine
▪
IV:
5
mg
over
5
min,
repeat
/20
min
until
DBP
95
mmHg,
No
more
than
4
doses.
If
not
give
Labetalol
or
Nifidipine.
▪
Maintenance:
10
mg/h
▪
Add
2ml
NS
to
reconstitute
20
mg
hydralazine.
Withdraw
0.5
ml
hydralazine
solution
and
add
9.5
ml
NS
to
give
total
10
ml
solution.
ABOUBAKR
ELNASHAR
▪Labetalol:
▪
IV:
20
mg;
subsequent
doses
of
40,
80,
80
mg
IV
at
20-min
intervals.
Maintenance:
40
mg/h
▪
Oral:
100
mg
BID
ABOUBAKR
ELNASHAR

18. ABOUBAKR
ELNASHAR
ABOUBAKR
ELNASHAR

19. ▪
Chronic,
moderate
▪
Nifedipine:
SR
tab:
30-60
mg
qd;
not
to
exceed
90-120
mg/d
▪
Hydralazine:
Oral:
25
mg
tds
▪
Labetalol:
▪
100
mg
bid
▪
should
be
avoided
in
asthma.
▪
Methyldopa
▪
was
the
most
commonly
used
therapies
in
UK.
▪
safe
in
long
term
follow-up
of
the
delivered
babies
▪
some
studies
have
suggested
some
benefits
of
labetalol.
ABOUBAKR
ELNASHAR
▪Atenolol:
increase
in
IUGR.
▪ACE
inhibitors
and
ARBs:
▪contraindicated
▪{unacceptable
fetal
adverse
effects}.
▪Diuretics
▪
relatively
contraindicated
for
hypertension
▪
should
be
reserved
for
pulmonary
oedema.
ABOUBAKR
ELNASHAR

20. IV.
Prevention
of
seizures
▪Indications:
Mg
S
should
be
considered
for
women
with
PET
for
whom
there
is
concern
about
the
risk
of
E.
▪
Severe
PET:
▪
Once
a
delivery
decision
has
been
made
and
in
the
immediate
postpartum
period.
▪
When
conservative
management
of
a
woman
with
severe
hypertension
and
a
premature
fetus
is
made
it
would
be
reasonable
not
to
treat
until
the
decision
to
deliver
has
been
made.
ABOUBAKR
ELNASHAR
▪If
Mg
So
is
given:
1.
It
should
be
continued
for
24
h
following
delivery
or
24
h
after
the
last
seizure,
whichever
is
the
later,
unless
there
is
a
clinical
reason
to
continue.
2.
Regular
assessment
of:
a.
Urine
output,
b.
Maternal
reflexes,
c.
Respiratory
rate
d.
Oxygen
saturation
.
ABOUBAKR
ELNASHAR

21. V.
Control
of
seizures
I.
1.
Do
not
leave
the
patient
alone.
2.
Prevent
maternal
injury
during
the
convulsion.
3.
Call
for
help
and
place
a
code
blue
call-
Medical
Emergency
call.
4.
Initiate
resuscitation.
5.
Turn
the
patient
into
left
lateral
position
when
able
to
do
so.
6.
Inform
consultant
obstetrician&anesthetist
on
call.
ABOUBAKR
ELNASHAR
II.
AIRWAY
1.
Assess
and
maintain
patency,
using
oral
suction
if
necessary.
2.
Insert
a
plastic
oral
airway
if
possible
3.
Administer
oxygen
therapy
via
face
mask.
III.
BREATHING
1.
Assess
respiratory
rate
and
ambubag
using
facial
mask/laryngeal
mask
or
endotracheal
tube
if
necessary.
ABOUBAKR
ELNASHAR

22. IV.
CIRCULATION
1.
Evaluate
Pulse
and
B
P.
If
absent,
initiate
CPR.
2.
Secure
IV
access
as
soon
as
possible
with
main
line
infusion,
with
three-way
tap
attached
Hartmann's
Solution
very
slow
rate,
as
fluid
intake
will
be
restricted
to
1
ml/kg/h
3.
Pulse
oximetry
is
helpful.
ABOUBAKR
ELNASHAR
V.
Mg
SO4
▪Therapy
of
choice
to
control
seizures.
▪Loading
dose:
4
g
infusion
pump
over
5–10
min
▪Maintainance:
1
g/h
for
24
h
after
the
last
seizure.
▪Recurrent
seizures
Further
bolus
of
2
g
Mg
SO4
or
an
increase
in
the
infusion
rate
to
1.5
g
or
2.0
g/h.
ABOUBAKR
ELNASHAR

23. ▪Prepare
loading
dose
Add
4g
(8ml)
of
50%
MgS04
to
12ml
of
NS.
Administer
slowly
IV
over
10
m.
▪
Prepare
Maintenance
dose
▪
Add
50g
(100
ml)
of
50%
MgS04
to
400ml
of
NS
(withdraw
100mls
from
500ml
bag
of
NS,
prior
to
adding
MgS04).
▪
Administer
IV
via
volumetric
pump
at
10ml/h
=1g/hour.
ABOUBAKR
ELNASHAR
VI.
Once
stabilized
▪Plans
should
be
made
to
deliver
the
woman
▪No
particular
hurry
and
a
delay
of
several
hours
to
make
sure
the
correct
care
is
in
hand
is
acceptable,
assuming
that
there
is
no
acute
fetal
concern
such
as
a
fetal
bradycardia.
▪The
woman’s
condition
will
always
take
priority
over
the
fetal
condition.
ABOUBAKR
ELNASHAR

24. VI.
Fluid
balance
1.
Fluid
restriction
is
advisable
{reduce
the
risk
of
fluid
overload
in
the
intrapartum
and
postpartum
periods}
Total
fluids
should
be
limited
to
80
ml/h
or
1
ml/kg/h
{a.
pulmonary
oedema
has
been
a
significant
cause
of
maternal
death.
b.
No
evidence
of
the
benefit
of
fluid
expansion
c.
fluid
restriction
regimen
is
associated
with
good
maternal
outcome.
d.
No
evidence
that
maintenance
of
a
specific
urine
output
is
important
to
prevent
renal
failure,
which
is
rare.}ABOUBAKR
ELNASHAR
2.
The
regime
of
fluid
restriction
should
be
maintained
until
there
is
a
postpartum
diuresis,
as
oliguria
is
common
with
severe
pre-eclampsia.
3.
If
there
is
associated
maternal
hge,
fluid
balance
is
more
difficult
and
fluid
restriction
is
inappropriate.
ABOUBAKR
ELNASHAR

25. VII.
Delivery
▪When:
•once
the
woman
is
stable
and
with
appropriate
senior
personnel
present.
•If
the
fetus
is
<34
w
and
delivery
can
be
deferred:
corticosteroids
should
be
given,
although
after
24
h
the
benefits
of
conservative
management
should
be
reassessed.
•Conservative
management
at
very
early
gestations
may
improve
the
perinatal
outcome
but
must
be
carefully
balanced
with
maternal
wellbeing.
ABOUBAKR
ELNASHAR
▪
Fetal
indications
▪
Severe
intrauterine
growth
restriction
▪
Nonreassuring
fetal
surveillance
▪
Oligohydramnios
▪
Maternal
indications
▪
Gestational
age
of
38
weeks
or
greater*
▪
Platelet
count
below
100
×
10
3
per
mm
3
(100
×
10
9
per
L)
▪
Progressive
deterioration
of
hepatic
function
▪
Progressive
deterioration
of
renal
function
▪
Suspected
placental
abruption
▪
Persistent
severe
headache
or
visual
changes
▪
Persistent
severe
epigastric
pain,
nausea,
or
vomiting
ABOUBAKR
ELNASHAR

26. ▪How?
•Depend
on
1.
presentation
2.
fetal
condition
3.
likelihood
of
success
of
induction
of
labour
•>34
w
with
a
cephalic
presentation:
▪
vaginal
delivery
should
be
considered.
▪
Discuss
the
mode
of
delivery
with
the
mother.
▪
Vaginal
Pg
will
increase
the
chance
of
success.
▪
Anti-hypertensive
treatment
should
be
continued
throughout
assessment
and
labour.
•<32
w:
CS
is
more
likely
as
success
of
induction
is
reduced
ABOUBAKR
ELNASHAR
▪Anaesthesia
▪In
the
absence
of
contraindications,
all
of
the
following
are
acceptable
for
women
undergoing
CS:
▪Epidural
▪Spinal
▪Combined
spinal-epidural,
and
▪General
anaesthesia.
(A)
▪Regional
anaesthesia
for
women
on
LMWH:
▪
12
h
after
a
prophylactic
dose
▪24
h
after
a
therapeutic
dose.
(B)
ABOUBAKR
ELNASHAR

27. ▪The
third
stage:
•5
u
IM
Syntocinon
or
5
u
IV
Syntocinon
given
slowly.
•Ergometrine
or
Syntometrine
should
not
be
given
for
prevention
of
hge
{can
further
increase
the
blood
pressure}.
ABOUBAKR
ELNASHAR
VIII.
Postpartum
management
1.
a.
Women
who
develop
hypertension
or
symptoms
of
PE
postnatally
(headaches,
visual
disturbances,
n
and
v
or
epigastric
pain):
referred
for
a
specialist
opinion
and
investigation
to
exclude
PE.
b.
Women
who
deliver
with
severe
PET
(or
E):
close
observation
postnatally
for
4
days
or
more
c.
Careful
review
to
ensure
improving
clinical
signs
is
needed
before
discharge.
ABOUBAKR
ELNASHAR

28. 2.
Anti-hypertensive
•Continued
as
dictated
by
BP.
•BP
should
not
exceed
160/110
mmHg
•Reduction
in
anti-hypertensive
therapy:
in
stepwise
fashion.
•Avoid
alpha
methyldopa
•In
breastfeeding:
labetalol,
atenolol,
nifedipine
and
enalapril
can
be
given
ABOUBAKR
ELNASHAR
3.
Follow-up
and
final
diagnosis
1.
An
assessment
of
BP
and
proteinuria
at
the
6
w.
If
hypertension
or
proteinuria
persists
then
further
investigation
is
recommended.
2.
Preconceptional
counselling
ABOUBAKR
ELNASHAR

29. ABOUBAKR
ELNASHAR
Thank
you
ABOUBAKR
ELNASHAR

30. 1)fluid
balance
in
moderately
and
severely
oliguric
preeclampsia
and
HELLP
To
prevent
fluid
depletion(prerenal
failure)
And
fluid
overload
(pulm
edema)
2-Eclampsia
26
w
controlled
can
pregenancy
be
continued
or
must
be
terminated
3-vaginal
delivery
in
severe
preeclampsia&
eclampsia
4-DD
between
HELLP
and
AFL
5-
Diagnosis
and
management
of
DIC
and
hemolysis
in
severe
preeclampsia
and
HELLP
6-
Absence
of
protinuria
can
exclude
preeclampsia
ABOUBAKR
ELNASHAR
hepatic
steatosis,
but
the
liver
may
appear
normal
(as
the
fat
is
microvesicul
ar).
CT
may
show
decreased
attenuation
suggestive
of
fatty
infiltration.
ABOUBAKR
ELNASHAR

31. ❑C.P:
may
be
asymptomatic
or
associated
with
massive
haemorrhage
depending
on
the
degree.
❑Diagnosis
↑FDPs
(these
may
be
elevated
post
delivery)
↑Soluble
fibrin
complexes
↓Fibrinogen
(fibrinogen
concentration
is
normally
elevated
in
mid-
and
late
pregnancy
so
a
level
<2
g/L
is
highly
significant)
↓Platelets
Prolongation
of
clotting
times
(thrombin
time,
APTT,
prothrombin
time).
ABOUBAKR
ELNASHAR
❑Management
treatment
of
the
underlying
cause
and
treatment
of
haemorrhage
and
coagulopathy.
1.
Treatment
of
the
cause
This
usually
necessitates
delivery
of
the
fetus
and
emptying
of
the
uterus.
Pregnancy
may
be
prolonged
in
cases
of
mild
DIC
associated
with
PET
at
early
gestational
ages,
but
such
conservative
management
necessitates
very
careful
monitoring.
2.
Treatment
of
massive
bleeding
according
to
predefined
and
agreed
protocols
in
close
collaboration
with
haematology
and
anaesthetic
staff.
.
Adequate
monitoring
with
a
central
venous
pressure
line
and
urinary
catheter
is
essential.
ABOUBAKR
ELNASHAR

32. ▪
Treatment
of
coagulopathy:
▪
FFP,
which
contains
all
the
coagulation
factors
▪
Red
cells
(only
needed
to
replace
losses)
▪
Platelet
concentrates
(may
be
given
to
a
bleeding
patient
if
the
platelet
count
is
<80×10
9
/L)
▪
Cryoprecipitate
or
recombinant
fibrinogen.
Use
may
be
considered
if
there
is
haemorrhage
and
the
fibrinogen
concentration
is
<1
g/L.
▪
Recombinant
factor
VIIa
is
a
powerful
but
expensive
pro-
haemostatic
tool
that
may
be
potentially
useful
in
obste
hge.
▪
The
coagulation
disturbance
usually
resolves
within
24
to
48
hs
after
delivery,
although
thrombocytopenia
may
persist
for
up
to
a
week
postpartum.
ABOUBAKR
ELNASHAR
▪
What
is
the
accurate
method
to
measure
blood
pressure
in
pregnant
woman
?
•·
What
are
measures
to
predict
pre-
eclampsia
?
•·
Has
low
molecular
wt.
heparin
a
role
in
improving
the
outcome
of
pregnancy
in
pre-
cclampsia
?
•·
What
types
of
tocolysis
can
be
taken
in
pre-
eclampsia
?
•·
What
is
the
post
–
operative
protocol
for
pre-
eclamptic
patient
for
-
Fluids
-
Anti
hypertensives
-
Analgesics
-
Antibiotics
ABOUBAKR
ELNASHAR

33. I.
Preconceptional
Risk
Factors
Rates
of
preeclampsia
depend
on:
severity
of
underlying
complications&
combinations
of
risk
factors.
Risk
%
Risk
factors
15-40
Chronic
hypertension/renal
disease
10-35
Pre
gestational
DM
10-20
Connective
tissue
disease
(lupus,
rheumatoid
arthritis)
10-40
Thrombophilia
(acquired
or
congenital)
10-15
Obesity/insulin
resistance
10-20
Age
older
than
40
y
10-35
Limited
sperm
exposure
10-15
Family
history
of
preeclampsia/
cardiovascular
disease
1.5
fold
Woman
born
as
SFGA
2-3
fold
Adverse
outcome
in
a
previous
pregnancy:
IUGR,
ab
placentae,IUFD
ABOUBAKR
ELNASHAR
II.
Pregnancy-Related
Factors
Regular
antenatal
care
is
mandatory
for
the
prevention&
early
detection
of
PE.
▪Risk
factors:
Magnitude
of
risk
depends
on
the
number
of
factors
✓Hydrops/hydropic
degeneration
of
the
placenta
✓Multifetal
gestation
✓Unexplained
FGR
✓Gestational
hypertension
✓UTI
✓Periodontal
infection
▪Markers
✓Biophysical
✓Biochemical
ABOUBAKR
ELNASHAR

34. I.
Biophysical
•Mean
arterial
pressure
•(2D
BP+S
BP)/3
•Better
predictor
of
PE
than
S&
D
BP
(BMJ
200817;336:111;
Meta-analysis
of
34
RCT)
2
nd
trimester
MA
BP
≥
90
mm
Hg
had
+ve
LR
3.5
and
–ve
LR
0.46
•BP
remains
the
cornerstone
of
early
diagnosis
although
it
has
limitations:
measurement
errors
associated
with
sphygmomanometer
effect
of
maternal
posture
on
BP
in
pregnant
women}.
ABOUBAKR
ELNASHAR
•Repeated
routine
urinalysis
throughout
pregnancy
NOT
useful
for
predicting
PE
(JAMA
2003:
12;289(10):1220)
ABOUBAKR
ELNASHAR

35. Uterine
artery
Doppler
ultrasound
•}impaired
trophoblastic
invasion
of
the
spiral
arteries:
reduction
in
uteroplacental
blood
flow}
•High
pulsatility
index
and/or
Notch
in
1
st
&
2
nd
trimesters:
poor
predictor
of
PE
(Papgeorghiou
&
Leslie,
2007)
Uterine
artery
Doppler
plus
biochemical
markers
•Promising
results
•Current
data
do
not
support
this
combination
for
routine
screening
for
PE
(Barton&
Sibai,
2008).
ABOUBAKR
ELNASHAR
•
Diastolic
Notch
in
uterine
artery
waveform
ABOUBAKR
ELNASHAR

36. The
Roll
over
test
Not
of
value
in
predicting
PE
(Mahomed
&Lasiende,1990)
ABOUBAKR
ELNASHAR
II.
Biochemical
Markers
Angiogenic
factors
before
&
after
the
onset
of
PE
(Barton&
Sibai,
2008).
Serum
placental
growth
factor:
reduced
Soluble
fms-like
tyrosine
kinase:
elevated
Endoglin:
elevated
ABOUBAKR
ELNASHAR

37. •Currently:
There
is
no
clinically
useful
screening
test
to
predict
PE
(WHO,
2004)
ABOUBAKR
ELNASHAR
Regular
antenatal
care
is
mandatory
for
the
prevention&
early
detection
of
PE.
For
prevention
of
PE
Bed
rest
Reduction
of
job
stress
High
dietary
fiber
intake
Low
dose
aspirin
Low
dose
aspirin/heparin
Ca
supplementation
ABOUBAKR
ELNASHAR