Pre eclampsia -Health awareness

Pre eclampsia

Preeclampsia is known to be one of the most common of the dangerous pregnancy complications where both fetus and mother can be severely affected. It is defined as pregnancy induced hypertension (systolic blood pressure > 140mmHg or diastolic blood pressure > 90 mmHg) associated with significant proteinuria (> 0.3g in a 24 hour urine collection).

The term preeclampsia is refers to a set of symptoms rather than any causative factors. The etiologic agent that is responsible for the development of preeclampsia still remains unknown. Pathophysiology changes in preeclampsia are attributable to intense vasoconstriction that is thought to be due to increased vascular reactivity. It appears that there is a substance or substances that have been release from the placenta which may esult to the endothelial dysfunction in the maternal blood vessels of the affected women. The most visible sign of the disease is the elevation of the blood pressure or ‘hypertensive crisis’. However, it is very important to remember that it also involves generalized damage to the maternal endothelium of kidneys and liver, with the release of vasopressive factors only secondary to the original damage. Hematology abnormality in preeclampsia is low platelet or thrombocytopenia. However, the exact mechanism for thrombocytopenia is still unknown. Vasoconstriction that occurs in pre eclampsia patients will lead to decreased renal perfusion. There will be subsequent reduction in the glomerular filtration rate (GFR) hence will cause the deteriorating of the renal function. As for hepatic damage, it ranges from mildly elevated liver enzyme levels to subcapsular liver hematoma and hepatic rupture. This is one of the severe consequences of HELLP syndrome. It might be as severe as eclamptic convulsion, which perhaps the most disturbing Central Nervous System (CNS) manifestations of pre eclampsia.

Preeclampsia is prevalent for those aged less than 18 years old and above 35 years old. In this case, Puan Julian is 33 years and there is tendency she will have this kind of complications. It may develop after 20 weeks gestation. However, it rarely occurred before the third trimester. If it happens before 32 weeks gestation, it is considered as early onset which highly associated with more severe morbidity. The progress of each case may differ and give rise to various complications. Naturally, most cases are diagnosed pre-term. However, it can also occur up to 6 weeks post partum. The core treatment is delivery of the baby and the placenta either by induction of labor, spontaneous vaginal delivery or even by caesarean section.

There are various symptoms of preeclampsia. Some common symptoms are nausea, vomiting and persistent severe headache that might mislead us and think of migraine or other cause of headache. The patient might complain of right upper quadrant or epigastric pain which some doctors might misdiagnose with acute astritis. Some patients might present with blurry of vision and scotomata. The alarming symptom will be decreased fetal movement that means the fetus already affected. The patients will be advised to come to hospital immediately if experience leaking liquor, rupture of membranes, vaginal bleeding or regular uterine contractions.

In patient having preeclampsia, the risk to the fetus is largely related to gestational age at delivery. The aim of management is to avoid cerebro vascular accident to the mother and to prolong the pregnancy enough to deliver a live baby that is sufficient to continue his/her life outside the womb. Experienced clinicians should be involved in managing pregnant lady that has been diagnosed with preeclampsia in view of various complications that they might encounter. It is known that pre eclampsia is associated with various complications and might cause death to both mother and fetus. Renal failure is not uncommon especially in those people with severe proteinuria and deteriorating renal failure. There is also possibility to develop disseminated intravascular coagulation where the patient might bleed. Other complications are intracranial hemorrhage, retinal detachment, pulmonary edema, liver rupture and abruptio placenta.

In mild preeclampsia, a home management with proper bed rest may be attempted. This will only be offered to selected patients that are reliable, compliance to medication and medical advices have stable home environment and have the ability to self monitoring the blood pressure. It is very important for the patients to have assistance at home, transportation and rapid access to the hospital should the associated symptoms present. As addition, a competent nurse from the health clinic may be provided to do frequent (even daily) home visits and proper assessment. Hospital management is a must in patients with moderate to severe preeclampsia and those with unreliable home situations.

Severe preeclampsia must be swiftly identified. This is important so the patient may urgently been referred to appropriate centre with specialist and facilities so close observation and timing for delivery can be done.As for the management of severe preeclampsia, the patient needs to be admitted to labor and delivery area immediately after been diagnosed with preeclampsia. Laboratory assessment should include hematocrit, platelet count, serum creatinine, aspartate aminoransferase, uric acid, urine protein and 24 hour urine collection for analysis. Maternal and fetal should be evaluated and monitored closely. Should the patient present with hypertensive crisis or symptoms of impending eclampsia with present of proteinuria, magnesium sulfate should be given within 24 hours. Antihypertensive agents will be given to mother if systolic >180 mmHg and diastolic > 110, or MAP >130 mmHg.

At this delivery area, we will assess both mother and fetus. If there is evidence of maternal distress, non reassuring of fetal status and the pregnancy is more than 34 weeks gestation, magnesium sulfate and steroid will be given to mother and proceed with the delivery of the fetus. The same thing will be done if the mother is in labor or presented with rupture of membranes or even if there is evidence of severe intrauterine growth retardation.

If the pregnancy is within 23 to 32 weeks gestation, steroids (dexamethasone) will given to the mother for the sake of the fetus should early delivery is decided later. Antihypertensive agent will be given to mother if needed depending on the blood pressure control. A daily evaluation of maternal and fetal conditions is mandatory and we aim for the delivery at 34 weeks or at term. We will keep the fetus as long as possible in utero till we are almost sure that the fetus may survive or might do better if outside the womb unless mother’s condition is compromise. If the fetus is nonviable, the termination of pregnancy will be decided for the sake of the mother. The decision of termination of pregnancy should be done by agreement of multidisciplinary team. The team should at least include the patient herself, her obstetrician, the specialist who is expert about the disease in question, the expert person in genetic counseling and also neonatalogist .

Pre eclampsia is very dangerous. This is one of the reasons why early and frequent atenatal check-up is mandatory for all pregnant mothers to screen them for the possible complications of pregnancy. Early intervention will lead for better outcome.

References:

Coppage, K.H. and Sibai, B.M. Hypertension Emergencies. In Foley, M.R.., Strong T.H.J and Garite, T.J. editors. Obstetric Intensive Care Manual 2^nd edition. Mc Graw-Hill Medical Publishing; 2004.p. 5 1-65
Clinical Practice Guidelines Management of Hypertension. 3^rd edition. Ministry of Health Malaysia, Academy of Medicine of Malaysia and Malaysian Society of Hypertension; 2008.
Wagner Lana K. Diagnosis and Management of Preeclampsia. American Family Physician, 2004; 70 (12):2317-2324
Gibson, P. and Carson, M.P. Hypertension and Pregnancy [Internet]. 2007. [cited 10 January 2009]. Available from: http: emedicine.medscape.com/article/261435-overview.
McPhee, S.J., Papakadis.M.A. and Tierney, L.M. Current Medical Diagnosis & Treatment. Forty Sixth edition. McGraw-Hill Companies Inc; 2007
James Denise. Therapeutic Abortion [Internet].2006. [cited 16 January 2009] Available from: http://emedicine.medscape.com/article/266440-overview .