?The definitive treatment of pre eclampsia is delivery to prevent development of maternal or fetal complications from disease progression.
?Mild pre-eclampsia ? At term, women are induced if there are no contraindications to vaginal birth. This minimizes the risk of progression to severe disease and its complications -- There is no reason to delay induction of women who are at least 37 weeks of gestation and have a favorable cervix (Bishop score greater than 6).
?Hospital Admission -- Close maternal monitoring upon diagnosis is important for disease severity and the rate of progression. Hospitalization is useful for making these assessments & facilitates rapid intervention in the event of fulminant progression to eclampsia, hypertensive crisis, abruptio placenta, or HELLP syndrome.
?Lab Follow up -- platelet count, serum creatinine, serum ALT and AST should be repeated once or twice weekly.
?Assessment of fetal well-being & fetal growth ? Ultrasound Doppler and Biophysical profile.
?Antenatal corticosteroids -- to promote fetal lung maturity should be administered to women less than 34 weeks of gestation.
Expectant Management of Pre Eclampsia:
In women with severe preeclampsia remote from term, the decision to continue pregnancy beyond that interval required for the administration of corticosteroids depends upon daily maternal and fetal assessment with continual review of the ongoing risks of conservative management versus the benefit of further fetal maturation. Such women should be cared for in a hospitalized setting and by, or in consultation with, a maternal-fetal medicine specialist.
?Hospitalize until delivery.
?Keep the patient at bed rest, except for bathroom privileges.
?Monitor blood pressure every 2 to 4 hours while awake.
?Assess maternal symptoms every 2 to 4 hours while awake.
?Strict recording of fluid intake and urine output.
?Complete blood count, electrolytes, and liver and renal function tests twice weekly.
?Antenatal corticosteroids if not previously given.
?Regular assessment of fetal wellbeing.
?Elective delivery after 34 weeks.
Management of Pre Eclampsia:
?Sodium restriction and diuretics have no role in routine therapy.
?L-arginine supplementation lowered blood pressure or improved kidney function in pre eclamptic women. Effect of L-arginine therapy on the glomerular injury of preeclampsia:
?Anti Hypertensive Treatment -- initiating antihypertensive therapy in pre-eclamptic/eclamptic women when the systolic blood pressure is >150 mm Hg & diastolic >100 mm Hg.
?Acute Therapy:
?Labetalol ? Intermittent or continuous infusion fall in blood pressure begins within 5 to 10 minutes and lasts from 3 to 6 hours.
?Hydralazine -- The fall in blood pressure begins within 10 to 30 minutes and lasts from 2 to 4 hours.
?Diazoxide ? used when BP control is not archived with Labetalol & Hydralazine
Drugs contraindicated in pregnancy:
?Sodium Nitroprusside
?ACE Inhibitors
?ARB's
Target blood pressures:
?Systolic b/w 130 to 150 mmHg
?Diastolic b/w 80 to 100 mm Hg
Breastfeeding mothers:
Beta-adrenergic blockers & calcium channel blockers enter breast milk; but considered "compatible" with breastfeeding by the American Academy of Pediatrics.
ACEi & ARB's are generally avoided during lactation in the neonatal period. Diuretics reduces milk volume.
Effects of BP Control on Fetus:
A 10 mmHg fall in mean arterial pressure was associated with a 176 g decrease in birth weight. This effect was unrelated to the type of hypertension or choice of medication.
Most experts agree that severe hypertension should be treated to prevent maternal vascular complications. However, there is no consensus as to the optimal blood pressure threshold for initiating therapy. We initiate antihypertensive therapy in adult women at systolic pressures between 150 and 160 mm Hg and diastolic blood pressures between 100 and 105 mm Hg.
?Uterine artery doppler is used in the prediction of IUGR.
?Pathological features include:
?elevation of uterine artery indices/ no fall in Resistance Index in mid trimester.
?persistence of early diastolic notch.
?Detection rates are better for severe than for mild disease.
?Detection rates 80-90 % for early onset pre-eclampsia while 41-45% for pre-eclampsia at any gestational age.
Umblical Artery Doppler:
?Umbilical arterial doppler waveforms reflect vascular resistance therefore provides information on downstream distribution of blood supply.
?Changes in blood flow resistance relate to vascular structure (placental histology) & vascular tone.
?Abnormal vascular tone as well as obliteration of fetal villous vessels raises umbilical artery Doppler resistance.
Ultrasound Obstet Gynecol 2004
Obstet- Gynecol Surv 2004
Middle Cerebral Artery Doppler:
Elevated placental blood flow resistance and impaired trans placental gas
Transfer
Increased venous shunting across ductus venosus
Increase proportion of umbilicus venous blood that bypasses the liver & reaches
left side of the heart through foramen ovale
Increased elevation of right ventricular afterload (placental resistance) forces
Redistribution of cardiac output towards the left ventricle and the LVO
Increase blood supply to brain Increase blood supply to heart
Tests for fetal well being:
?These include
?CTG
?Biophysical profile
?Reduced variability or decelerations is associated with increased peri natal morbidity and mortality
?Chronic fetal compromise is associated with decreased fetal body and breathing movements on BPP
Complications of IUGR:
?Congenital anomalies
?Hypoglycemia
?Hypothermia
?Respiratory distress
?Mental retardation
?Meconium aspiration
?Polycythemia
?Jaundice
Symptoms Of Pre Eclampsia
A major study has suggested that taking aspirin during pregnancy could reduce the risk of the potentially dangerous condition pre-eclampsia. The study by the University of Sydney analysed University of Sydney suggested cases of pre-eclampsia, which is caused by a defect in the placenta, could fall by 10% if aspirin was taken widely.
However, experts have urged caution as there are a number of small-risks linked to long-term aspirin usage.
Pre-eclampsia affects approximately 7% of pregnancies and can trigger high blood pressure and kidney problems. If uncontrolled it can increase the chances of both mother and baby dying. Up to 35% of premature births in the UK are connected to the condition, although the precise reason it develops is still unknown.
Pre-eclampsia is known to cause excessive blood clotting in the placenta, which supplies nutrients and oxygen to the foetus, and various experts have suggested that aspirin, which inhibits clotting, could counter this. Recent research has found that taking "low-dose aspirin" during pregnancy reduced the risk not only of pre-eclampsia, but also premature birth, and of "poor pregnancy outcome" in general.
However, concerns about using aspirin during pregnancy have been raised as there is an increased chance of bleeding, which is potentially a serious issue within pregnancy and birth. Despite this, the study found no evidence that taking aspirin long term might be linked to bleeding problems at any stage, although the researchers said that their evidence was not strong enough to rule this out entirely.
In conclusion they said the potential benefits of taking the drug might outweigh the risks, particularly in women at higher risk of pre-eclampsia, such as overweight or older mothers, or those with a previous or family history of the condition. They wrote: "From a public-health perspective, especially for populations with a high risk of pre-eclampsia, even these moderate benefits could make more widespread use of anti-platelet agents (aspirin) worthwhile."
Mike Rich, chief executive of charity Action on Pre-Eclampsia, said the study would help spread the message about the potential benefits of aspirin to a wider audience of doctors, but that "under no circumstances should pregnant women self-medicate with aspirin. While this study suggests that aspirin can have benefits to women at high risk, the decision to use aspirin should only be made in consultation with your doctor."
A spokesman for the Royal College of Obstetricians and Gynaecologists added: "It is a moderate reduction of around 10% but given that pre-eclampsia is potentially serious for some women and their babies, this is an important finding. No single sub-group of women seems to benefit particularly from low-dose aspirin. The decision on whether to take it in pregnancy should be made following discussion between the woman and her obstetrician, taking into account her individual risk of developing the condition."
Both Dr. D.s. Merchant & Chris Marshall are contributors for EditorialToday. The above articles have been edited for relevancy and timeliness. All write-ups, reviews, tips and guides published by EditorialToday.com and its partners or affiliates are for informational purposes only. They should not be used for any legal or any other type of advice. We do not endorse any author, contributor, writer or article posted by our team.
Dr. D.s. Merchant has sinced written about articles on various topics from The Internet, Health Care and Health. Dr. Syed Mujtaba H. Bilgrami, Resident Family Medicine (AKUH). He has written on a range of related issues as pregnancy planning, and. Dr. D.s. Merchant's top article generates over 9900 views. to your Favourites.
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