Pre-eclampsia Matthew Beaumont

Pre- eclampsia Hypertensive disorder of pregnancy Placental origin Only cure = delivery Eclampsia (G.sudden occurrence): epileptiform seizures

Diagnosis Proteinuria >0.3g/24h AND HTN >140/90mmHG (after 20w) PREeclampsia P= proteinuria R= rising blood pressure E= oedema

Severity Course: Spectrum: Grades: progressive but variable + unpredictable Spectrum: life threatening at 24w to mild HTN at term Grades: Mild Moderate Severe

Pathophysiology Stage 1: Development of disease <20w Asymptomatic Incomplete invasion of the trophoblast (into spiral arterioles) Atheromatous lesions Decreased uteroplacental blood flow

Pathophysiology 2 Stage 2: Manifestation of disease Ischaemic placenta → exaggerated immune response → widespread endothelial cell damage Vasoconstriction Increased vascular permeability Clotting dysfunction

Manifestation of disease Increased vascular resistance= Hypertension Increased vascular permeability= proteinuria Reduced placental blood flow= IUGR Reduced cerebral perfusion= eclampsia

Epidemiology: 5% pregnancies Predisposing factors: Mnemonic: Nulliparity New Previous history pre-eclamptics Obesity often Family history forget Older maternal age old Diabetes diabetics Autoimmune disease (anti-phospholipid) always Hypertension Pre-existing (x6) have Big gap between pregnancies big Twins (Large placentas) twins High risk: Low dose aspirin (75mg) from w12

Clinical features Asymptomatic (until late) Headache Drowsiness Visual disturbance Nausea+ Vomiting Epigastric pain Oedema (massive/sudden onset) –feet/ankles/face and hands Learning aid: Pre-eclampsia dance- work top to bottom

Complications Fetal IUGR Stillbirth Pre-term birth Placental abruption Maternal Eclampsia (grand mal seizure)- 0.05% UK Cerebrovascular haemorrhage HELLP syndrome Renal failure Pulmonary oedema Fetal IUGR Stillbirth Pre-term birth Placental abruption Hypoxia

HELLP syndrome H (haemolysis) – Dark urine, raised LDH, anaemia EL (elevated liver enzymes)- Epigastric pain, liver failure, abnormal clotting LP (low platelets)

Investigations Diagnosis: Bloods: Fetal: Screening: Bedside dipstick urinalysis (1+/2+ quantify) 24hurine collection: 0.3g/24h. Protein:creatinine ratio: 30mg/nmol Bloods: Hb, LFTs, platelets, lactate, U+E Fetal: USS (growth) CTG Umbilical artery doppler (if abnormal CTG) Screening: regular BP + urinalysis checks

Management Admit: HTN + Proteinuria, symptoms Drugs: Nifedipine p.o. + Labetalol i.v. Magnesium sulphate i.v.- prevent eclampsia (toxicity) Steroids- fetal lung maturity

Delivery Only cured by delivery Weigh risk disease complications Vs benefits of increasing fetal maturity Complications/severe= indication for delivery (whatever the gestation) Complications commonly occur after delivery (24h postpartum)