1. Pre Eclampsia S Rajendran

2. Pre eclampsia (PET)  Disorder of the epithelium  Peculiar to pregnancy - arising from the failure of maternal adaptation to pregnancy  Multisystemic  Manifested by HypertensionHypertension Renal impairment - accompanied by proteinuriaRenal impairment - accompanied by proteinuria Fluid retentionFluid retention Intravascular coagulationIntravascular coagulation

3. Pre eclampsia  Impact:  2 % pregnancies  Significant maternal morbidity & mortality (40 000 deaths worldwide, 14 in UK (2004 CEMD)  Significant neonatal morbidity & mortality  20% of SCBU/NNU occupancy  15% of iatrogenic preterm deliveries  Long term : development of hypertension, Diabetes, IHD

4. Risk Factors  1. Socio demographic  Age>40  SE status  Ethnic groups  2. Genetic  Mother/ sister with PET  3. Pregnancy factors  Multiple pregnancy  Primipara  Previous early onset severe PET  4. PMH  Obesity  Chronic renal disease  Chronic hypertension  Diabetes  Thrombophilia  SLE

5. Pathogenesis  Theories:  Various Reduction in placental blood flowReduction in placental blood flow Either due to abnormal placentationEither due to abnormal placentation Maternal microvascular diseaseMaternal microvascular disease Release of circulating factors target maternal vascular endothelial cellsRelease of circulating factors target maternal vascular endothelial cells

6. Pathogenesis - cont  Early pregnancy Failure of communication between mother - fetal systemsFailure of communication between mother - fetal systems Failure of physiological adaptationFailure of physiological adaptation Therefore - failed trophoblastic invasion of maternal spiral arteriolesTherefore - failed trophoblastic invasion of maternal spiral arterioles Thomboxane (vasosonstrictors) increase rel to PGI2 and NO (Vasodilators)Thomboxane (vasosonstrictors) increase rel to PGI2 and NO (Vasodilators) Failure of plasma volume expansionFailure of plasma volume expansion Development of high pressure systemDevelopment of high pressure system

7. Pathogenesis - cont  Placenta perfused under high pressure  Endothelial damage  Microthrombi formation  Placetal size reduced  IUGR

8. Pathogenesis - clinical syndrome  1. CVS/ Pulm High CO stateHigh CO state High PVRHigh PVR LVFLVF Pulmonary odema - ‘leaky endothelium’Pulmonary odema - ‘leaky endothelium’ ARDSARDS

9. Pathogenesis - clinical syndrome  2. Kidneys Glomerular endothelial cells swellGlomerular endothelial cells swell Block capillariesBlock capillaries ‘leaking’ - proteinuria (>300mg/24hrs)‘leaking’ - proteinuria (>300mg/24hrs) Impaired renal function testsImpaired renal function tests

10. Pathogenesis - clinical syndrome  3. Liver Fibrin deposits - hepatocellular damageFibrin deposits - hepatocellular damage Distension, odema - epigastric painDistension, odema - epigastric pain Subcapsular haemorrhageSubcapsular haemorrhage DIC - abnormal LFTsDIC - abnormal LFTs HEELPHEELP

11. Pathogenesis - clinical syndrome  4. CNS  Vasoconstriction as a protective response - headaches. Visual disturbance  Hyperreflexia  Small vessel damage - infarcts, haemorrhages - Eclampsia, CVA

12. Diagnosis  Hypertension > 160/90 on two occasions  Proteinuria > 300 mg/24  Altered renal function tests Raised UARaised UA Raised serum CrRaised serum Cr  Altered LFTs Raised AST/ALTRaised AST/ALT Derranged clotting factorsDerranged clotting factors  Coagulation Platelet consumption - DICPlatelet consumption - DIC

13. Management  1. Treat blood pressure To prevent CVATo prevent CVA To allow fetal maturityTo allow fetal maturity  2. monitor maternal well being BP, 24 urine proteinBP, 24 urine protein BiochemistryBiochemistry SymptomsSymptoms  3. monitor fetal wellbeing USS for growthUSS for growth DopplerDoppler CTGCTG Steroids (if preterm delivery envisaged)Steroids (if preterm delivery envisaged)

14. Management  Delivery is the only cure!!  So management relies on delivery as soon as practically possible in the most suitable way possible  Balance between maternal and fetal risks

15. Treatment  1. Antihypertensives Long term - methyl dopa safestLong term - methyl dopa safest But - slow acting. Poor antihypertensiveBut - slow acting. Poor antihypertensive Other SEOther SE Labetalol - good effective in acute management of severe hypertension (IV and Oral )Labetalol - good effective in acute management of severe hypertension (IV and Oral ) But placental hypoperfusion Nifedipine - good in acute management But - placental hypoperfusion Hydralazine - IV only useful in acute management

16. Eclampsia  Fitting !! Grand malGrand mal Self limitingSelf limiting BP can be normalBP can be normal Any woman in pregnancy who fits should have eclampsia management until proven otherwiseAny woman in pregnancy who fits should have eclampsia management until proven otherwise Management:Management:  Treat fit - Mg SO4  Prevent further fitting - Mg SO4  Stabilise mother & BP  Deliver