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Pre Eclampsia . S Rajendran . Pre eclampsia (PET). Disorder of the epithelium Peculiar to pregnancy - arising from the failure of maternal adaptation to pregnancy Multisystemic Manifested by Hypertension Renal impairment - accompanied by proteinuria Fluid retention

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Pre Eclampsia

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Pre eclampsia l.jpg

Pre Eclampsia

S Rajendran


Pre eclampsia pet l.jpg

Pre eclampsia (PET)

  • Disorder of the epithelium

  • Peculiar to pregnancy - arising from the failure of maternal adaptation to pregnancy

  • Multisystemic

  • Manifested by

    • Hypertension

    • Renal impairment - accompanied by proteinuria

    • Fluid retention

    • Intravascular coagulation


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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


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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


  • Pathogenesis l.jpg

    Pathogenesis

    • Theories:

    • Various

      • Reduction in placental blood flow

      • Either due to abnormal placentation

      • Maternal microvascular disease

      • Release of circulating factors target maternal vascular endothelial cells


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    Pathogenesis - cont

    • Early pregnancy

      • Failure of communication between mother - fetal systems

      • Failure of physiological adaptation

      • Therefore - failed trophoblastic invasion of maternal spiral arterioles

      • Thomboxane (vasosonstrictors) increase rel to PGI2 and NO (Vasodilators)

      • Failure of plasma volume expansion

      • Development of high pressure system


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    Pathogenesis - cont

    • Placenta perfused under high pressure

    • Endothelial damage

    • Microthrombi formation

    • Placetal size reduced

    • IUGR


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    Pathogenesis - clinical syndrome

    • 1. CVS/ Pulm

      • High CO state

      • High PVR

      • LVF

      • Pulmonary odema - ‘leaky endothelium’

      • ARDS


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    Pathogenesis - clinical syndrome

    • 2. Kidneys

      • Glomerular endothelial cells swell

      • Block capillaries

      • ‘leaking’ - proteinuria (>300mg/24hrs)

      • Impaired renal function tests


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    Pathogenesis - clinical syndrome

    • 3. Liver

      • Fibrin deposits - hepatocellular damage

      • Distension, odema - epigastric pain

      • Subcapsular haemorrhage

      • DIC - abnormal LFTs

      • HEELP


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    Pathogenesis - clinical syndrome

    • 4. CNS

    • Vasoconstriction as a protective response - headaches. Visual disturbance

    • Hyperreflexia

    • Small vessel damage - infarcts, haemorrhages - Eclampsia , CVA


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    Diagnosis

    • Hypertension > 160/90 on two occasions

    • Proteinuria > 300 mg/24

    • Altered renal function tests

      • Raised UA

      • Raised serum Cr

    • Altered LFTs

      • Raised AST/ALT

      • Derranged clotting factors

    • Coagulation

      • Platelet consumption - DIC


    Management l.jpg

    Management

    • 1. Treat blood pressure

      • To prevent CVA

      • To allow fetal maturity

    • 2. monitor maternal well being

      • BP, 24 urine protein

      • Biochemistry

      • Symptoms

    • 3. monitor fetal wellbeing

      • USS for growth

      • Doppler

      • CTG

      • Steroids (if preterm delivery envisaged)


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    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


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    Treatment

    • 1. Antihypertensives

      • Long term - methyl dopa safest

      • But - slow acting . Poor antihypertensive

      • Other SE

      • 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


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    Eclampsia

    • Fitting !!

      • Grand mal

      • Self limiting

      • BP can be normal

      • Any woman in pregnancy who fits should have eclampsia management until proven otherwise

      • Management:

        • Treat fit - Mg SO4

        • Prevent further fitting - Mg SO4

        • Stabilise mother & BP

        • Deliver


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