see: [RWH magnesium guideline](x-devonthink-item://A2E7E80E-CFC3-4D3F-8C02-E56A0577CC8D), [RWH - pre-eclampsia](x-devonthink-item://D7606638-4FAE-44B2-B66B-0D0E8A7C2B8F), [Dunn - hypertension in pregnancy](x-devonthink-item://A278C0F8-AFA9-44CE-8A9E-D4846BF0712F) [Cameron - pre-eclampsia](x-devonthink-item://C3FDFB82-B660-493F-B69C-F15712F57FF2?page=14) > *Gestational hypertension* during pregnancy and resolves within 6 weeks post-partum > *pre-eclampsia* is HTN with organ-system dysfunction **>20 weeks gestation** > *eclampsia* is a seizure complicating pre-eclampsia and leads to high maternal and foetal morbidity and mortality **Diagnosis of pre-eclampsia:** - SBP >140 and/or DSB >90 on 2 occasions over several hours, proteinuria (protein:Cr >30mg/mmol) - traditional definition was HTN > 20 weeks gestation + protenuria - The Society of Obstetric Medicine of Australia and New Zealand (SOMANZ) has broadened this definition. While SOMANZ recognizes the traditional definition as essential for research purposes, it proposes the clinical definition extends beyond proteinuria to emphasize that ==pre-eclampsia is a multiorgan disease==. - Hence, pre-eclampsia is recognized when hypertension is associated with evidence of dysfunction of maternal end-organs and/or the fetus. This definition of pre-eclampsia is not universally accepted, but neither is there worldwide consensus on the classification of hypertensive disorders of pregnancy. None of the classification systems have been proven to be more reliable in identifying pre-eclampsia than another. # normal physiology - The blood pressure (BP) in a normal pregnancy falls in the first trimester, reaching a lowest in the second, and returns to the normal range by the third trimester. - HTN is BP >140/90 # pathophysiology - unclear exactly what causes pre-eclampsia - dysfunction of uteroplacental bed causing - systemic vasospasm - ischaemia - thrombosis - endothelial dysufnction - may result in: - maternal organ damage - placental insufficiency - fetal compromise - causes unclear: - ?high resistance vessels that jepordise blood supply to placenta - ?endothelial dysfunction → high systemic vascular resistance→ hypoperfusion of organs - ?immunologia cause - Placental blood flow is approximately 50% normal by the time symptoms occur. > **Risk factors:** > - age >40 > - BMP >30 > - Gestational HTN > - prior history or FMx of pre-eclampsia > - antiphosophlipid syndrome > - diabetes # Clinical features **neurological** - related to cerebral oedema - [[Headache]] - visual disturbance -- photopsia, scotomata, PRES, retinal vasospasm - [[Seizures]] -- eclampsia - hyper-reflexia with sustained clonus (>3 beats) - ankle/foot usually - rapidly flex the foot into dorsiflexion to induce a stretch to the gastrocnemius-- subsequent beating of the foot will result; >3 beats abnormal - vomiting **cardiovascular** - LV diastolic dysfunction - risk of APO - oedema, especially feet, hands, face (nb this is also present in normal pregnancy) **GI** - severe epigastric or RUQ pain - ↑ LFTs (HELLP) **Renal** - ==proteinuria== - significant is ration >30 mg/mol protein/Cr - oliguria <500mL/day - Cr > 90 **Haematological** - *haemolysis* -- schistocytes, elevated bili, LDH >600, lw haptoglobin - [[thrombocytopaenia]] -- <100,000 -- look for [[DIC]] > weight gain >2kg/week suggests pre-eclampsia ## HELLP *marker of severe pre-eclampsia* full syndrome is uncommon; 2/3 are adequate for the diagnosis > - hemolysis > - transaminitis >2x normal > - low platelets <100,000 - more common in multiparous women # Assessing severity of pre-eclampsia - SBP >160, DBP >110 - cerebral or visual symptoms persistent - acute left heart failure - persistent RUQ or epigastric pain without alternative diagnosis - HELLP syndrome - foetal growth restriction ## severe pre-eclampsia Defined as ==systolic blood pressure > 170== and/or diastolic blood pressure of 110mmHg or higher measured on at least two occasions over several hours, combined with ==proteinuria== >300 mg total protein in a 24-h urine collection, or ratio of protein to creatinine >30 mg/mmol. All usually accompanied by ==other haematological, neurological, hepatic, or renal derangement== # treat pre-eclampsia See also [[#Management|Eclampsia management]] below - A target **blood pressure** should be determined and documented. The target should be tailored to the woman’s controlled blood pressure (systolic 140-160, diastolic 90-100). Care should be taken to avoid lowering the blood pressure too much as this will negatively affect placental perfusion with subsequent fetal compromise. - ==BP ≥170/110 mmHg requires prompt treatment== - IV [[labetalol]] drug of choice - **Prophylaxis** with [[Magnesium]] sulphate should be implemented where there are ==premonitory signs of eclampsia== : - (increased *reflexes* associated with *clonus* and/or *severe headache*, visual changes) or following diagnosis of *severe pre-eclampsia* (diastolic B/P >110 mmHg, proteinuria >300mg/24 hours, abnormal AST, and ALT and LDH), thrombocytopenia <100x109/L). - IV fluid balance - avoid too much fluid - 84 mL/ hour unless shocked - if oliguria, consider 250mL hartman’s stat - Pain management - Refer for delivery - Consider betamethasone 11.4mg IM Q24 h x2 to prevent resp distress syndrome if <34 weeks - [[CTG monitoring]] # Eclampsia - self-limiting seizures - can occur any time after 20 weeks gestation until ==6 weeks post partum==, but usually within first 24 hours - not always associated with HTN, but more likely in severe pre-eclampsia with BP > 170/110 - magnitude of BP not a reliable way of predicting eclampsia # Management > [!treatment] > **Seizures** > - stop the seizure with [[midazolam]] or other benzo (clonazepam 2mg Q5 min) > - *prevent further seizure* -- treat with [[Magnesium|MgSO4]] loading dose 4g IV in 100mL NaCl over 15 min, then infusion 2g/h . target 2-3.5mmol/L ; check QID > > **Blood pressure** > - [[labetalol]] > - 200mg can be given orally and another dose 20 minutes later if no response > - IV 20mg slow IV push over 2 minutes ; can given another bolus 10 minutes later > - If 2 IV boluses insufficient, commence infusion starting at 20mg/hour and titrate by 5mg range 20-160mg/h > - max dose IV for 24 hours is 300mg > - Give woman 300mL NaCl fluid pre-load (even in women who are fluid-restricted) > - [[hydralazine]] > - 5-10mg IV over 5-10 minutes > - infusion 5 mg/hour > - nifedipine > - 5-10mg po Q30 min > - do NOT combine with MGSO4; can cause precipitous hypotension > > **Fluid balance** > > **expedite birth if:** > - eclampsia > - HELLP > - BP uncontrolled on 3x anti-hypertensives and still 170/110 > - abnormal renal function > - concerns of foetal well-being notes: - Mechanism of action of magnesium not well understood - labetalol lower adverse effects - better than [[hydralazine]] in many patients - *hydralazine prefered* in women with asthma or congestive heart failure ![[Pasted image 20231120004458.png]] # Related Questions ## eclampsia - [ ] 1Q: [Post Partum Seizure](x-devonthink-item://4134DDB3-6E12-474A-9F6F-64135C0C6048?page=36) -- [Answer](x-devonthink-item://AC92B5F1-8EE6-461A-B03E-F70AE7DC1275?page=36) - [ ] 2Q: [Eclampsia](x-devonthink-item://2CB6E202-E7C1-46E8-B49F-435AB6C937F0?page=14) -- [Answer](x-devonthink-item://78503782-404C-41A2-A3AE-B1A26F578DF5?page=17) - [ ] 3Q: [Eclampsia](x-devonthink-item://310EEEDE-D794-4365-8865-5B3DD1C20510?page=14) -- [Answer](x-devonthink-item://6D5125AD-DE4D-435B-8D13-6EA35DB8E785?page=19) -- [prop](x-devonthink-item://D0A460D5-938B-4002-A684-EFD9189B08C1?page=7) - [ ] 4Q: [Headache in Third Trimester](x-devonthink-item://7495767E-7B93-4C14-A35D-AFEF8CF7D0B8?page=10) -- [Answer](x-devonthink-item://01E87078-FF7E-4661-BAEF-58FAE1C99A04?page=7) ## hellp syndrome - [ ] 5Q: [HELLP Syndrome](x-devonthink-item://834C484F-DDAA-4819-8DF0-84AE5E70DA1D?page=43) -- [Answer](x-devonthink-item://D46998FE-62E2-4A3A-860D-C32C94B86E42?page=20) ## pre-eclampsia - [ ] 6Q: [Pre-eclampsia](x-devonthink-item://2F267333-5FEC-47E5-83D1-CC05B23EB91A?page=5) -- [Answer](x-devonthink-item://C6CAC39D-CAE8-4F76-9C45-689A0464D936?page=2) - [x] DUPLICATE Q: [Eclampsia](x-devonthink-item://2CB6E202-E7C1-46E8-B49F-435AB6C937F0?page=14) -- [Answer](x-devonthink-item://78503782-404C-41A2-A3AE-B1A26F578DF5?page=17) - [x] DUPLICATE Q: [Eclampsia](x-devonthink-item://310EEEDE-D794-4365-8865-5B3DD1C20510?page=14) -- [Answer](x-devonthink-item://6D5125AD-DE4D-435B-8D13-6EA35DB8E785?page=19) - [ ] 7Q: [Pre-eclampsia](x-devonthink-item://7FCD3940-4BB4-45FE-86A6-E5707E82D5B5?page=30) -- [Answer](x-devonthink-item://3263A68A-96A6-43EC-985B-43260C3509BF?page=10) - [x] DUPLICATE Q: [HELLP Syndrome](x-devonthink-item://834C484F-DDAA-4819-8DF0-84AE5E70DA1D?page=43) -- [Answer](x-devonthink-item://D46998FE-62E2-4A3A-860D-C32C94B86E42?page=20) - [ ] 8Q: [Pre-eclampsia](x-devonthink-item://0C18BB01-C981-4C61-B0E9-93B507919817?page=9) -- [Answer](x-devonthink-item://75D8E35B-EE77-4D1B-A665-438451C976AE?page=5) - [ ] 9Q: [Headache and Hypertension in Late Pregnancy](x-devonthink-item://7061D1B4-0AB9-4963-B3B0-23BDD975B2CD?page=44) -- [Answer](x-devonthink-item://3F30C77E-E23E-4200-89FE-48A41618E0C2?page=29) - [AFEM 2021.1 Q 18](x-devonthink-item://6AA65429-F81B-4D2A-8AD1-14075DA7A42B?page=68)