Preeclampsia and its management

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Preeclampsia and its management

Definitions, Classifications

Hypertension in pregnancy is a common medical complication and it is reported in %5-10 of pregnant women. Blood pressure over 140/90 in two measurements of 4 hour intervals is called high blood pressure and it requires further test and evaluations. Hypertension in pregnancy is classified as:

Chronic Hypertension: blood pressure is high before the 20th week of gestation and it continues to be high for 6 more weeks after birth. Usually, blood pressure was also high before the pregnancy but diagnosis was not made.

Gestational Hypertension: Blood pressure is on and over 140/90 in the first 24 hours after childbirth or during pregnancy, however there are no symptoms of preeclampsia and blood pressure returns back to normal in 6 weeks.

Preeclampsia: After 20th week of pregnancy or after childbirth, urinary loss of proteins along with high blood pressure. Edema is not a diagnostic criterion for preeclampsia because it may occur in normal pregnancies too.

Chronic hypertension and superimposed preeclampsia: Addition of proteinuria to chronic hypertension, or in patients who had hypertension and proteinuria before the 20th week, hypertension and proteinuria becoming more severe and preeclampsia symptoms occurrence.

Risk factors of Preeclampsia

First pregnancy, mother age below 20 or over 40, low socioeconomic level, obesity, multiple pregnancy, preeclampsia history in the family or in prior pregnancies, systemic diseases such as chronic hypertension, kidney diseases, diabetes mellitus, systemic lupus erythematosus and antiphospholipid syndrome can be counted among the risk factors of preeclampsia. The cause of preeclampsia is not yet clear.

Prof. Dr. Süleyman Engin Akhan
Ref: http://www.netterimages.com/image/3020.htm

The first to be investigated must be protein loss in urine in case of high blood pressure in pregnancy. In case of detection of 1+ and more protein in the consecutive two urine samples taken with six hours intervals, it is evaluated as proteinuria. Protein measurement of urine sample of 24 hours is more accurate and the case of protein presence over 300 mg in urine sample of 24 hours is considered as proteinuria. In preeclampsia, headache, blurred vision, visual problems such as sensitivity to light and temporary loss of vision, vertigo, sudden weight loss upper abdominal pain especially in the right, nausea-vomiting and reduction of urine may also occur. Additional to proteinuria, impairments in liver and kidney function tests and reduced thrombocyte count may also be seen in laboratory tests. Also, restricted development of babies and reduction of amniotic fluid may occur. Preeclampsia may cause various clinics like slight blood pressure increase extending to multiple organ dysfunctions and it is obligatory to define the severity of the disease in order to manage it right. Therefore, it is categorized as mild and severe preeclampsia, eclampsia and HELLP syndrome (‘hemolysis, elevated liver enzymes, low platelets):

Mild preeclampsia: Blood pressure is below 160/110 mmHg and proteinuria is minimal or 1+. There is no headache, visual problems, upper abdominal pain, reduced urination, edema of the lungs and laboratory tests are normal. Also, baby’s growth and amniotic fluid amount is normal. In order to evaluate the baby and the mother, pregnant women who were diagnosed with preeclampsia must be hospitalized. In cases above 37th week, normal birth can be induced with drugs if the cervix is appropriate, if not, patient could wait in the hospital in close follow-up until the 40th week.

Severe preeclampsia: Blood pressure is above 160/110 mmHg, proteinuria is 5 gram/24h or above. Headache, visual problem, reduced urination accompanies the case.

Eclampsia: Additional to preeclampsia, seizures like epilepsy seizures accompany the clinical presentation. Treatment is childbirth and magnesium sulphate should be administered.

HELLP syndrome: Additional hemolysis, increased liver enzymes and reduced thrombocytes are present in the case. Whatever the gestational week is, childbirth must be done right away. Brain and liver hemorrhage and general bleeding disorder may develop. If thrombocyte count is lower than 50000/dl, it must be corrected by giving thrombocytes to the patient before childbirth. Also, steroid (dexamethasone) treatment may be applied.

In those whose cervix is improper, gestational week is below 30, who had restricted development in the baby and reduction in the amniotic fluid, cesarean birth may be applied.

Complications of preeclampsia increase proportional to its severity and they are; kidney failure, liver hematoma, brain edema and hemorrhage, edema of the lung, retina’s decollment, ablation placenta, disseminated intravascular coagulopathy, restricted development of baby, mother’s death, baby’s death and prematurity related problems.

Patients who developed severe preeclampsia, eclampsia or HELLP syndrome after childbirth must take magnesium sulphate for 24 hours in order to prevent the seizures. Also, blood pressure drugs may be used for some time according to pressure levels and patients are advised to be evaluated for hypertension 6-12 weeks after childbirth. However, patients are discharged when general condition and laboratory symptoms got better and blood pressure is taken under control.