Hi Curofians i have conducted a study on Epidemiology And Fetomaternal Outcomes In Cases Of Pre-eclampsia.
On this World Hypertension Day i'm sharing it with you. Please read the article and share your valuable opinion.
All around the world about 10 % of all pregnancies are complicated by hypertensive disorders. Hemorrhage, infection and hypertension together forms a deadly triad which constitute a major cause of maternal morbidity and mortality. (1) In hospital practice in India, the incidence of pre-eclampsia varies from 5% to 15% and of eclampsia about 1.5%. (2) Maternal mortality worldwide is systematically reviewed by World Health Organisation (WHO) and it was reported that 16% of maternal deaths were due to hypertensive disorders in developed countries.(3) In India, hypertensive disorders constitute 3rd most important cause of maternal mortality. (1)
The revised classification for hypertensive disorders in pregnancy is by the International Society for the Study of Hypertension in Pregnancy (ISSHP)(4) in 2014: 1. Chronic hypertension 2. Gestational hypertension 3. Pre-eclampsia – de novo or superimposed on chronic hypertension 4. White coat hypertension. Preeclampsia is defined as multisystem, multi-factorial disease with Blood Pressure (B.P) reading of ≥140/90 mm Hg on two occasions 4 hours apart and > 300mg protein in 24 hour urine specimen after 20 weeks of gestation in a previously normotensive women. Severe Preeclampsia is defined as B.P reading of ≥160/110 mm Hg and >5 gram protein in 24 hour urine specimen or symptoms of end organ failure like deranged LFT, thrombocytopenia, oliguria, visual disturbances, pulmonary oedema etc. (1) Eclampsia is defined as the development of seizures which cannot be attributed to other causes and /or unexplained coma during pregnancy or puerperium in a woman with pre-eclampsia.(5) Eclampsia is most common in the third trimester and becomes more frequent nearby term. (6)
*If using protein: creatinine ratio to quantify proteinuria in pregnant women:
• use 30 mg/mmol as a threshold for significant proteinuria
• if the result is 30 mg/mmol or above and there is still uncertainty about the diagnosis of pre-eclampsia, consider re-testing on a new sample, alongside clinical review.
*If using albumin: creatinine ratio as an alternative to protein: creatinine ratio to diagnose pre-eclampsia in pregnant women with hypertension:
• use 8 mg/mmol as a diagnostic threshold
• if the result is 8 mg/mmol or above and there is still uncertainty about the diagnosis of pre-eclampsia, consider re-testing on a new sample, alongside clinical review.
The perinatal mortality due to eclampsia is high upto the extent of about 30-50%.(7) In women presenting with convulsions during pregnancy, labour or puerperium its advisable to do a diagnosis of eclampsia for possible existence.(8)
Causes of maternal deaths following eclampsia are cardiopulmonary failure, acute renal failure, cerebrovascular accident (CVA), HELLP syndrome (Haemolysis, Elevated liver enzymes and Low platelets) and abruptio placentae.(9) In cases of eclampsia, poor fetal outcome is attributed to factors such as iatrogenic prematurity, respiratory distress syndrome (RDS), intrauterine asphyxia, intrauterine growth restriction (IUGR) and intrauterine death (IUD). In women with chronic hypertension, carry out an ultrasound for fetal growth and amniotic fluid volume assessment, and umbilical artery doppler velocimetry at 28 weeks, 32 weeks and 36 weeks. Ultrasound for fetal growth and amniotic fluid volume assessment and umbilical artery doppler velocimetry starting at between 28 and 30 weeks (or at least 2 weeks before previous gestational age of onset if earlier than 28 weeks) and repeating 4 weeks later in women with previous needs to be carried in women with previous
1. Severe pre-eclampsia
2. Pre-eclampsia that resulted in birth before 34 weeks
3. Pre-eclampsia with a baby whose birth weight was less than the 10th centile
4. Intrauterine death
5. Placental abruption.
Not only this, IUGR may lead to neuro-developmental defects in children at later stages of life.(10) The only treatment for eclampsia is delivery of the baby. According to WHO report 2008, eclampsia constitutes for 12% of all maternal deaths in developing countries. (8) Eclampsia can be antepartum (38-53%), intrapartum (18-36%), or postpartum (11-44%).(11)
No acceptable biochemical marker is available till now for early detection of preeclampsia however some maternal and pregnancy characteristics have been identified as risk factors for development of pre-eclampsia which include nulliparity, previous history of preeclampsia, maternal age over 40, multiple gestation, molar pregnancy, pregestational diabetes, vascular, endothelial or renal diseases, maternal smoking, obesity and certain genetic factors.(12)
Placental growth factor (PlGF)-based testing to help rule out preeclampsia between 20 weeks and up to 35 weeks of pregnancy, if women with chronic hypertension are suspected of developing pre-eclampsia can be offered.
The antihypertensive medications which can be used in pre-eclamsia are Labetalol, Nifedipine, hydralazine.
Pregnant women can be adviced to take 75- 150 mg Aspirin daily from 12 weeks until birth of the baby if they are high risk for developing pre-eclampsia as follows:
1. Hypertensive disease during a previous pregnancy.
2. Chronic kidney disease.
3. Autoimmune diseases like Systemic Lupus Erythematosus (SLE) or Anti-Phospholipid Syndrome.
4. Type 1 or type 2 diabetes
5. Chronic hypertension.
Women at moderate risk for pre-eclampsia are following:
1. First pregnancy
2. Age 40 years or older
3. Pregnancy interval of more than 10 years
4. Body mass index (BMI) of 35 kg/m2 or more at first visit
5. Family history of pre-eclampsia
6. Multi-fetal pregnancy.
Advice on rest, exercise and work to women with chronic hypertension or at risk of hypertensive disorders during pregnancy as healthy pregnant women
Maternal and perinatal mortality and morbidity due to preeclampsia can be prevented by providing a good access to quality antenatal care, early diagnosis and identification of risk factors, careful monitoring and timely interventions. (1)
Give advice and treatment to women with hypertensive disorders of pregnancy in line with the NICE guideline on intrapartum care, unless there are recommendations in this guideline on the same topic. Offer care in accordance with the NICE guideline on intrapartum care for women with hypertension whether treated or untreated, and not just on the basis of blood pressure in labour.
During labour, measure blood pressure:
a. Hourly, in women with hypertension
b. Every 15–30 minutes until blood pressure is less than 160/110 mmhg in women with severe hypertension.
Continue use of antenatal antihypertensive treatment during labour.
Determine the need for haematological and biochemical tests during labour in women with hypertension using the same criteria as in the antenatal period even if regional analgesia is being considered.
Do not preload women who have severe pre-eclampsia with intravenous fluids before establishing low-dose epidural analgesia or combined spinal epidural analgesia.
Management of second stage of labour :Do not routinely limit the duration of the second stage of labour in women with controlled hypertension. Consider operative or assisted birth in the second stage of labour for women with severe hypertension whose hypertension has not responded to initial treatment.
Anticonvulsants :If a woman in a critical care setting who has severe hypertension or severe preeclampsia has or previously had an eclamptic fit, give intravenous magnesium sulfate. Consider giving intravenous magnesium sulfate to women with severe preeclampsia who are in a critical care setting if birth is planned within 24 hours. Consider the need for magnesium sulfate treatment, if 1 or more of the following features of severe pre-eclampsia is present:
• ongoing or recurring severe headaches
• visual scotomata
• nausea or vomiting
• epigastric pain
• oliguria and severe hypertension
• progressive deterioration in laboratory blood tests (such as rising creatinine or liver transaminases, or falling platelet count).
Use the Collaborative Eclampsia Trial regimen for administration of magnesium sulphate:
• A loading dose of 4 g should be given intravenously over 5 to 15 minutes, followed by an infusion of 1 g/hour maintained for 24 hours. If the woman has had an eclamptic fit, the infusion should be continued for 24 hours after the last fit.
• Recurrent fits should be treated with a further dose of 2–4 g given intravenously over 5 to 15 minutes.
Do not use diazepam, phenytoin or other anticonvulsants as an alternative to magnesium sulfate in women with eclampsia.
Mothers have to be explained about the risk of passage of antihypertensive drugs via breast milk. Enalapril can be offered to treat hypertension in women during the postnatal period, with appropriate monitoring of maternal renal function and maternal serum potassium.
For women with hypertension in the postnatal period, if blood pressure is not controlled with a single medicine, consider a combination of nifedipine (or amlodipine) and enalapril. If this combination is not tolerated or is ineffective, consider either:
• adding atenolol or labetalol to the combination treatment or
• swapping 1 of the medicines already being used for atenolol or labetalol. When treating women with antihypertensive medication during the postnatal period, use medicines that are taken once daily when possible. Where possible, avoid using diuretics or angiotensin receptor blockers to treat hypertension in women in the postnatal period who are breastfeeding or expressing milk.
Advise women with hypertensive disorders of pregnancy that the overall risk of recurrence in future pregnancies is approximately 1 in 5 has to be given.
Advise women who have had a hypertensive disorder of pregnancy that this is associated with an increased risk of hypertension and cardiovascular disease in later life.
Advise women who have had pre-eclampsia that the likelihood of recurrence increases with an inter-pregnancy interval greater than 10 years. (13)
CASE STUDY: I along with my colleagues conducted study on epidemiology and fetomaternal outcomes in cases of pre-eclampsia over a period of 5 years (2010- 2014) in Goa medical College, Bambolim Goa. During the study period there were 22,591 deliveries. There were 1468 mild and severe pre-eclampsia cases and 309 imminent eclampsia and eclampsia cases. The proportion of Pregnancy Induced Hypertension (PIH) cases was found to be 7.87% and that of eclampsia being 1.37%. Most of the patients belonged to the age group between 26-30 years that is 40.35%. 69.11% patients were primigravidas. Most of the patients (84.29%) presented between 29-36 weeks. 56.96% and 28.48% patients had headache and headache plus vomiting as premonitory symptoms respectively. 98% patients had antepartum eclampsia. 38.15% patients BPs were controlled using Nifedipine. 60.19% of imminent eclampsia/ eclampsia and 42.03% of pre-eclampsia patients were delivered by Caesarean section. Most common indication for LSCS being previous LSCS (37.61%) followed by unfavourable cervix (31.88%). Among the complications, HELLP syndrome was seen in 5.83% patients and abruptio placentae seen in 3.83%. 68.09% babies had birth weight less than 2.5 kg. Most common complication seen in babies was prematurity (40%). Maternal mortality in our study was found to be 1.3% and perinatal mortality was found to be 18%.
We concluded that Pre-eclampsia is one of the medical complications which occur during pregnancy and is responsible for significant feto-maternal morbidity and mortality. As pre-eclampsia cannot be fully prevented, diagnosis of high-risk patients on time and quick treatment when pre-eclampsia is in its mild stage can help prevent complications. To conclude, our study highlights various risk factors for pre-eclampsia. Unbooked, young primigravida women who are in their advanced period of gestation are at elevated risk for pre-eclampsia-related morbidity and mortality. In order to prevent this, early registration, along with improving ANC care and also access to medical facilities may help to diagnose the complications well in time and thus help in decreasing adverse outcomes. As exact etiopathology of pre-eclampsia is still unknown more research is needed in understanding pre-eclampsia so that effective strategy can be planned for predicting as well as preventing adverse outcomes. Education and empowerment of women is very much needed and also accessible health care especially to the socioeconomically deprived and rural population is very much essential.
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