Pre-eclampsia

Pregnancy Induced Hypertension

Asymptomatic hypertension during pregnancy occurs in 5-20% of women, typically primigravida, those with numerous pregnancies, diabetes mellitus, or essential hypertension. It occurs most frequently during the third trimester of pregnancy.

It is classified into three clinical groups:

1. Pre -eclampsia
2. Eclampsia
3. Gestational hypertension

Pre-eclampsia

Pre-eclampsia is a multi-disorder characterized by the presence of hypertension of at least 140/90mm Hg on two consecutive occasions at least 4 hours apart and the presence of at least 300mg proteinuria in a 24-hour urine collection after the 20th week of gestation. Toxemia is a condition that occurs when a woman with gestational hypertension has an increase in protein in her urine.

Incidence

Pre-eclampsia affects roughly 10% of primigravida women and 5% of multigravida women. If not treated promptly, it can be fatal to both the mother and the fetus.

Epidemiology

1. Primigravida is more prevalent.
2. Affected women's first-degree relatives are three to four times more likely to be affected.

Etiology

1. Predisposition to genetic disease
2. Placental development abnormality
3. Activation of vascular endothelial cells
4. An immunological reaction that is abnormal
5. Diabetic pre-existing condition
6. First contact with fetal tissue
7. Inadequate dietary intakes of protein, calcium, salt, and vitamins E and A
8. Mole hydatidiform

Predisposing factors

1. Young primigravida under the age of 18
2. Elderly primigravida over the age of 35
3. Pre-eclampsia, eclampsia, and hypertension run in families.
4. The poor and marginalized sectors suffer more from a lack of prenatal care than from dietary deficiencies.
5. Hydatidiform mole, multiple pregnancies, and Rh-incompatibility are among pregnancy complications.
6. Diabetes, nephritis, and other medical conditions

Signs and Symptoms

1. Sudden weight increase
2. Edema of the ankles that persists when waking from bed in the early morning, with swelling radiating to the face, belly wall, and vulva.
3. Blood pressure gradually rises.
4. Visual symptoms such as hazy vision, impaired vision, and dim vision
5. Pain in the epigastric region and the right upper quadrant
6. Sleep disturbance
7. Headache
8. Oliguria is defined as a urine volume of less than 300ml every 24 hours.

Degree of Severity

1. Pre-eclampsia of mild severity
2. Diastolic blood pressure is more than 90mmHg, but it is 20mmHg higher than it was in early pregnancy.
3. Severe pre-eclampsia occurs when mean arterial pressure (MPA) surpasses 105mmHg.
4. Systolic blood pressure greater than 160mmHg or diastolic blood pressure greater than 10mmHg on at least two separate occasions at least four hours apart.
5. Proteinuria greater than 5g in 24 hours (or 4+ on qualitative evaluation).
6. Oliguria > 400ml in 24 hours
7. A neurological or visual abnormality.
8. An excruciating headache or epigastric discomfort.

Investigation

Maternal

1. Urinalysis by dipstick
2. 24-hour urine collection
3. Complete blood count (platelets, hematocrit)
4. Renal function test (uric acid, creatinine, urea)
5. Liver function test
6. Coagulation profile

Fetal

1. Uss (growth parameters, fetal size,)
2. CTG or FHS
3. BPP
4. Doppler

Complication

Maternal

1. Pulmonary edema
2. Renal failure
3. Eclampsia
4. Oliguria and anuria
5. Preterm labor
6. Post-partum hemorrhage
7. Shock
8. Sepsis
9. HELLP syndrome ( H= Haemolysis, EL=Elevated Liver enzyme, LP= Low Platelets count)
10. Placental abruption
11. Dimness vision

Fetal

1. Reduced placental function, resulting in low birth weight or IUGR
2. Intrauterine death caused by placental circulation compression
3. Asphyxia
4. Prematurity
5. Restriction of intrauterine growth

Remote Complication

1. Residual Hypertension
2. Recurrent Pre-eclampsia
3. Chronic Renal Disease

Prevention

1. A routine antenatal check-up at regular intervals from the start of the pregnancy for early diagnosis of rapid weight growth or a predisposition for rising blood pressure, particularly diastolic.
2. Advise the mother to rest in the left lateral position for at least two hours at noon and ten hours at night.
3. Advise the woman to consume an adequate amount of protein-rich, nutritionally balanced foods.
4. Education for female family members about the importance of woman care and diet for the mother's and baby's health.
5. Mothers and family members are educated on birth preparation.

Management

Antenatal Management

1. To maintain regular good contact with health personnel, monitor the patient's blood pressure, urine test for proteinuria, and fetal condition on a weekly basis.
2. Advise the mother to get 12-14 hours of sleep per day.
3. If there are any symptoms of severe fetal growth restriction, admit the lady to the hospital for adequate evaluation and treatment.
4. Inform the mother and her family about the risk signals of pre-eclampsia and eclampsia.
5. Allow regular labor and children to resume if all observations stay stable.

Hospital Setting Management

If the illness situation worsens or there is any significant fetal distress, the lady is immediately admitted to the hospital. This condition is addressed by getting enough rest, checking blood pressure every day, testing urine for protein urea with a dipstick, and counting fetal kicks every day.

1. Maintain the patient's optimal resting position in the left lateral position.
2. Advise the mother to have a well-balanced diet with about 100gm of protein and 2500kcal of calories each day.
3. Continue to give the patient folate, iron, and calcium supplements.
4. Diuretics are not recommended because they reduce placental perfusion and may cause electrolyte imbalance and newborn thrombocytopenia.
5. Sedatives are avoided whenever possible, however, they may be necessary to increase compliance with rest.
6. Antihypertensive medicines- typically, if blood pressure returns to normal with appropriate rest, sleep, and sedatives, the use of blood pressure-controlling pharmaceuticals is decreased, but in rare circumstances, medication is still used, such as:
   - Persistent blood pressure spikes, particularly diastolic, are greater than 100mmHg. It is more vital to use the medicine.

In Hypertensive Crisis

1. Maternal well-being should be monitored:
2. Blood pressure should be checked every four hours or as needed.
3. Daily weighing of the mother and documentation of any signs of edema

Daily Intake and Output Charting

1. Proteinuria is diagnosed through urine analysis.
2. Hemoglobin, platelet count, urea, uric acid, creatinine, and liver function tests are all performed in the blood.
3. Examination of the eyes
4. Maintain fetal well-being:
5. Fetal heart sounds are monitored every 4-6 hours.
6. Counting and documenting the fetal movement

USG 3 Weekly to Access Fetal Growth

1. Never abandon the patient.
2. The necessary medications and delivery equipment should be maintained on hand.
3. Nursing care should be given in accordance with the patient's overall condition.
4. Counsel the patient and family on the diet, hygiene, and maternal care.

References

• HealthLine. 2005. 2017 http://www.healthline.com/health/preeclampsia
• Mayo Clinic. 1998. 03 July 2014 http://www.mayoclinic.org/diseases-conditions/preeclampsia/basics/definition/con-20031644
• Tuitui R. 2002, A textbook of Midwifery A (Antenatal), 3rd edition, Vidyarthi Pustak Bhandari (Publisher and Distributor), Bhotahity, Kathmandu
• Medscape. 1994. 2017 http://emedicine.medscape.com/article/1476919-overview
• NHS Choice. http://www.nhs.uk/Conditions/Pre-eclampsia/Pages/Introduction.aspx
• Web MD. 2005. 2017 http://www.webmd.com/baby/guide/preeclampsia-eclampsia#1
• Tuitui R. 2002, A textbook of Midwifery C (Antenatal), 3rd edition, Vidyarthi Pustak Bhandari (Publisher and Distributor), Bhotahity, Kathmandu