Preeclampsia and eclampsia

Notes
  • Preeclampsia (formerly known as toxemia of pregnancy) is a new-onset hypertension, proteinuria and progressive edema that may occur after 20th week of gestation to 6th week after birth. If it is not satisfactorily treated, it can lead to eclampsia (which are seizures that occur in women with preeclampsia without any other known cause).
  • The prevalence of preeclampsia and eclampsia is highest among primigravida followed by pregnant teenager and women over 40.
  • Statistics: 0.5% cases of preeclampsia develop into eclampsia; the prevalence of preeclampsia in nulliparity is 2 - 6%; 90% of cases of preeclampsia occur after the 34th week of gestation, and 5% after birth.
  • Causes of preeclampsia and eclampsia are not fully known.
  • In preeclampsia, the serum concentration of the antiangiogenic soluble Fms-like tyrosine kinase 1 (sFlt-1) is raised but placental growth factor (PlGF) is reduced.

##Risk factors for preeclampsia and eclampsia

  • History of preeclampsia among family members
  • Pregnancy with twins, triplets or multiples (Multifetal pregnancy)
  • Nulliparity (high risk)
  • Obesity
  • Older woman (those above 40 have higher risk)
  • Adolescent age (those below 17)
  • Preeclampsia in previous pregnancies
  • Preexisting chronic hypertension, diabetes, thrombotic disorders, lupus, rheumatoid arthritis, renal disease, and vascular disorders
  • Pregnancy arising from egg donation or donor insemination
  • Black race
  • Angiotensinogen gene T235

##Effects or consequences of preeclampsia on the baby:

  • Underweight baby
  • Premature birth
  • Learning disabilities
  • Epilepsy
  • Cerebral palsy
  • Learning and vision disorders

##Effects or consequences of preeclampsia on the mother:

  • Seizure
  • Heart failure
  • Hepatic hemorrhage
  • Placental abruption
  • Postpartum hemorrhage
  • Pulmonary edema
  • Reversible blindness
  • Still birth
  • Stroke
Symptoms
  • Mild preeclampsia may be asymptomatic
  • Proteinuria
  • Hypertension (systolic blood pressure ≥ 160 mm Hg or diastolic blood pressure ≥110 mm Hg, on two occasions at least 4 hours apart while the patient is on bed rest)
  • Sudden but and progressive edema of the feet, legs, face and hands
  • Hepatic dysfunction (as evidenced by raised levels of AST /ALT and epigastric pain that responds poorly to analgesics)
  • Sudden weight gain
  • Altered mental status
  • Dizziness
  • Severe headaches
  • Nausea
  • Dyspnea
  • Progressive renal insufficiency
  • Decrease of urine output
  • Abdominal pain
  • Pulmonary edema
  • Blurred vision, flashing light, floaters and blindness
  • Vomiting
  • Thrombocytopenia
  • Seizures (in case of eclampsia)
Diagnosis
  • Monitor of BP
  • Urinalysis
  • Serum creatinine
  • ALT/AST
  • Blood clotting
  • FBC
  • Head CT scan in suspected cases of intracranial hemorrhage
  • Ultrasonography (to assess the status of the fetus and evaluate for growth restriction)
  • Cardiotocography (the standard fetal nonstress test)
Differential
  • Gestational hypertension
  • Chronic hypertension
  • Epilepsy
  • Liver, renal or pancreatic diseases
  • Antiphospholipid syndrome
  • Haemolytic uraemic syndrome
  • Thrombotic thrombocytopenic purpura
Prevention
  • Antenatal monitor of the pregnancy
Management
  • Delivery is the only known cure for preeclampsia
  • Induction of labor or Cesarean section (the decision is informed by severity of the condition, gestational age and health of the fetus)
  • In case of mild preeclampsia bed rest with frequent medical monitoring is prescribed and induction of labor is recommended at 37th weeks of gestation (as opposed to 40 weeks of full gestation period).

##In case of severe preeclampsia:

  • Delivery is usually recommended after 34th week of gestation
  • IV magnesium sulphate is administered to prevent seizures
  • Anti-epileptics in case eclampsia sets in
  • BP control with hydralazine, labetalol, nifedipine and sodium nitroprusside (cases refractory to other medications)
  • Avoid diuretics
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