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ESSAY 198 - Pre-eclampsia

Posted by Balakrishnan V.
This patient has preeclampsia, which is a common complication of pregnancy. The urgent need is evaluation of severity of her condition and stabilisation of her blood pressure considering her risk of cerebral haemorrhage and involment of end organ indicated by proteinuria of more than 300 mg/ 24 hours. The ultimate treatment is delivery.
To determine severity of the disease I would take quick history of duration of onset of high bloodpressure, presence of any symptoms of sever disease like headache, nausea, vomiting, floaters in front of the eyes, icrease in body oedema, epigastric or hypogastric pain and level of her alertness. Whether she is using any antihypertensives. Does she has any urinary tract problem like nephrolithiasis which can give rise to proteinuria.
If she has increase BMI I will ensure that her blood pressure is measured by appropriate cuff. I will see her tendon reflexes, ankle clonus and hypogastric tenderness.
I would send her blood for urgent results of full blood count, U&E, uric acid and creatinin, LFTs, Coagulation profile to assess severity of her condition and to have baseline counts for her further monitoring. As fall in Platelet count is a sensitive indicator of deterioration of patients condition. Serum Uric acid and creatinin levels rise indication worsening of renal involvement. Liver enzyme rises and coagulation profile disrupt in HELLP syndrome which is a complication of preeclampsia.
It is necessary to start treatment of hypertension with consultant\'s supervision. The choice of antihypertensive depends upon unit\'s protocol, oral Methyl Dopa is used in most of the units but its action is slow. If her condition needs fast action intravenous labetolol or hydralazine can be used. Sublingual nifedipine can be used to quicky lower the blood pressure but this can cause dizziness due to hypotension and fetal hypoxia. So care must be taken during ntihypertensive therapy and BP should be monitored more often in start of the treatment. MgSO should be started if she has signs or symptoms or blood results show that she has sever disease as MgSO significantly reduce the risk of developing eclampsia.
For fetal assessment I would do her ultrasound and Doppler to see fetal measurements, liquor volume and umbilical artery flow velocity.
Her further management will depend upon her blood results and response to antihypertensives. Multidisciplinary approach involving obstetrician, physician, anaesthetist and neonatologist will be required. BP should be monitored 4 hourly with strict record of intake and output. 24 hours urinery protein clearance is determined. If bio chemical results are with in normal limits they shoud be repeated after every 48 hours.
Counselling of the patient should be done that if her condition deteriorates delivery will be unavoidable. Risks of operative delivery, prematurity and need of the baby to be kept in SCBU should be explined and her wishes should be taken into account. She should have an appointment with the anasthetist, paediatrian and SCBU staff. Steroids should be given for fetal lung maturity in view of possible preterm delivery. The frequency of fetal survellance is difficult to define but in case of normal BP, biochemical values and Doppler, weekly Doppler scan and fortnightly growth scan is acceptable.
In case of uncontrolled BP and deteriorating biochemical values delivery will e the only treatment. If cervix is unfavourable caesarean section has t be done, regional anaesthesia is less risky than general anaesthasia. Senior staff shoud do the operation and she should be kept in labour ward under one to one monitoring as post natal eclampsia rate is higher than antenatal or intrapartum. She should be given adequate thromboprophylaxis.
She should be given postnatal followup appointment of 6 weeks and her BP should be monitored by community midwife and her GP in the mean time. She should be given proper contraception before her discharge.


Posted by Sarwat F.
Initial assessment will include asking about signs and symptoms of imminent eclampsia like headache, visual symptoms, epigastric pain and oliguria. I will review her chart for any additional information that may be useful in management like fetal growth. I will examine the woman; check her Blood pressure, pulse temperature and reflexes. I will do abdominal examination to ascertain the lie and presentation and fetal heart rate. As this woman is having preeclampsia she may need delivery so history and examination will help me in deciding the mode of delivery although final method will be decided according to severity of preeclampsia. I will obtain an intravenous access and take blood for full blood picture, urea and electrolytes, liver function tests, group and hold, uric acid. Aim of management is to control blood pressure, prevent fits and other complications of preeclampsia like impaired liver and renal function, cerebrovascular accidents, pulmonary edema. I will infirm my senior obstetrician, and if woman develops severe preeclampsia anaesthetist, delivery suite, theatres, blood bank and porters. As she is only 28 weeks she will be given steroids that is betamthasone 12 mg. if preeclampsia is not very severe and SCBU facilities are not available, in utero transfer will be considered. For severe preeclampsia intravenous magnesium sulphate will be given to prevent fits, in a dose of 4 grams initially then 1 gram per hour. Blood pressure will be controlled with intravenous labetolol, hydralazine can also be given in case labetolol is not available but it is given carefully as it is associated with fetal distress and placental abruption. Severe eclampsia can only improve with delivery of baby so mode of delivery will be decided according to examination findings and wishes of patient. At 28 weeks bishops scoring is most likelt to be unfavourable and caesarean section is needed in most cases.senior person will be doing caesarean section as lower segment is not formed. Woman will be counseled about all the risks and benefits and informed consent taken. A paediatrician must be present at the time of delivery. After delivery monitoring is very important as majority of complications occur in postnatal period. Woman may need to be transferred to intensive care unit but this depends on hospital protocol. Her BP, pulse, temperature, respiratory rate, input, output are monitored every 15 min for 2 hours, 30 mins for 4 hrs and then hourly. Her blood tests that is full blood picture, electrolytes, uric acid, liver and renal fuction tests are repeated as this will aid in clinical management. Woman will be explained about all the events. Thromboembolism risk assessment is done and heparin is given if needed. TED stockings are provided and adequate hydration is maintained. Patient is monitored for next few days. Postnatal appointment is given. This will be an opportunity to discuss implications on future pregnancy mainly if classical section is done. Also various interventions in subsequent pregnancy like aspirin and uterine artery Doppler are discussed.
Posted by OJO AJIBADE  .
The diagnosis is severe pre-eclampsia.Bearing in mind that she is healthy i.e asymptomatic;history of previous high blood pressure treatment and renal disease will be noted with its medications documented;the blood pressure will be rechecked by appropriate cuff;the eyes will be checked for pappiloedema; any epigasric tenderness;hyper-reflexia;ankle for clonus to exclude imminent eclampsia will be noted.
Urinalysis will done to determine the extent of proteinuria and possible offering her 24hr urinary protein estimation.If the diagnosis is confirmed;she will be admitted;Intravenous line will be sited ;blood will be taken for full blood count to determine her haemoglobin and platelet level;urea and electrolyte;liverfunction test and coagulation status will be done to assess respectively the renal; liver and coagulation status. At least 2 units of Blood will be crossmatched in case of emergency delivery by caeserian section.
Blood pressure will be lowewered by intravenous labetalol given slowly over 10 mins.Other drugs that can be used are hyralazine(iv) and nifedipine(P.o) though the latter may not be fast enough in lowering the BP compared to the iv route.The blood pressure should be monitored every 15mins to prevent maternal hypotension and fetal bradycardia.She will also be given magnesium sulphate 4g iv slowly to prevent seizures. Strict fluid balance will be kept to prevent overhydration. Input will be 125mls/hr and output 30mls/kg/day.I will inform senior colleague eg consultant about her condition.
The baby will be monitored by twice daily CTG and liquor volume estimation.She will have ultrasound done to assess growth and umbilical artery doppler .She will be given dexamethasone 12 mg dly for 2 days for fetal lung maturation in case of early delivery.
If the patient is stabilised with controlled BP and reducing proteinuria;conservative management with antihypertensive is justifed to improve fetal maturity and neonatal outcome.She can be managed as such till 36 wks if she stabilised and fetal condition is satisfactory;then she will be booked for induction of labour(IOL) depending on presentation and condition of the cervix .If IOL is successful;the 3rd stage should be managed by syntocinon i.v.
If however;maternal or fetal condition deteriorates eg difficulty in BP control;Rising LFTS values OR deteriorating renal status or fetal distress noticed then the patient should be informed about situation and inform about the need for emergency caeserian section as delivery is the treatment.Consent will be taken ;the thaetre staffs and noenatologist will be informed.
The C-S should be supervised by consultant. Post-delivery she will be transfered to HDU for further management.Vital signs will be monitored every 15 mins;strict input output chart;iv infusion of magnesium sulphate will be continued at 1g/hr and labetalol treatment titrated against the blood pressure until stabilised.
Before discharged I will ensure normal renal & liver function test;daily BP check;continue with antihypertensive if necessary;inform her GP and arrange postnatal 6 wks visit for review . If BP is persistetly high postpartum she will be investigated for renal disease.
She wiil be advised on contraception and to book early on consultant led unit next pregnancy for adequate care as she is at risk of reccurrence .
Posted by Sreekala S.
BP of 170/115 and 3+proteinuria is classified as a severe PIH. She should receive multidisciplinary care approach involving the consultant obstetrician, anaesthetist, haematologist, paediatrician and the midwives. The initial assessment should be by asking for symptoms like Headache, visual disturbances, epigastric pain, reduced urine output and reflexes to be checked to make sure there are no impending signs or symptoms of Eclampsia. An IV access should be gained and bloods obtained for group and save, FBC, LFT, U&E and urates. FBC and LFT should be done to make sure there is no HELLP syndrome . U&E and urates are useful to know the severity and prognosis. CTG should be commenced to know the fetal status. Abdominal examination should be done to know the presentation.
Oral labetalol 200mg should be given stat. Magnesium sulphate loading dose given depending on the local hospital protocol and should be a consultant decision. She should be put on the HDU chart and observations taken every 15 minutes until BP is stabilised .If there is no response with oral labetalol it may be repeated after 1hour and may need IV labetalol or hydralazine depending on the local protocol. Foleys catheterization should be done and hourly urine output monitored. Total input of fluids should be restricted to 80ml/hr as there is a risk of pulmonary edema if fluids are overloaded. Reflexes should be checked every 4hours. Maintenance dose of Magnesium sulphate should be given only if the reflexes are present, Respiratory rate more than 14/mt and has a hourly urine output of more than 25ml as MgSO4 is excreted in urine and if urine output is reduced, there could be toxicity due to MgSO4 which can be life threatening. If MgSO4 toxicity is suspected calcium gluconate should be administered. MgSO4 should be given atleast for 24hrs after delivery or 24hrs after commencement whichever is the later. An ultrasound may be needed to confirm the presentation and for fetal well being/AFI.
Bloods should be repeated 12hrly or earlier if her condition deteriorates.
Tbe basic principle of her management is to stabilize her BP and deliver the baby. Once BP is stabilized, options should be discussed regarding mode of delivery. Cervix should be assessed and IOL considered with Prostaglandin gel as there is a higher failure rate with Syntocinon infusion.The risks of continuation of pregnancy outweigh the benefits and therefore she should be explained the risks of continuing the pregnancy like Eclmapsia, HELLP, Multi organ failure,DIC, cerebro vascular accident and the risks of deliverying like prematurely like RDS, transient tachypnoea of the new born and necrotizing enterocolitis. She should be allowed to take an informed decision.She should have a continuous CTG monitoring in labour. Caesarean section would be indicated if the CTG is non reactive, bloods are abnormal with development of HELLP or if she deteriorates.
SCBU should be informed as the baby is preterm and a paediatrician should be present at delivery.
Postnatally her BP should be monitored and bloods repeated as the risk of eclampsia and complications still persist. Oral antihypertensives in the form of oral labetalol may be continued for about 10 days and gradually tapered off.

Posted by Aroosha B.
Initial assessment will be done by taking a detailed history. In history a further detail of any other symptoms like headache, pain epigastrium, visual disturbances should be asked. General examination and especially for the presence of clonus and papilloedema should be looked for. Investigations should be carried out to assess the severity of condition and investigations should include full blood count, renail function test, liver function test and 24 hour urinary protean. Coagulation profile is not indicated if platelet count is more than 100.
Once the severe hypertension and proteinuria has been confirmed the management is only termination of pregnancy. However it may be delayed in fetal interest if maternal blood pressure is adequately controlled and she is stabilized. Blood pressure should be checked after every 15 minutes until the woman is stabilized and then after every 30 minutes in the initial stage of assessment. The blood pressure should be checked 4 hourly if the woman is stable and asymptomatic. Her blood pressure should be controlled either oral or I/V labetolol, Nifedwnipine orally or I/V hydralazine as high BP is associated with significant maternal morbidity due to risk of vascular heamorrage. MgSO4 should be started as I/V 4 gm bolus in 20 ml given slowly in 5-10 minutes and infusion started at rate of 1gm/hour. Sever preeclampsia is associated with risk intravascular hypovolemia and leaky capillaries so strict record of I/O should be done indewelling catheter and hourly urinary output. Fluids should be given at a rate of 80-100 ml/hr. Fetal condition should be assessed by CTG although CTG is a snapshot view of fetal condition. If maternal condition is stabilized and time can be gained then steroids for fetal lung maturity should be given and fetal well being further assessed by detailed USG and Doppler studies as there is 30 % risk of IUGR in pre eclampsia.
The senior obstetrician, anesthetist should be involved in her care. The decision for delivery should be taken at senior level. Induction of labour at this gestational age is less likely to be successful so delivery by LSCS is usually is the choice. An epidural anesthesia can be used if coagulation profile is normal. After delivery the patient should be monitored for 24 to 48 hrs. as the risk of post partum eclampsia is 44 %. The anti hypertensive therapy should be continued. It may need to be stopped or to be continued for 3 months depending upon her blood pressure control. Women with persisting hypertension and proteineuria may have reneal disease and should be considered for further investigation. An assessment of blood pressure and proteanuria at 6 weeks post natel should be done by GP. A follow up visit should be arranged to discuss the events of pregnancy, preconception counseling should be offered and risk factor and any preventative therapy be discussed.
Posted by Vinayak B.
Likely diagnosis is severe preeclmpsia at 28 weeks of gestation . Patient is high risk candidate at risk of HELLP syndrome, impending eclampsia/eclampsia. For which definitive treatment is termination of pregnancy .

Initial assessment done to assess severity of the case, need of maternal stabilization , fetal evaluation which will aid in magement of case. History should be obtained regarding Epigastric pain, headache, visual disturbance or vomiting which can predict impending eclampsia. Blood pressure should be rechecked with appropriate cuff. Urine albumin rechecked with spot protein creatinine ratio which is more sensitive than dipstick urine test . Presence of clonus looked for which is more informative than knee jerk in assessing impending eclampsia. Per abdominal examination done to asses gestation and fetal well being and growth by confirming symphysiofundal height and ultrasound examination to reconfirm gestational age. Patient should be told about her condition and should be admitted in high risk unit as patient needs further evaluation and delivery if detoriates. Admission done at unit wherSCBU facilities are available. Or patient should be transferred to highet centre after stabilization.

Severity of the disease will be judged with blood investigations FBC, RFT Inclusive of uric acid , LFT, coagulation profile. Raised lft with hemolysis with low platelet will be suggestive of HELLP. Raised uric acid will guide towards fetal well being . fundoscopy done to exclude papilloedema. Urine microscopy to exclude associated urinary tract infection.

Further management depends on stablisation of hypertension , careful continued monitoring for fetal and maternal condition and deciding optimum time for delivery.
Blood pressure controlled with antihypertensives with the aim ogf bringing map below 120. methyldopa or labetelol orally are the drug of choice if no response iv labetelol or hydralazine given no role of ace inhibitor or lasix. Blodd pressure monitored every 15 min ? 30 min followed by 4 hrly once controlled.
Input out put strictly monitored. With 24 hours urine protein. Antenatal steroids given to prevent rds as patient may need early termination.blood investigations repaeated daily or more frequently as per patients condition.
Fetal condition monitored with cardiotocography or Doppler study if growth lag suspected.

Senior person should be informed and examine the patient to decide about delivery or expectant management . if termination is decided magenesum sulphate canbe given as prophylaxisor as a treatment if patient has seizure. As per unit protocols. I v fluid should be monitored carfully 80 ml/ hr to avoid pulmonary oedema. Spo2 should be monitored. Magnesium sulphate should be continued 24 hrs after delivery.

As definitive management is termination of pregnancy. Anesthetist neonatologist should be informed . epidural anesthesia is preferred. Lowersegment cesarean section is the preferred mode of delivery in vie w of preterm gestation with poor bishop. Cs should be done by senior person as porly formed lowersegment.thromboprophylaxis in post op period with continuation magnesium sulphate drip for 24 hrs as c40%chances ongf convulsion postpartum monitor output . patellar refles respiratory depression while on magsulph.Continue hypertensives in post ope period drug of choice is atenelol than methyl dopa .

Detail notes to be given to patient follow up at 2/ 6 weeks pnc to note the hypertension and albuminuria if persistant refer to renal physiscian for further evaluation


Posted by SWATI M.
This woman has severe pre-eclampsia and it is associated with significant maternal and perinatal morbidity and mortalitry especially if treatment is delayed.
History of severe headache, epigastric pain, vomiting ,visual disturbances and fetal movements should be enquired.Review her antenatal records for BP readings and confirm gestational age from dates and scan.
On clinical examination look for epigastric tenderness, uterine size, FHS, fetal presentation, deep tendon reflexes and signs of clonus.
Investigations include FBC with PCV, renal function tests ? serum urea ,creatinine, liver function tests ? ALT ,AST, coagulation studies ? platelets,prothrombin time, APT.
Fetal monitoring should be done by CTG .

Subsequent management includes control of BP, prevention of complications and timely delivery.
Involve senior obstetrician in her management.Involve senior neaonatalogist and anaesthetist.If she is asymptomatic, start oral labetalol and monitor BP every 15 -30 min till stable .The conservative management should be undertaken and continued only if she remains asymptomatic,clinically stable ,lab reports are normal and fetal condition remains stable ,give corticosteroids ? betamethasone 2 doses,12mg 24 hours apart.The aim of conservative management is to achieve fetal maturity but maternal safety should always be taken into account first and Should she deteriorate during this period or develops fetal distress ,she needs urgent delivery.

If she is symptomatic or clinical examination shows exaggerated tendon reflexes / clonus or altered lab reports suggest HELLP syndrome she needs urgent delivery with prophylactic magnesium sulphate, IV antihypertensives.Counsel woman and her family. Antihypertensives labetalol should be given intravenous.Urinary catheterisation should be done. At 28 weeks ,cervix is most likely to be unfavourable and may need caesarean section.senior person should undertake the procedure.Anaesthetist will decide upon type of anaethesia used which depends on clinical condition.Senior neonatalogist should be present at delivery. Arrange ex-utero transfer for baby if SCBU fascilities are not available locally.
Use syntocinon for management of third stage and avoid use of ergometrine.
Monitor in HDU /ICU for 24 ? 48 hours or till settles.Monitor BP to adjust antihypertensives.Once acute phase is over switch to oral.Continue MgSO4 for 24 hours after delivery or seizure whichever is later. Appropriate thromboprophylactic measures should be undertaken.Restrict IV fluids to 80 mls / hr if urine output is satisfactory .If urine output decreases ,she needs invasive monitoring with CVP line with involvement of renal physician. Monitor LFT ,RFT ,coagulation studies every 4 -6 hours depending upon clinical condition.Involve haematologist if she develops DIC / HELLP.
Keep woman and family informed at all stages.Proper documentation is important.

Advice on contraception and give letter to GP at discharge.
Arrange follow up appointment after 6 weeks for BP check up and evaluation for renal disease if hypertension persist.
Posted by Ismatara B.
The woman is suffering from severe preeclampsia (PE). As severe PE is associated with Eclampsia, Cerebrovascular accident and other potantial involvment of end organ, Senior obstetric, anaesthetic staff and experienced midwives should be involved in the assessment and management of this patient. Review her antenatal record BP and dating scan.
A careful clinical assessment should be taken with a history of epigastric pain, visual disturbance, epigasric pain and/or vomiting. Examination should include any signs of clonus, papiloedema, liver tenderness to check any organ involvement. Repeat BP, method (korotkoff phase 5 rested and sitting at a 45-degree angle)used should be consisted and documented. Her BP should be checked each 15 minutes until she stabilized and then every 30 min in initial phase of assessment and Her blood should be sent for FBC, Liver function and renal function tests, platelet count to assess the severity of the condition and to have baseline counts for further monitoring. Clotting studies are not required if platelet count > than 100x106 /L. Close fluid balance with input and output chart is essential.
Her Further managment based on her assessment( history & blood report), stabilisation, continued monitoring and delivery at optimal time for mother and baby. Counselling should be done to involve the patient in decision-making. Local hospital protocol should be maintained. A conservative approach may be taken if the condition is stable and biochemical analyses are normal. It should be repeated at least daily when results are normal or more often if abnormal as these will reflect her condition and other organ involvement.24 hrs urinary protein clearance should also be done to assess renal function. Her BP should be checked 4-hourly if she is stable To assess fetal wellbeing, daily CTG should be done. To assess fetal growth and liquor volume US Scan fortnightly and weekly Umbilical artery Doppler should be done, as study shows that using absent or reversed end diastolic flow improves neonatal outcome.
Antihypertensives should be given in the form of Labetolol iv or orally, nifedipine iv or orally or iv Hydralazine can be used. Clinician should use drug with which they are familiar.
Anticonvulsant should be given where there is risk of eclampsia and if decision of delivery has taken. MgSo4 is preferable due to its lesser side effects. During MgSo4 ankle reflexes, respiratory rate, urine output, oxygen saturation should be monitored to avoid drug toxicity.
Fluid is limited to 80ml/hr or 1ml/kg/hr to avoid fluid overload.
In case of uncontrolled BP and abnormal biochemical values, the decision of delivery should be undertaken. In that situation steroids (Betamethasone 12mg 24 hrly-2 doses) should be given for lung maturity. If cervix is unfavorable or malpresentation, an experienced obstetrician should do caesarean section, as lower segment is not yet formed. Prostaglandin may increase the chance of vaginal delivery in unfavourable cervix. Neonatologist should present during labour to improve neonatal outcome. Labour ward should be kept under one to one care as postnatal eclampsia is commoner than ante and intrapartum. In third stage ergometrine should be avoided as it may increase further BP and 5 units Syntocinon im or iv is recommended. Antihypertensive, intrapartum CTG should be continued to reduce maternal and neonatal morbidity and mortality. Thromboprophylaxis should be given according to risk factors assessment. She needs inpatient care 4days or more following delivery and careful review is needed before discharge to avoid postpartum eclmpsia. Antihypertensive should be continued after delivery as dictated by BP, monitored by midwives or GP. A postnatal follow up should be given at 6 weeks with assessment of BP and proteinuria. If persist she may have renal disease and needs further investigation. preconceptional counselling should be offered where the events that occurred, any risk factors, and any preventive therapies can be discussed.
















Posted by SANGEETA P.
Pre eclampsia is a multisystem disorder which can affect virtually all the systems of the mother as well as the fetus, depending upon the severity.
Initial assessment of this women will be taking the history of hypertension before pregnancy(essential hypertension), headache , visual disturbance, abdominal pain specially epigastric pain which may reflect the severity of disease, onset and degree of oedema, though oedema does not have the good predictive value for the degree of pre eclampsia but sudden onset and rapid oedema may have a significany value.History of medication is important as she may already be on anti hypertensives.
assessment of BP is done every 15 minutes initially till mother is stabilised ,then every 30 minutes and later on every 4hourly if she is managed conservatively.BP is taken at rested position at the level of heart with appropriate size cuff.This woman has 3+ proteinuria which roughly corresponds to proteinuria of 3gms/litre.Dipstick has a high false positive as well as high negative rate which can be reduced by doing other appropriate tests like protein creatinine ratio or preferably 24 hours urine protein which will refelect the severity of pre eclampsia.Full blood count should be done which will give the baseline of Hb level, platelets count as it will go down as the severity of disease go up and it may be significantly low(less than 100 /ml e.g HELLP syndrome).Liver function test like ALT, AST, renal function test like uric acid, which correlates well with the poor outcome for the baby and mother.Normally these tests will be done at least daily if they are normal, but may need to be done more frequently if the results are abnormal or the clinical situation worsens.Clotting profile is not recommended unless the platelet count is beow 100/ml.Fetal asessment should include the CTG which will tell the well being of the fetus at that stage and mother should have continuous electronic monitoring in labour.If the time allows scan should be done for the assess ment of fetal weight, liquor volume s reduced liquor volume may indicate the growth restriction.If she is managed conservatively ,should have serial growth scans for the growth restriction measurment, liquor voloume +/- umbilical artery doppler.
Management plan of this woman with severe pre eclampsia should involve senior obstetricians, senior mid wives and the senior anaesthetists.Blood pressure should be controlled using anti hypertensives.Acute controll can be done by using IV labetolol, Nifedipine or hydralazine and once controlled , woman can be maintained on either labetolol or methyldopa which are safe in pregnancy.Use of atenolol is associated with IUGR and ACE inhibitor and diuretics should be avoided in
pregnancy.Labetolol should be avoided ijn asthmatics.
Decision regarding the time of delivery should be balanced with the risk of prematurity, although mother\'s condition is given preference over fetal condition.If the maternal symptoms worsens or the BP is uncontrolled despite of appropriate medications or the biochemistry worsens, day for delivery should be planned with the senior staff involving the senior pediatric staff as well.woman should be given an oppurtunity to discuss all outcomes of the baby with the paediatric staff.2 doses of steroid 12 mgs of betamethasone 12 hourly should be given Im to prevent respiratory distress syndrome.Mode of deliveru is decided on the bais of degree of severity of Pre eclampsia, bishop\'s score, maternal wish and the fetal presentation and condition on the scan. Mgso4 has a role in Severe pre eclampsia as it may reduce the incidence of eclampsia.Senior staff should be involved in the decision of starting the woman on MGSO4, and the hospital protocol should be followed, njormally its given 4mg stat as infusion and then 1mg/hr with the monitoring of urine output, deep tendon reflexes and respiratory rate.Its continued for 24 hours either from the first dose or 24 hours after delivery .The infusion is halted if urine output is below 20mls/hr or refles are lost.if there is any concern regarding respiratory arrest, calcium gluconate(10mls over 10 minutes) given.Third stage should be managed with the IV or IM syntocinon bolus of 5iu.Syntometrine should be avoided as it may increase the BP further.
Post partum she still needs close monitoring as about 44% fits occur in this period.monitoring of BP, strict input /output charting,as there is increased risk of pulmonary oedema, fluid intake is restricted to 85mls/hour.
Antihypertensives should be continued depending on the BP, they might have to be continued at times for 3 months.Either Atenolol, labetolol, nifedipine or captopril can be used in post natally.Methyl dopa can be used though has concern regarding the side effect of depression.She should have a 6/52 check up with the GP and should have the formal visit to the hospital in the consultant clinic to discuss all the events regarding the delivery and she should be given an oppurtunity to ask any questions if she has any.Contraception advise should be given as she may not be able to take combined pills with the hypertension.before planning the next pregnancy should have an appointment in the preconceptional clinics .
Posted by adnan S.
Sever pre-eclampsia is the diagnosis a serious complication of pregnancy,with a potential to involve multi-system organs like hepatic ,renal,pulmonary CNS and coagulation system .
The patient should be admitted for the initial assessment ,history of headache,visual disturbance,epigastric pain or vomiting indicate worsening of pre-eclampsia.Examination is done to check her BP with appropriate size cuff which should be placed at the level of the heart with mercury sphygmomanometer or the automated machine which has been validated in pregnancy to establish baseline blood pressure.Peripheral oedema may be present .Abdominal examination is done to note epigastric tenderness, fetal lie, presentation and size is also noted .Tendon reflexes are checked to note clonus which indicate risk of convulsion .Fundal examination is done to note any signs of papilloedema.
Investigations include FBC,liver functions and renal function tests serum uric acid are done ,Clotting screening are not required if the platelet count is >100,000/L.
The blood pressure is monitored by checking every 15 minutes until and then every 30mts in the initial phase of assessment . The BP is checked 4 hourly if patient is stable,asymptomatic..FBC,LFT,and renal functions should be repeated at least daily when the results are normal but more often if the clinical condition changes or if there are abnormalities.
Fetal assessment is done initially with CTG but difficult to interprit at this gestation of 28wks.Ultrasound done for fetal assessment like measurement of fetal size umblical artery Doplpler,and liquor volume.
Management of this patient based on careful assessment,stabilization ,continued monitoring and delivery at the optimal time for the mother and the baby by the multidisciplinary team consist of senior obstetrician,anesthetist,senior midwives.The definitive treatment is delivery of the fetus but risks associated with prematurity and therefore aim should be to treat maternal hypertension ,ascertain fetal wellbeing and prolong pregnancy which may improve perinatal outcome.
For the treatment of hypertension antihypertensives like labetalol which can be given orally or intravenously ,nifedipin given orally or intravenous hydralazine can used for the acute management .If conservative management is planned methyldopa and labetolol are the most commonly used drugs but no evidence that any particular drug is superior.Atnolol,should be avoided as it is associated with an increase in increase fetal growth retardation,ACEinhibitors and diuretics should be avoided.Nifedepin is an alternative which should be given orally .Corticosteroids should be given for lung maturity as it is likely that delivery would be required within 2 weeks and SCBU should be informed.Eclampsia prophylaxis with magnesium sulphate depends on clinical finding may not be necessary if asymptamatic ,BP,well controlled and blood results are normal.Fetal monitoring is done with regular growth scan and umblical artery doppler.Timing of delivery depends on blood results ,response of BP to treatment and presence /absence of fetal compromise. If BP is well controlled blood test are normal expectant management is planned with BP assessment 4-6hourly ,daily urine analysis ,blood tests twice weekly and normal fetal growth ,delivery at around 37 wks .Delivery should be considerd immediately if inability to control blood pressure ,deteriorating haematological or biochemical indices ,eclampsia,HELLP syndrome and fetal compromise develops.The mode of delivery will be C-Section as induction of labour less likely to be successful at this gestation .
The 3rd should be managed with syntocinon,ergometrine or syntometrine should not be given for prevention of haemorrhage,as this can further increase the blood pressure.
After delivery risk of eclampsia increases hence she should have continued close observation posnatally.The incidence of eclampsia falls after fourth post partum day. Careful rewiew is done befor discharge from hospital,antihypertensives should be continued depending upon the blob pressure.Follow up appointment with GP is given for assessment of BP and proteinuria at 6 weeks,if hypertension or proteinuria persists then further investigations are required.A formal postnatal rewiew is offerd to discuss the events of pregnancy .Preconceptional counselling should be offerd .

Posted by Vinayak B.
dear Dr paul,
i think my essay is missed out for correction a reminder please