Case ReportSevere preeclampsia

Shillea Olimpia MelytaFAA 111 0040

FACULTY OF MEDICINEUNIVERSITY OF PALANGKA RAYARSUD dr. DORIS SYLVANUS PALANGKA RAYA2015

I. History I.1 Identification of Patients Name: Mrs. L Age: 43 years Education: Junior High school Religion: Hindu Occupation: Swasta Tribe / Nation: Dayak / Indonesia Address: Kereng bangkirai Taheta Palangkaraya IDENTITY OF PATIENTS

Husband's name: Mr. U Age: 51 years Education: Elementary School Religion: Hindu Occupation: Swasta Tribe / Nation: Dayak / Indonesia MRS dated January 23, 2015 at 10:30 pm

I.2 Complaints-Main complaints: Swelling -History Disease Now: Os come with swelling of the hands, feet and tingling of hands and feet from one month ago. Os claimed to have been pregnant for 7 to 25 weeks' gestation. During this os no history of high blood pressure, only in this pregnant high blood pressure, there is heartburn, pastures eyes blurred (-), a history of seizures (-), Small bowel movements (+) like tea, nausea (-) , vomiting (-), cough (-), shortness of breath (-), abdominal contraction (-), blood mucus (-), water out from vaginal (-), fetal movements (+), ANC (-), ultrasound ( -) History of trauma (-), History of Operations (-), Fever (-).

I.3 History MenstruationMenarche: 14 years Cycle: 28 days Duration: 3-5 days Quantity: 2 times a day dressing pads Dysmenorrhea: - HPHT: 18-07-2014 TP: 25-05-2015

I.4 History of Marriage:Marital status: Legal Marriage to: 1 Married Age: 28 years Older married: 15 years Husband when married Age: 36 years Number of living children: 4 childThe number of child deaths: 2 child

Formerly Disease history: History Hypertension (-), DM (-), asthma (-), allergy (-), gatritis (+), cors disease (-), kidney disease (-), SC Operation (-). Family Disease History: History Chronic Disease, Hypertension (-). History contaceptions: KB Inject 3 months

The general state: Not good Awareness: Compos mentis Vital Signs: Blood pressure: 240/130 mmHg Pulse: 110 x / minute RR: 20 x / minute Temperature: 36.1 Cephal: Conjunctival anemis (- / -), sclera jaundice (- / -), palpebra not edema Collum: lymphadenopathy (-), increased JVP (-)

Continues...Thorax: Pulmo: I: symmetrical shape, retraction (- / -), symmetrical breathing motion P: fremitus touch symmetric P: sonor / resonant A: vesicular breath sounds, ronkhi - / -, wheezing - / - Cor : I: ICTUS cordis (-) P: thrill (-) P: Right limit ICS II LS dextra, left LMK ICS IV A: S1 S2 regular single, Murmur (-), Gallop (-) Abdomen: Convex, BU (+) Normal, timpani, Pain Press (-) Extremities: Above: warm, pitting edema (+ / +), no deformity, CRT

b. Obstetrics Status 1. Examination outside Inspection: abdomen looks convex Palpation: Leopold 1: TFU 2 fingers above the umbilicus (McD 25 cm) Leopold 2: Back Left Leopold 3: Head of Presentation Leopold 4: Not signed The pelvic Auscultation: FHR: (+) 135 x / minute 2. Examination in Inspekulo and Vaginal toucher not done

III. Laboratory results dated January 23, 2015Hb: 11.4 g% (L: 14-18 P: 12-16) Hematocrit: 36% (L: 35-55 C: 36-48%) Erythrocytes: 3.75 million / mm3 (P: 4.0 to 5.5 jt / mm3) Leukocytes: 9,900 / mm3 (5,000-10,000 / mm3) Platelets: 134,000 / mm3 (150000-400000 / mm3) GDS: 136 mg / dl (

Diagnose G7P6A0, Age Pregnancy 25 weeks, not inpartu, a fetals intra-uterine single life, head presentation with severe Preeclampsia

IVFD: RL 500 cc + 6 grams of MgSO4 40% 20 MDGs Inj. Dexametasone 3 x 1 amp PO: Nifedipine 3 x 10 g Methyldopa 3 x 500 mg

The treatment

follow up

CHAPTER II

Preeclampsia - EclampsiaHypertension after 20 weeks gestationProteinuria > than 300 mg/dl or +1 dipstickConvulsions: eclampsia

PreeclampsiaIncidence: 5 - 8% of all pregnancies.Etiology remains elusive.Major cause for maternal and perinatal mortality and morbidity.To date no treatment for prevention (baby ASA or calcium) or cure, except delivery.However, the maternal benefits must be weighed against the neonatal risks of preterm delivery.

PreeclampsiaDefinition = New onset of hypertension and proteinuria after 20 weeks gestation.Systolic blood pressure 140 mmHg OR diastolic blood pressure 90 mmHgProteinuria of 0.3 g or greater in a 24-hour urine specimen Preeclampsia before 20 weeks, think MOLAR PREGNANCY!CategoriesMild PreeclampsiaSevere PreeclampsiaEclampsiaOccurrence of generalized convulsion and/or coma in the setting of preeclampsia, with no other neurological condition.

PreeclampsiaSevere Preeclampsia must have one of the following:Symptoms of central nervous system dysfunction = Blurred vision, scotomata, altered mental status, severe headacheSymptoms of liver capsule distention = Right upper quadrant or epigastric painNausea, vomitingHepatocellular injury = Serum transaminase concentration at least twice normalSystolic blood pressure 160 mm Hg or diastolic 110 mm Hg on two occasions at least six hours apartThrombocytopenia =

Severe Preeclampsia CriteriaIn order to make the diagnosis, one of the following should be present:

Blood pressure of 160 mm Hg systolic or higher or 110 mm Hg diastolic or higher on two occasions at least 6 hours apart while the patient is on bed rest

Proteinuria of 5 g or higher in a 24-hour urine specimen or 3+ or greater on two random urine samples collected at least 4 hours apart

Oliguria of less than 500 mL in 24 hours

Cerebral or visual disturbances

Pulmonary edema or cyanosis Epigastric or right upper-quadrant pain

Impaired liver function

Thrombocytopenia

Fetal growth restriction

ACOG,Practice Bull.2002

Etiology1. abnormal trophoblast invasion of the blood vessels of the uterus. 2. immunological intolerance between maternal and fetoplacental tissue. 3. Maladaptation mother against cardiovascular changes or changes in the inflammatory response of normal pregnancy. 4. Factor nutritional deficiencies. 5. Genetic factors

Risk Factors for Hypertension in PregnancyNulliparityPreeclampsia in a previous pregnancyAge >40 years or

Defective trophoplast invasion hypoperfused placenta release factors (growth factors,Cytokines) vascular endothelial cellactivation.Vasospasm hypertensionEndothelial cell damage oedema, hemoconcentrationKidneys,glomeruloendotheliosis proteinuria,reduced uric excretion and oligouria.

Liver,subendothelial fibrin deposition elevated liver,hemorrhage,infarction,liver rupture and epigastric pain.Blood thrombocytopenia,DIC,HELLP syndrome.Placental vasospasm placental infarction,placental abruptio& uteroplacental perfusion IUGR.CNS vasospasm&oedema headache, visual symptons(blurred vision,spots,

PathophysiologyEndothelial cell injuryGeneralized vasoconstriction

Possible mechanisms in PreeclampsiaFriedman and Lindheimer,1999

Preeclampsia - PathophysiologyMay be initiated by placental factors that enter the maternal circulation and cause endothelial dysfunction resulting in hypertension and proteinuria.

Recently, soluble fms-like tyrosine kinase 1 (sFlt-1) an antiangiogenic protein has been found to be increased in preeclampsia (Maynard et al.J Clin Invest 2003)

Angiogenic FactorsEndothelium

Preeclampsia - PathophysiologysFlt-1 acts by binding to placental growth factor(PGF) and vascular endothelial growth factor (VEGF), preventing the interaction with endothelial receptors on the cell surface and inducing endothelial dysfuntion.

Exogenous administration of sFlt-1 in pregnant rats induces hypertension, proteinuria, and glomerular endotheliosis.

Circulating Angiogenic Factors and the Risk of Preeclampsia

Circulating angiogenic factorsIncreased levels of sFlt-1 and reduced levels of PIGF predict the subsequent development of preeclampsia

Preeclampsia - PathophysiologySoluble Endoglin (CD105), a cell receptor for transforming growth factor-beta (TGF-), has been localized to both placental syncytiotrophoblasts and endothelial cells.

The primary role include angiogenesis, endothelial cell differentiation and regulation of vascular tone through endothelial nitric oxide synthetase (enos)

Preeclampsia - PathophysiologySoluble endoglin as a second trimester marker for preeclampsia

Soluble endoglin elevated in patients destined to develop severe early-onset preeclampsiaRobinson JC, Johnson D. AJOG 2007:197

Circulating angiogenic factorsIncrease sFlt-1Increase EndoglinDecrease PGIF

in patients that will develop clinical preeclampsiaLevine et al, NEJM; 2004Robinson CJ, Johnson DD. AJOG 2007

Preeclampsia: ManagementMild: 140/90, +1 proteinuria. Management: conservative, bedrest, deliver if close to term

Severe: Significant HTN, proteinuria (>5g/24hrs) or any systemic manifestation of the disease. Management: Consider delivery

Eclampsia: Delivery

Spasm of vesselsVessel stenosisHigher periphery resistanceBlood pressure elevateInjury of endotheliocyteProteinuriaEdemaHypertensionPathology

Preeclampsia superimposed on Chronic HypertensionAffects 10-25% of patients with chronic HTNPreexisting Hypertension with the following additional signs/symptoms: New onset proteinuriaHypertension and proteinuria beginning prior to 20 weeks of gestation.A sudden increase in blood pressure.Thrombocytopenia.Elevated aminotransferases.

Treatment of PreeclampsiaDefinitive Treatment = DeliveryMajor indication for antihypertensive therapy is prevention of stroke. Diastolic pressure 105-110 mmHg or systolic pressure 160 mmHgChoice of drug therapy:Acute IV labetalol, IV hydralazine, SR Nifedipine Long-term Oral methyldopa or labetalol

Evaluation of Hypertension in PregnancyHistoryID and ComplaintHPI (S/S of Preeclampsia)Past Medical Hx, Past Family Hx Past Obstetrical Hx, Past Gyne HxSocial HxMedications, AllergiesPrenatal serology, blood workAssess for Hypertension in Pregnancy risk factors

PhysicalVitalsHEENT = Vision CardiovascularRespiratoryAbdominal = Epigastric pain, RUQ painNeuromuscular and Extremities = Reflex, Clonus, EdemaFetus = Leopolds, FM, NST

Evaluation of Hypertension in PregnancyLaboratory TestsCBC (Hgb, Plts)Renal Function (Cr, UA, Albumin)Liver Function (AST, ALT, ALP, LD)Coagulation (PT, PTT, INR, Fibrinogen)Urine Protein (Dipstick, 24 hour)

Management of Hypertension in PregnancyDepends on severity of hypertension and gestational age!!!!

Observational ManagementRestricted activityClose Maternal and Fetal MonitoringBP MonitoringS/S of preeclampsiaFetal growth and well being (NST, and U/S)Routine weekly or biweekly blood work

Management of Hypertension in PregnancyMedical ManagementAcute Therapy = IV Labetalol, IV Hydralazine, SR Nifedipine Expectant Therapy = Oral Labetalol, Methyldopa, NifedipineEclampsia prevention = MgSO4

Contraindicated antihypertensive drugsACE inhibitorsAngiotensin receptor antagonists

Management of Hypertension in PregnancyProceed with DeliveryVaginal Delivery VS Cesarean SectionDepends on severity of hypertension!May need to administer antenatal corticosteroids depending on gestation!

Complications of mother

Heart failureCerebrova- scular accidentPlacenta abruptionDICRenal failureHELLPS syndromePostpartum hemorrhage

FetusFGRfetal distressfetal deathneonatal asphyxia

Complications of fetus

HELLP SYNDROMEIs a severe form of pre-eclampsiaAffects approx 10% of women with severe preeclampsia and 30-50% of women with eclampsia.Characterized by:Hemolysis, Elevated liver enzymesLow platelet count. Increased mortality rate and DIC

MANAGEMENT OF SEVERE PRE ECLAMPSIA AND ECLAMPSIANote: Severe pre-eclampsia is managed like eclampsia

Management protocol for eclampsiaKeep airway clearControl convulsionsControl BPControl fluid balanceAntibioticsInvestigationsDeliver the mother

MANAGEMENT CONTBP CONTROLKeep SBP between 140 -160 mm Hg and DBP between 90 -110 mm Hg ?Why these levels: Avoid potential reduction in either uteroplacental blood flow or cerebral perfusion pressure. Drugs: Anti HPTs: Hydralazine, nifedipine, or labetalol Diuretics are not used except in the presence of pulmonary edema

MANAGEMENT: CONTROL CONVULSIONSI. An overview on MgSO4. Mechanism: Cerebral vasodilator reducing cerebral vasospasm ischemia (brain).Superior to other anti-convulsants used to control and prevent fits;Important part of mgt of eclampsiaRecurrence rate after MgSO4 = 10 -15%Improves maternal and fetal outcome

CONTROL CONVULSIONS - REGIMEN1. INTRAMUSCULAR REGIMENi. Loading doseGive MgSO4 4 g (i.e. 20mls of 20% solution) + 200mls NS or sterile water I.V over 5 minutesFollow promptly with 10g (i.e. 20ml of 50% solution), 5g in each buttock as deep I.M with 1ml of 2% lignocaine in the same syringe

MANAGEMENT CONTCONTROL CONVULSIONS - REGIMEN1. INTRAMUSCULAR REGIMEN cont

ii. Maintenance doseMgSO4 5 g (i.e. 10ml of 50% solution) + 1 ml lignocaine 2% 4 hourly in alternate buttocks. NOTE: IM inj. are painful and are complicated by local abscess formation in 0.5% of cases. The intravenous (IV) route is therefore preferred

MANAGEMENT CONTCONTROL CONVULSIONS - REGIMEN2. INTRAVENOUS REGIMENi. Loading doseMgSO4 4 g (i.e. 20mls of 20% solution) + 200mls NS I.V over 5 minutesii. Maintenance doseMgSO4 4 g (i.e. 20ml of 20% solution) IN 500ml NS 4 hourly for 24 hrs after the last fits

MANAGEMENT CONTCONTROL CONVULSIONS - REGIMENRecurrent fits (any regimen): Therapeutic dose may not have been reachedGive 2g (i.e. 10ml of 20% solution) i.v. over 5 minutes

Treatment duration: Continue for 24 hours after delivery or last convulsion, whichever occurs first

MANAGEMENT CONTDELIVER THE MOTHERDelivery should be within 6-8 hours of onset of fitsVaginal delivery is the safest mode of deliveryAssessment R/O contraindications to SVDBishop scoreIf the cervix is favourable - induce labourOtherwise prepare for C/S

MANAGEMENT CONTManagement of labour1st stageRelieve pain: pethidine 25 mg iv every 2-4 hoursAugmentation of labourMonitor FHR,2nd stage: Assist with vacuum extraction3rd stage: Active managementOxytocin 10 IU i.m after delivery of anterior shoulder Cord tractionSqueezing clots after delivery of the placenta

MANAGEMENT CONTManagement of labourIf there is delay perform C/SPost delivery: Continue observation for at least 48 hrs post deliveryRecord and monitor BP and urine output for at least 48 hours after delivery, Keep the pt in hospital until BP stabilizes, Continue with aldomet PO until BP back to normal

Thankyou

*9/29/2014***************