PRE- ECLAMPSIA : definition, clinical feature , complication , management

“It is a multisystem disorder of unknown etiology characterized by development of hypertension to the extent of 140/90 mm Hg or more with proteinuria after the 20 th week in a previously normotensive and nonproteinuric women “

Some amount of edema is common in normal pregnancy.

Edema has been excluded from the diagnostic criteria unless it is pathological.

“PIH is defined as the hypertension that develops as a direct result of the gravid state. It include ….

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

Incidence :

1. The incidence of pre eclampsia in hospital practice varies widely from 5 to 15%
2. The incidence in primigravidae is about 10% and in multi gravidae 5%

Risk factor of pre-eclampsia :

1. Primigravida : young or elderly (first time exposure to chronic villi)
2. Family history :hypertension, pre-eclampsia
3. Placental abnormalities
4. Obesity : BMI >35 kg , insulin resistance
5. Preexisting vascular disease
6. New paternity , pregnancy following ART
7. Thrombophilias : antiphospholipid syndrome , protein C , S deficiency, factor V leiden

Diagnostic criteria :

• An absolute rise of blood pressure of at least 140/90 mmHg ,if the previous blood pressure is not known or a rise in systolic pressure of at least 30 mmHg , or rise in diastolic pressure of at least 15 mmHg over the previously known blood pressure is called pregnancy induced hypertension.
• Blood pressure is measured on the right arm with the patient lying on her side at 45 degree to the horizontal

EDEMA :

• Pitting edema over the ankles after 12 hours bed rest or excessive gain in weight of more than 4lb a week in the later month of pregnancy may be the earliest evidence of pre-eclampsia .
• However the some amount of edema is common in the normal pregnancy .

PROTEINURIA :

• Presence of total protein in 24 hour urine of 0.3 g or more

CLINICAL TYPES :

The clinical classification of pre-eclampsia is arbitrary and principally depend on the level of blood pressure for management purpose

Proteinuria is important, however level of blood pressure is considered more significant to predict maternal and fetal outcome.

1. This include cases of sustained rise of blood pressure of more than 140/90 mmHg but less than 160 mmHg systolic or 110mmHg diastolic without significant proteinuria

SEVERE: 

1. A persistent systolic blood pressure above or equal to 160 mmHg or diastolic pressure above 110 mmHg
2. Proteinuria-Present
3. Oliguria
4. Platelet count less than 100000/mm3
5. Elevated liver enzyme
6. Cerebral or visual disturbance
7. Persistent severe epigastric pain
8.  Retinal hemorrhage , exudates or papilledema
9. Intrauterine growth restriction of the fetus
10. Pulmonary edema

CLINICAL FEATURES :
SYMPTOMS : Pre-eclampsia is principally a syndrome of signs and when symptoms appear, it is usually late.

1. Slight swelling over the ankles which persists on rising from the bed in the morning or tightness of the ring on the finger is the early manifestation of edema .
2. Gradually ,the swelling may extend to the face, abdominal wall , vulva and even the whole body .

ALARMING SYMPTOMS :These are usually associated with acute onset of the syndrome…

1. HEADACHE : either located over the occipital or frontal region
   
2. DISTURBED SLEEP
3. DIMINISHED URINE OUTPUT :urinary output of less than 400 mL in 24 hours .
4. EPIGASTRIC PAIN : acute pain in the epigastric region associated with vomiting,
5. EYE SYMPTOMS : there may be blurring , scotomata ,dimness of vision or at time complete blindness , retinal detachment .

SIGN :

1. Abnormal weight gain
2. Rise of blood pressure
3. Edema
4. Pulmonary edema
5. Abdominal examination may reveal evidences of chronic placental insufficient , such as scanty liquor or growth retardation of the fetus.

INVESTIGATION :

1. Urine examination
2. ophthalmic examination
3. blood values
4. Antenatal fetal monitoring

COMPLICATION :

1. Chances of eclampsia
2. Accidental hemorrhage
3. Oliguria and anuria
4. dimness of vision
5. Preterm labor
6. HELLP syndrome
7. Cerebral hemorrhage
8. Acute respiratory syndrome
9. postpartum hemorrhage
10. shock
11. sepsis