Pre-eclampsia, Eclampsia and HELLP syndrome

Pre-Eclampsia
Definitiona disorder associated with pregnancy consisting of hypertension, proteinuria and new-onset dependent oedema, most commonly after 20 weeks of gestation

Diagnosis

Hypertension- syst > 140mmHg or 30mm above pre-preg

diastolic > 90 mmHg or 15mm above pre-preg Two abnormal measurements, on two occasions, more than 6 hours apart

Emergencies:

Emergency hypertension Pulmonary edema Severe bleedings Acute renal failure Brain accident/seizures Hepatic ruptured

Epidemiology

Freq (US) pre-eclampsia: 6-8% of pregnancies

eclampsia: 0.05-0.2%

Etiology

Exact pathophysiology unknown Possible causes

dysfunction of the uteroplacental bed leading to vasoconstriction, platelet aggregation and hypercoagulability altered CoV reactivity, vasospasm, microthrombi, implantation problems, hypertension etc

Mortality/Morbidity

Maternal: 8-36% most frequently related to seizure activity

Fetal: 13-30% most frequently related to iatrogenic prematurity

Risk Factors

Low socioeconomic class Multiple foetuses, or hydatid Maternal age <20 or >35yrs Primip Gestational or pre-gestational DM Renal disease Afro Caribbean- twice as likely Family history- four times the risk

Symptoms

Headache Oedema Visual disturbance Focal neurology, fits, anxiety, amnesia Abdo pain Decreased urine output None

Signs

Hypertension Tachycardia and tachypnoea Creps or wheeze on auscultation Neurological deficit Hyperreflexia Petechiae, intracranial haemorrhage Generalised oedema Small uterus for dates

Investigation

Hypertension Urinalysis- proteinuria greater than 2+ Blood tests CT head Foetal USS

Fetal complications of severe preeclampsia

Intrauterine growth retardation Premature delivery Abruptio placentae Fetal distress/fetal demise
Associated maternal risks General/regional anesthesia DIC Hemorrhage

Maternal complications of severe preeclampsia

Cardiovascular dysfunction (cardiac failure, hypertension) Renal dysfunction (oliguria, reduced GFR, elevated creatinine, acute tubular necrosis, cortical necrosis) Respiratory dysfunction (ARDS, pulmonary edema) Hepatic dysfunction (elevated liver enzymes, subcapsular hematoma, HELLP syndrome) Cerebral dysfunction (encephalopathy, ischemia, cortical blindness, retinal detachment, infarction, hemorrhage, edema, eclampsia)

Complications/prognosis

Permanent neuro damage Renal insufficiency Abruption Death 25% of eclamptics will be so in future pregnancies Increased risk of essential hypertension

HELLP syndrome

Undiagnosed pre-eclampsia progresses to causeHaemolysis Elevated Liver enzymes Low Platelets

May also occur de novo

HELLP

Incidence-

0.1-0.6% of pregnancies 4-12% of pre-eclampsia Similar to pre-eclampsia with

RUQ/epigastric pain Jaundice Microangiopathic anaemia Deranged LFTs

Treatment- ABC, O&G, admit, deliver

Eclampsia
Definitionpre eclampsia complicated with seizures

Delivery of the fetus and placenta is the definitive management of severe preeclampsia. Once severe disease has been established and is progressing, delivery of the fetus and placenta must be accomplished to limit maternal risk.

Int Care Med 1997: 23: 248-255