Managing severe preeclampsia in pregnancy (2)

Continued from last Tuesday

If not promptly treated, hypertensive disorders during pregnancy can be associated with significant maternal, foetal, and neonatal decompensation (inability of the heart to maintain adequate circulation) and mortality.

The best mode of treatment is to deliver the baby before the onset of complications, after taking good control of the blood pressure during pregnancy and continued in labour and delivery.

When the pregnancy is above 37 weeks, irrespective of the severity of the disease, delivery should be seriously considered. There’s no point in waiting till the onset of complications before rushing to do any emergency delivery.

In mild or moderate preeclampsia, especially in early gestation between 23 weeks and to below 30 weeks, expectant management can be considered. Specifically, in well-controlled preeclampsia, there is a lack of unanimity as to the optimum time to deliver the mother safely and also ensure the delivery of a live, healthy infant – both of which are paramount.

In such controlled cases where blood pressure is normalised and there are no signs of metabolic complication, conservative management is optimal in order to give the foetus time to mature.

Optimal time to deliver should take into cognizance the risk benefit ratio between the delivery of a premature baby (with all the associated complications of prematurity) and avoiding significant complications to the mother from excessively high blood pressure.

Such complications to the mother include eclampsia or generalised fits, brain haemorrhage, stroke, paralysis, multi-organ damage and/or death due to the very high blood pressure and multi-organ damage.

Therefore, expectant management can be considered in a situation with controlled hypertension, urinary protein of more than 5,000mg/24 hours and/or oliguria (less than 0.5 ml/kg/hr of urine) that resolves with routine fluid and food intake, elevated liver enzymes of more than two times upper limit of normal without epigastric pain or right upper quadrant tenderness.

Delivery should be expedited (within 72 hours and irrespective of estimated gestational age) if there is sudden onset of deterioration in maternal or foetal wellbeing, such as if the hypertension becomes severe and uncontrollable, if the mother develops fits (eclampsia) or in the presence of persistent severe headache or visual changes, epigastric pain or right upper quadrant abdominal tenderness, respiratory difficulty or pulmonary oedema, compromised kidney functions, abnormal blood test parameters like platelet count below 100,000 cells/dL, elevated liver enzymes more than two times the upper limit of normal, with foetal complications.

These include foetal distress and significantly abnormal cardiotocograph readings. Such women must be closely monitored during the delivery process in a consultant obstetrician-led unit. This is done in conjunction with consultant anaesthetist and neonatologist or neonatal intensivist, especially if the baby is in extremes of maturity and needs to be admitted for care in the neonatal intensive care unit post-delivery.

In the pregnancies less than 36 weeks, delivery should be after the mother has completed betamethasone steroid injections to mature the baby’s lung.

To prevent preeclampsia, a number of therapeutic initiatives (starting before 16 weeks of pregnancy) are available, and they include low-dose aspirin and calcium supplementation. However, there has not been very good consistencies in the beneficial effects of these therapies, pointing to other factors such as genetics, immunological factors, abnormal trophoblastic invasion and adaptation of spiral arteries that work synergistically in the causes of preeclampsia.

As for our client Mrs. A.B., her condition deteriorated, her BP became largely unresponsive to multiple antihypertensives with deranged liver profiles associated with right hepatic pain and tenderness.

Furthermore, her baby’s growth became stunted and static at 29 weeks of pregnancy, with ultrasound estimated foetal weight of 980 grams. Mrs A.B. was stabilised clinically with titrated intravenous magnesium sulphate and crystalloids infusions and delivered in our maternity unit successfully by caesarean section after 48 hours of treatment.

During this time, she had betamethasone steroid injections to mature her baby’s lungs to ameliorate foetal risks of prematurity, including respiratory distress syndrome. The baby was managed in our well-equipped neonatal intensive care unit by our neonatology consultant, using surfactant, respiratorator and then the Cpap equipment, among others.

The baby spent eight weeks in our neonatal intensive care unit, and was discharged home in good health to the loving arms of her parents.

Concluded.