Managing severe preeclampsia in pregnancy

Mrs. AB is 35 years old. She is currently about 24 weeks into her first pregnancy, which was achieved following fertility treatment at the Assisted Reproductive Technology at Medical Art Centre.

She has no significant surgical history, but suffered from high blood pressure, also known as hypertension; and was on treatment for this prior to pregnancy. At 24 weeks of pregnancy, she developed a further rise in her blood pressure, associated with the presence of protein in the urine – a condition known as preeclampsia.

This resulted in a significant decline in her baby’s growth (intra–uterine growth retardation), found on ultrasound scan of her pregnancy. A series of laboratory tests were requested, including a full blood count, kidney and liver profile, urine protein content and blood clotting profile. All came back to be within the normal range. She and her baby were closely monitored and followed up in our obstetric consultant-led clinic, which is fully equipped to look after high-risk pregnancies like preeclampsia, multiple or higher order pregnancies, and obstetric emergencies, among others.
ADVERTISEMENT

What you should know about preeclampsia

Approximately 10 per cent of pregnancies are complicated by high blood pressure. Thirty per cent of these are already present before occurrence of pregnancy – that is, chronic hypertension; while the remaining 70 per cent are due to preeclampsia – also previously referred to as toxaemia of pregnancy.

Symptoms

Preeclampsia is an enigmatic disease that can cause multiple organ dysfunctions in pregnant women, with severe consequences if ignored and not promptly treated. These complications, occurring usually during the last three months of pregnancy, may include kidney or liver failure, bleeding disorders, bleeding into the brain tissue, generalised seizures or fits (known as eclampsia) and death.

Preeclampsia is a rise in blood pressure after 20 weeks of pregnancy, usually returning to normal within three months post-delivery. Clinically, it causes hypertension, protein in the urine, with or without swollen feet.

The disease can present in mild form (where the blood pressure is more than or equal to 140/90 mmHg), moderate and severe (BP more than 160/ 110 mmHg) forms.

Preeclampsia can present with one or more of the following: protein in the urine of more than or equal to 300 mg/day or 1g/L, kidney, liver, brain and/or blood dysfunctions. Foetal complications, including restriction of foetal growth, hydrops or swelling, death while still in the womb or stillbirth can be associated.

Theories regarding the cause of preeclampsia include genetic predisposition, abnormal placental formation or placental tissue invasion, blood clotting abnormalities, vascular endothelial damage, cardiovascular maladaptation, immunologic phenomena, and dietary deficiencies or excesses.

Risk factors

Risk factors for preeclampsia are as follow: first pregnancy, pregnancy during the teenage years or in those over 40 years of age, black race, family history or genetic predisposition, chronic hypertension and kidney disease. Others include antiphospholipid syndrome (an autoimmune disease), twin or higher order gestation and obesity.

The clinical manifestations of preeclampsia can be many. In mild cases it may be asymptomatic that is, no obvious complains from the patient however, in cases that have moderate to severe preeclampsia the patient may complain of headache, disorientation, visual disturbances, respiratory difficulty, right-sided upper (quadrant) abdominal pain, unusual anxiety and they are also at increased risk of convulsions that is, Eclampsia.

Diagnosis

Criteria for the diagnosis of severe preeclampsia include a blood pressure more than 160/110 mmHg; sudden onset of deterioration in kidney function or failure; protein of 5g in a 24-hour urine sample; and reduced urine production of less than 500ml in 24 hours).

Others are generalised seizures/convulsions (eclampsia); fluid in the lungs (pulmonary oedema); HELLP syndrome (haemolysis, elevated liver enzymes and low platelets); symptoms suggesting organ involvement such as headache, visual disturbances and epigastric or right upper abdominal pain; foetal growth retardation and oligohydramnios (reduced amniotic fluid).

Clinical tests used to predict preeclampsia include, Average Mean Arterial Pressure of more than 85-90 mmHg. MAP at 20 weeks of more than 90 mmHg, rollover test at 28-32 weeks or a combination of the above.

Others include Doppler velocimetry of the uterine and umbilical vessel at 18-26wks, foetal survival – gestational age/birth weight and Angiotensin infusion test at 26-30 weeks.

To be concluded.