Pre eclampsia

Case: 41/M/F, G1P0 at 29W+2d POA

High blood pressure and proteinuria 3+

Question

a) Investigation and reason

b) Treatment plan

c) Time of delivery and why?

My impression: High blood pressure with proteinuria could lead to Pre eclampsia which is worrisome due to serious complication. Therefore, PE should be ruled out first before considering other condition that may falsely give positive result to proteinuria.

PE is defined as:

Hypertension unique to pregnancy, diagnosed after 20W of gestation and associated with new onset proteinuria; Eclampsia if seizure occur.

If woman already having pre existing HPT but after 20W she develops new onset proteinuria, sudden increase in BP, thrombocytopenia or elevated liver enzymes, then PE with superimposed on chronic hypertension must be suspected.

HELLP (Hemolysis, Elevated liver enzyme, low platelet) is a variant of PE with involvement of liver giving rise to tender epigastric pain, and finally DIC.

Investigation

1) Repeat Dipstick testing within 6H

PE shows by urinary albumin >300mg/24 hour@ >1g/l in 2 random urine 6 hour a part.

1+ = 0.3 g/l, 2+ = 1 g/l and 3+ = 3 g/l.

2) 24 Hour proteinuria to see severity of PE. Severe PE >5000mg/24 hr.

3) BP should be checked every 15 minutes until women are stable. Then,

4) Close monitoring of BP (at least 4Hourly) + reflex, clonus.

5) PE profile twice a week (severe PE) or once a week(mild PE) compose of

a) Platelet count (decrease)

b) Uric acid (1^st indication of renal impairment)

c) Sr Creatinine level (renal function)

d) Liver enzyme, AST (liver damage)

e) Urine albumin as mention in above.

6) Clotting study if platelet < 100 x 10⁶/l

7) Input/Output Fluid Chart.

8) CTG for fetal well being.

9) Serial ultrasound measurements of fetal size, umbilical artery Doppler and liquor volume

Treatment plan

Mild PE

T. Methyldopa 250mg tds, max 3g/day or

T. Labetolol 100 mg tds, max 300mg tds

Or, Nifedipine

Severe PE

IV hydrallazine start 5mg, double if no effect until 35mg. change drug if fails or

IV Labetolol start 10 mg, double if no effect until max 300mg/day)

** MgSo4 slow infusion 4g 10-15 minutes. Maintenance dose IV ig/hour

When to Deliver

1. Delivery is definitive treatment if mother life is compromised. (Very high uncontrolled BP, platelet <100,>150 iU/L

2. Can wait until term if well controlled and fetal is not compromised.

3. If gestation >34W, then delivery after stabilization is recommended

4. In this case, prolong delivery for 24 Hr to give steroid injection for lung maturity

[RCOG Guideline No. 10(A) March 06]