Makindo Medical Notes

Patients with resistant severe hypertension or persistent cerebral symptoms while on magnesium sulfate should be delivered immediately, irrespective of gestational age. Approximately 5% of women with preeclampsia show signs and symptoms postpartum.

About

• Hypertensive disorders affect 7-10% of pregnant women.
• Possible association with fetal Long Chain Acyl-CoA Dehydrogenase Deficiency.

Preeclampsia (HTN + Proteinuria)

• Hypertension starting after 20 weeks of pregnancy, with significant proteinuria that resolves within 12 weeks postpartum.
• Proteinuria: ≥300 mg per 24-hour collection or 1+ on dipstick (on two occasions, ≥4 hours apart).
• Severe preeclampsia shows proteinuria ≥3+.

Effects

• Maternal hypertension reduces blood supply to the fetus, possibly leading to growth restriction or other developmental issues.

Eclampsia (Seizures)

• Characterized by grand mal seizures in pregnant or postpartum women with preeclampsia, unexplainable by other causes.
• Most cases occur in the third trimester after 28 weeks.

Severe Preeclampsia

• Defined by DBP ≥110 mmHg, SBP ≥160 mmHg, and/or symptoms or biochemical/hematological impairments.

HELLP Syndrome

• Haemolysis, Elevated Liver enzymes, and Low Platelets.
• Often accompanied by severe hypertension and systemic complications.

Clinical Presentation

• Severe headache, sudden swelling of face/hands/feet, visual disturbances, epigastric pain, vomiting, clonus, papilledema, liver tenderness, and HELLP syndrome indicators (e.g., platelets <100 x 10⁶/L, ALT/AST >70 IU/L).

Complications

• Eclamptic seizures, cerebral hemorrhage, stroke, renal failure, liver hematoma or rupture, placental abruption, preterm delivery, and death.
• Preeclampsia may develop or worsen after delivery.

Investigations

• FBC, U&E, LFTs, urate, creatinine.
• Coagulation screen if platelets <100 x 10⁶/L.
• ECG and CT head as needed to rule out stroke or hemorrhage.
• Blood group and hold serum.

Assessment

• Test urine for protein regularly.
• Record fluid intake and output; monitor with MEOWS chart.
• Fetal assessment with continuous cardiotocography (if in labor).
• Fetal ultrasound for estimated fetal weight, amniotic fluid volume, placental maturity.
• Fetal umbilical artery and middle cerebral artery Doppler studies if growth restriction is suspected.

24-Hour Urine Collection

• For total protein, creatinine clearance, and catecholamines (if needed).

Management of Seizures

• Stabilize ABCs; consult obstetrics immediately.
• Magnesium Sulfate: IV loading dose of 4-6 g over 20 minutes; maintenance dose of 1-2 g per hour for 24-48 hours.

Management of Hypertension

• Hydralazine: 5-10 mg IV administered slowly.
• Labetalol: 20-40 mg IV, repeated every 15 minutes as necessary.

Maternal and Fetal Health

• Evaluate maternal and fetal status to decide on delivery, especially if severe hypertension is resistant or cerebral symptoms persist on magnesium sulfate.
• Administer corticosteroids for fetal lung maturation if gestational age is 24-34 weeks.

References

• Eclampsia: An Overview - Clinical Presentation, Diagnosis, and Management
• Management of Severe Preeclampsia and Eclampsia