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
- H aemolysis, E levated L iver enzymes, and L ow P latelets.
- 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 haematoma 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