Pre-eclampsia needs team based approach as it affects not only the women but fetus as well - Prof. Farrukh Zaman


 Obstetrics and Gynae session at PHL annual Congress
Pre-eclampsia needs team based approach
as it affects not only the women but fetus as
well - Prof. Farrukh Zaman
Hypertension disorders are still the most common
cause of still birth and neonatal death

LAHORE: Prof. Rubina Sohail was the first speaker in the special session devoted to Obstetrics & Gynaecology during the PHL annual conference held here last month. The topic of her presentation was “Hypertension in pregnancy: Impact on Maternal Health”. Commenting on the presentation Prof. Farrukh Zaman emphasized the importance of team based approach to pre-eclampsia management because it not only affect the women but the fetus as well. Almost one third of pregnant women, it was stated are affected by hypertension and many of them will develop eclampsia. It usually develops after 20th week of pregnancy. A Blood Pressure reading of 140/90 after few hours interval and on two occasions will need to be treated. However a BP of 160/110 even on one occasion will be eclampsia needing treatment.

Hypertension in pregnancy, it was further stated, is classified as gestational hypertension, chronic hypertension, pre eclampsia which can be mild, moderate and severe eclampsia. It accounts for 4-18% of all pregnancies. Hypertension disorders are still the most common cause of still birth and neonatal death. Delivery is the only cure for pre-eclampsia. Management outcome depends on gestational age and severity of the disease. These patients must be in hospital. Induction of labor is indicated after 37 weeks of gestation. These patients should be recommended bed rest and frequently evaluated. Some physical activity is recommended. C. Section should be reserved for obstetric indications after 37 weeks of gestation through vaginal delivery is preferred. Mild disease does not need any treatment just monitor these patients. Liver also gets impacted. In some cases one might have to intervene early and deliver early if needed.

Speaking about the complications of pre-eclampsia it was pointed out that there is two fold increase in Ischemic Heart Disease. It is important that the team managing these patients should include fetal medicine specialist, physician and the Gynecologist. This disease needs team based approach by neonatologist and interventionist in case of fits.

Prof. Azizur Rehman also discussed the treatment of hypertension in pregnancy. He pointed out that chronic hypertension should be diagnosed during first trimester and treated before pregnancy. Gestational hypertension develops during pregnancy which is due to pregnancy related hormonal changes. At times it is difficult to treat and has bad prognosis. He suggested treatment before pregnancy and during pregnancy till the blood pressure is controlled. The patient should be advised to take balanced diet and have regular exercise. Methyldopa is the oldest and safest drug during pregnancy. The recommended dose is 200-500mg BD. Labetalol 100-1200mg is safe and is better tolerated. Its IV preparation is also available. Metaprolol is also safe though there have been some reports of fetal growth retardation. Nifidipine 30-120mg once daily is safe. Hydralazine BD QID is also safe and its IV preparation is also available. ACEIs and ARBs are contra indicated during pregnancy.

During hypertension crisis, the patient should be hospitalized. Patient should be given Hydralazine, Labetalol and Nitroglycerin. Treatment goal should be to have a Blood Pressure of less than 140/909. A BP of 150/90 needs immediate treatment. Blood Pressure of 170/110 is hypertension emergency and such patients should be hospitalized. BP of 160/110 has severe risk while BP of 150/100 is a moderate risk and treatment will benefit. However, a BP of 140/90 treatment does not involve significant benefit and significant risks. Proper diagnosis of hypertension during pregnancy was important, he added.

Dr. Wajiha Inam’s presentation was on Gestational Hypertension. She pointed out that cardiac diseases are the most common cause of death in pregnancy. Pre-existing hypertension, IHD and thrombotic disorders all need to be treated appropriately. Complications are encountered in about 15% of patients during pregnancy. About 10% of pregnant patients are at high risk of developing pre-eclampsia, eclampsia and its prevalence is high in developing countries. She suggested that all hypertensive women should also be screened for other diseases. Women suffering from hypertension are at risk of developing pre–eclampsia during pregnancy and have more complications which include premature delivery, intra uterine death and intra uterine growth retardation can also occur. Convulsions are also seen in some cases of pre-eclampsia. Speaking about the signs and symptoms she mentioned rapidly swelling face, fingers, legs, nausea, vomiting besides epigastric pain.

Speaking about the crisis in pre-eclampsia she mentioned HELL syndrome, Placental abruption can also take place. It is also associated with ischemic, hemorrhagic bleeding. Diagnosis is made on high diastolic blood pressure of 90 on two occasions or 110 DBP on one occasion. Treatment consists of screening for pre eclampsia, treatment of hypertension, early referral to specialists and fetal surveillance. Delivery is planned in a team based approach. Blood Pressure of 140/90 should be treated immediately. A Diastolic Blood Pressure of 90-110 should also be treated but with a BP of 160/110 hypertension treatment becomes mandatory. She also mentioned about HELLP syndrome, convulsions and delivery, she stated, was the only cure. These patients should be put on Low Dose Aspirin Therapy from 12-weeks of gestation. Methyldopa and Nifidipine are the other safe, effective drugs. Almost 50% of women with severe pre-eclampsia will give pre-term birth.

This was followed by discussion on different case scenarios by Prof. Rubina Sohail. The first case she presented was a thirty years old with 34 weeks of pregnancy having a blood pressure of 117/115. Before anesthesia she developed tonic clonic fits, went into renal failure. She had other complications as well as many other organs were also involved. She was taken to the operation theatre for C-sections but she had fits. She was given magnesium sulphate, blood pressure was constantly monitored and she delivered a baby. Blood pressure of such patients should be constantly monitored but do not reduce it too low than 140/90. Make sure that such patients do not come back with another pregnancy for next at least three years. Long acting reversible methods can be adopted to avoid pregnancy. They should be advised to space the pregnancies and they can also be advised tubal ligation.

The second case which she presented was a 39 years old un-booked case with 38 plus five weeks gestation who presented in emergency. Transverse lie at 4 cm dilation. She had one year history of IHD and hypertension. Her BP was 140/100. Emergency C-sections was planned. She is now better on Aspirin and Beta blockers. Be mindful of anesthetic complications during C. Section. After delivery BP of such patients, she stated, will come down and stress will be reduced. Have a cardiologist on board. Get an Echocardiography done, keep the patient pain and stress free. Reduce her anxiety. Prof. Rubina Sohail suggested that such patients should always be managed by multidisciplinary approach. Skills of the obstetricians are very important. There should be no tears in the uterus and baby should be delivered safe.

Continuing Prof. Rubina Sohail further stated that in all such cases C-sections should be done by Senior Registrar or Assistant Professor because less time for surgery and more expertize will be beneficial for the patient. Preferably shift such patients to tertiary care facilities if no such facilities are available in your hospital. However, if you cannot transfer the patient, then do the C. Section. Now Rural Ambulance Service is available in Punjab and the patients can be shifted to other facilities.

The next case was a 27 year’s old 32 weeks gestation who presented with fatigue and lethargy. She had a history of Type-1 diabetes for the last one year. She had history of hypertension, retinopathy, and renal disease. She already had two first trimester pregnancy loss. She went into diabetic ketoacidosis because of poor control of diabetes. For managing such patients, Ketone meters, she said are now easily available. They can be used. Do ketones, administer immediate fluids as replacement is needed. She then discussed in detail the diagnostic criteria of DKA. Hypokalemia is most often the cause of death in such cases. If potassium is elevated, do not give potassium. Hypokalemia will trigger arrhythmia which might kill the patient. It is not insulin failure but it is considered failure of the doctor if the patient dies of arrhythmias. Manage the patient by putting them on fluids and monitor electrolytes, she remarked.