31 Chief complaint : . Present illness: G1P0 GA 34+2wks 1st ANC at GA 8 wks x13 visits BP GA 12 wks urine protein/sugar neg.

in/sugar neg. GA 34+2 wks urine protein 4+ BP 175/124 mmHg Lab I ,II HBsAg : -ve , VDRL : NR ,

Anti-HIV : -ve

 ANC U/S single viable fetus, transverse lie, FHS +ve, placenta previa, AFI 32 cm

 Past

history : no underlying 8 (Gut obstuction) Personal history Family history /

 Weight

81 kg. Height 175cm. Vital signs: BT=36.6 C PR=90/min RR=20/min BP 175/124 mmHg Heart : normal S1,S2, no murmur Lung : normal breath sound, no adventitious sound

Abdomen: distend, Linea nigra present ,no scar Height of fundus: 3/4>umbilicus Lie : transverse FHR=130 beats/min no uterine contraction PV: cervix not dilatate, 0% effacement, station -3, firm, MI (PV ultrasound placenta previa )

 urine protein 1+ Coagulogram PTT 42. 42.8 sec CBC PT 9.9 sec
WBC
x x x x x

7790 /mm3
60 % 30 % 5% 4% 1%

INR

0.83

Neut Lymph Mono Eos Baso

Hb

12 g/dL Hct 35 % MCV 89 fL Platelet 177,000/mm3

Electrolytes
Na K Cl CO2 ALP AST ALT TP ALB

136.5 mmol/L 4.68 mmol/L 106.6 mmol/L 17 mmol/L 350 U/L 34 U/L 27 U/L 5.6 g/L 2.0 g/L

BUN 24 mg/dL CRE 1.4 mg/dL Uric acid 11.1 mg/dL 11. TBIL 0.2 mg/dL DBIL 0.1 mg/dL

Case G1P0 GA 34+2 wk by U/S

History

of high blood pressure ( 140/90 mmHg) since GA 12 wk (by U/S) BP 175/124 mmHg Urine protein 4+ edema 2+ both legs Placenta previa Transverse lie Polyhydramnios

 Admit CBC,

UA, BUN/Cr, Elyte, LFT, Coag, Uric acid

NPO Record
x

V/S Bed rest

10% MgSO4 4mg IV push slowly Then 50% MgSO4 20g + 5%D/W 1000 ml IV drip 50 ml/hr (1 g/hr)

observe DTR q 1 hr if absent notify observe RR q 1 hr if 14 notify observe urine output q 1 hr if < 30 ml/hr notify

record BP if BP 160/110 give Nicardipine 2 mg IV stat then 1 mg IV q 30 min Observe

Retain foley catheter Mg level at 1st and 4th hours G/M for PRC 4 unit, FFP 4 unit Consult

 2. 3.
1.

MgSO4 - cortex - Ach neuromuscular junction -mild vasodilator MgSO4

-Loading dose: 10%MgSO4 50 cc IV push slowly>5 min -Maintenance dose: 50%MgSO4 20cc in 5% D/N/2 1000cc IV drip in 1g/hr 24 hr

Mg level loading dose rate Mg level keep theraupeutic level 4-7.5 mEq/L If RR<14/min , absent deep tendon reflex, urine output <30 cc/hr or <100 cc/4hr -pls notify Evaluation of patient status for MgSO4 toxicity(antidote 10% calcium gluconate 10 cc IV)

Retain Foleys catheter Record vital sign ,urine output q 1 hr Deep tendon reflex q 4 hr

5-10 mEq/L Prolonged PR, widened QRS 7-10 mEq/L - Low urine output 10-14 mEq/L Depressed tendon reflexes 12-15 mEq/L SA, AV node block, respiratory paralysis >15 mEq/L - Cardiac arrest

If diastolic BP 110 mmHg after rest and MgSO4 infusion : antihypertensive drugs :nepresol ,nicardipine

Induction Amniotomy Oxytocin IV : water intoxication prostaglandin Cesarean section indication fetal distress

 24 hr Physiologic diuresis 12 hr 1 wk BP 2 BP <160/110 mmHg discharge

MgSO4

 Case

G1P0 GA 34+2 wk with severe preeclampsia Cesarean section BW 2,970 g APGAR 8,10 omphalocele, hypospadia, tong tie BP 144/93 mmHg MgSO4 24 hr

Most common medical problem encountered during pregnancy 8% of pregnancies Third leading cause of maternal mortality, after thromboembolism and non-obstetric injuries Maternal DBP > 110 is associated with placental abruption and fetal growth restriction risk of

Superimposed preeclampsia cause most of the morbidity

4 categories:

Gestational Hypertension Pregnancy-Induced Preeclampsia Hypertension Eclampsia (PIH) HELLP Syndrome Superimposed Preeclampsia Pregnancy-aggravated Hypertension (PAH) Chronic Hypertension

Definition

BP > 140/90 mmHg for first time, at GA 20 wks

No proteinuria BP return to normal < 12 wks post partum May become preeclampsia

Definition
Mild

Preeclampsia
140/90 mmHg at GA 20 wks

Criteria A+B y A) BP

y B) Proteinuria 300 mg/24hrs or 1+ dipstick

Severe

Preeclampsia

Criteria A+B y A) BP

160/110 mmHg at GA 20 wks

Proteinuria 5 g/24hrs or 2+ dipstick

y B) Proteinuria

Criteria 1) BP 160/110 mmHg 2) Proteinuria 5 g/24hrs or 2+ dipstick 3) Cr 1.2g/dL (unless known as previous elevated) 4) Plt < 100,000 /mm3 5) Microangiopathic hemolysis ( LDH ) 6) Elevated ALT or AST 7) Presenting symptoms eg. y Persistent headache or other cerebral or visual disturbance y Persistent epigastric pain 8) Pulmonary edema 9) Urine output <500 ml/24hr 10)Oligohydraminos and slowly growth fetus 11)Grand mal seizure (Eclampsia)

First pregnancy Age younger than 18 or older than 35 Prior Hx of preeclampsia Black race Medical risk factors for preeclampsia - chronic HTN, renal disease, diabetes, anti-phospholipid syndrome Twins Family history

Mild vs. Severe Preeclampsia

Mild Systolic arterial pressure Diastolic Proteinuria Headache Visual disturbance Epigastric pain Oliguria Serum creatinine Thrombocytopenia Liver enz. elevation levation Fetal growth restriction Pulmonary edema 140 mm Hg 160 mm Hg Severe 160 mm Hg

90 mmHg
300 mg/24 hr Dipstick 1+ or 2 + Mild -

110 mmHg
5 g/24 hr Dipstick 3+ or 4+ + + + +

+ Marked Obvious +

Previous preeclampsia with tonic-clonic seizure

BP 140/90 mmHg, at GA < 20 wks And persist 12 wks postpartum

Criteria 1) Chronic Hypertension 2)

SBP 30mmHg( ) or DBP 15mmHg( )

2 times in 6 hrs 3) New onset proteinuria 300mg/24hrs at GA 20wks (No proteinuria at GA < 20wks)

Exact mechanism not known

Immunologic Genetic Placental ischemia

Endothelial cell dysfunction Vasospasm Hyper-responsive response to vasoactive hormones (Imbalance between level of Prostaglandin(PGI2) and Thromboxane A2(TXA2) and angiotensin II & epinephrine)

Visual disturbances Headache Epigastric pain Rapidly increasing or nondependent edema - may be a signal of developing preeclampsia Rapid weight gain - result of edema due to capillary leak as well as renal Na and fluid retention

Maternal complications:

Leading cause of maternal death in PIH is intracranial hemorrhage Seizures Pulmonary edema ARF Proteinuria Hepatic swelling with or without liver dysfunction DIC (usually associated with placental abruption and is uncommon as a primary manifestation of preeclampsia)

Fetal complications:
Abruptio placentae IUGR Premature delivery Intrauterine fetal death(DFIU)

Hemolysis Elevated Liver enzymes Low Platelets

< 36 wks Malaise (90%), epigastric pain (90%), N/V (50%) Self-limiting Multi-system failure

Severe Preeclampsia with A + B + C

A. Hemolysis
Abnormal peripheral blood smear LDH(Lactate dehydrogenase) > 600 U/L Total bilirubin > 1.2 mg/dl

B. Elevated liver enzyme

Serum Aspartate transferase(AST) > 70 U/L

(>3 SD above Normal) Serum Alanine transaminase(ALT) elevate

C. Low platelet count < 100,000 /mm3

Hemostasis is not problematic unless PLT < 40,000

Rate of fall in PLT count is important PLT count normal within 72 hrs of delivery Thrombocytopenia may persist for longer periods. Definitive cure is delivery

Management of maternal hemodynamics & prevention of eclampsia are key to a favorable outcome MgSO4
Rx of choice for severe-preeclampsia to prevent seizure Does not significantly reduce systemic BP at the serum

concentration that are efficacious in treating preeclampsia

Principle Mild Preeclampsia

- Rest - Severe preeclampsia - Surveillance

Severe Preeclampsia
- Control BP - Prevent seizures - Deliver the fetus

Hydralazine Labetalol Nitroglycerin Nicardipine Esmolol Na Nitroprusside risk of cyanide toxicity in the fetus

Ex.Nicardipine
1-2 mg IV at one minute interval until control is obtained, then 1-2 mg IV q hour Or Nicardipine 1:10 IV drip 5mg/h can tritrate dose (Max 15 mg/hr)

MgSO4 - Drug of choice (Prevent seizure) Narrow therapeutic index Reduce > 50% w/o any serious maternal morbidity 4g IV Bolus over 10 minutes, then infusion 2g/hr Renal failure - rate of infusion by serum Mg levels Plasma Level should be between 4-7 mEq/L Monitor clinical signs for toxicity
Decrease RR Absent DTR Decrease Urine output

Toxic : 10 ml of 10% Ca Gluconate IV slowly

Lab : CBC, Eletrolyte, BUN, Cr, LFT, coagulogram Urine dipstick, Urine protein 24 hr Retain Foley catheter & monitor urine output EFM U/S Dexamethasone if GA < 34

Maternal indications

Gestational age greater than or equal to 37 weeks of gestation Platelet count less than 100,000 cells per cubic millimeter Deteriorating liver function Progressive deterioration in renal function (eg, creatinine >2 mg/dL, oliguria) Abruptio placentae Persistent severe headaches or visual changes Persistent severe epigastric pain, nausea, or vomiting Severe fetal growth restriction Nonreassuring results from fetal testing Oligohydramnios

Fetal indications

Care of airway Anticonvulsant (Magnesium sulfate, Diazepam) Control BP Intrauterine resuscitation NPO, avoid argitation Terminate pregnancy (vaginal route or C/S) stabilize patient, 1 2 hr

Treatment as severe Preeclampsia Plt transfusion indication

Clinical of bleeding Plt< 20,000 Plan C/S

keep >40,000-50,000

Delivery : NL or C/S

Terminate pregnancy Severe Preeclampsia

Thank you for attention