HYPERTENSIVE DISEASE IN
PREGNANCY WITH ASSOCIATED
NEONATAL OUTCOMES
Presented by Dr.Kagema Frank
DISCUSSION
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Introduction
Diagnosis of PE/E[pre eclampsia/eclampsia]
Management of PE/E
Screening and management of PE/E in kenya
. Effects of pre-eclampsia on late preterm
fetal outcomes
6. Optimizing fetal outcomes in PE/E
7. Prevention of PE/E and conclusion
1. INTRODUCTION
• Hypertensive diseases in pregnancy are a major
cause of significant maternal and neonatal morbidity
and mortality
• Currently 300,000 women + 3 million babies die
annually due to pregnancy and delivery.
• Worldwide, hypertensive disease is the 2nd largest
cause of maternal mortality – 12% after PPH-27%.
• According to WHO systematic review of preterm
births 2009/2010, 15-20% were due to medically
indicated or elective preterm deliveries.
Neonatal Outcomes introduction
• Pre-eclampsia is a progressive disorder, necessitating
delivery to halt the pregnancies for the benefit of
mother and fetus.
• Late preterm infants account for about ⅔ of all
preterm deliveries and are at significant risk of
morbidity and mortality and represents the fastest
growing subset of preterm births.
• PE/E is an important contributor to late preterm
births due to the need for premature delivery and
placental insufficiency.
2. DIAGNOSIS OF PE/E
Mild PE –
• Systolic BP 140 ≤ 160mmHg
• Diastolic BP >90 ≤ 110mmHg
• Proteinuria > 300mg ≤ 5g/day
Severe PE: Multi-organ involvement
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Systolic BP >160mmHg
Diastolic BP >110mmHg
Thrombocytopenia <100,000/ul
Pulmonary edema
Oliguria < 500mls/day
Convulsions
3.MANAGEMENT PRINCIPLES IN PE/E
• Definitive cure for PE/E is delivery to minimize the
maternal morbidity and mortality.
• Balance the need for achieving in utero fetal
maturation with fetal maternal risks of continuing
pregnancy.
• Generally, for mild PE delivery is recommended at 37
weeks and severe PE at no later than 34 weeks.
.
PE/E basic management principles
Control of BP using antihypertensive -only 24% of
labor ward facilities [QOC Survey 2010] had
Hydralazine.
Monitor end organ effects especially hematological,
renal and hepatological.
Prevent eclampsia by judicious use of MgSO4- for
severe PE/E; 80% of labor ward facilites have
MgS04.[QOC Survey 2010]
Monitor fetal wellbeing-
4. SCREENING AND MANAGEMENT OF PE/E IN
KENYA
• Effective and internationally accepted guidelines are
available for screening and management of PE/E.
• In a countrywide QOC survey 2010/KSPA, 96% of
mothers had their BP checked during ANC and 89%
had BP machines available
• Urine testing for proteins during ANC was 59%
• Only 25% of health providers asked mothers about
signs of PE/E in current or previous pregnancies or
counselled clients to return if they experienced signs
of PE/E
Screening & mgt cont’d
• BP measurement at initial assessment of labor was
71%, but providers recorded BP on Partograph every
4 hours in 55% of deliveries.
• Other screening tasks for PE/E in labor (danger signs
+ BP check) were completed in only 20% of all
deliveries.
• Most of the providers (83%) indicated they knew
how to diagnose severe PE/E
• Over ¾ (77%) of the health providers indicated had
knowledge on diagnose and treatment of severe
PE/E, but less than half (36%) knew how to initiate
and follow up management of convulsions.
5. EFFECTS OF PRE-ECLAMPSIA ON LATE
PRETERM FETAL OUTCOMES
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1: Risk of fetal demise/stillbirth
Severe PE/E- represents significant stillbirth rate of
21/1000 live births
Mild eclampsia- the risk of fetal demise is 9/1000 live
births
In general obstetric population still birth rate beyond
28 weeks is 3/1000 live births.
NB: The risk increases substantially after 36 weeks.
Effects of PE/E Cont’d
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2: IUGR
IUGR- a pathological process of reduced fetal growth
with attendant increase in prenatal mortality
PE/E is a significant contributor to IUGR
3: Hematological effect
PE/E can result in neonatal thrombocytopenia and is
apparent at birth or first two days of life and resolves
by 10 days of life spontaneously
50% incidence of neutropenia which resolves after
several weeks.
Effects of PE/E Cont’d
4) Bronch-pulmonary dysplasia
•Studies have shown that BPD occurs in infants of
mothers with PE/E but only where the PE/E is severe
enough to lead to fetal growth restriction.
5) Neuro-developmental outcome
•The outcomes are highly variable
•Studies still inconclusive on whether PE/E reduces
cerebral palsy + intra-ventricular hemorrhage
6) Fetal origins of adult disease states
•Epidemiological studies show that infants exposed to
PE/E are at increased risk of diabetes and
cardiovascular morbidity in adulthood.
6. OPTIMIZING FETAL OUTCOMES IN PE/E
• Limited therapeutic options in management of
PE with benefits to fetus.
• Antenatal steroids – decrease morbidity and
improve survival rather to infants born before
34 weeks.
• MgS04- herein shown to have a neuroprotective effect on the preterm infant
including cerebral palsy and gross motor
dysfunction
7. Prevention of PE/E
• In a systematic review in pubmed, calcium
and low dose aspirin were the interventions
shown to prevent pre-eclampsia.
Conclusion
Better understanding of the patho-physiology of
PE/E is needed since PE/E disrupts
mechanisms regulating fetal growth and
development with the attendant dangers of
elective preterm deliveries.
MDG 4/5
- The Promise
• Children are our future, and their mothers are
its guardians. ~ Kofi Annan
• Millennium Development Goals promise to
reduce maternal deaths by three quarters and
cut child mortality by two thirds, let us
rededicate ourselves to that mission."
..END