Preeclampsia

Definition
Pregnancy-specific hypertensive disease with
multisystem involvement that usually occurs
after 20 weeks of gestasion.
The new-onset hypertension and new-onset
proteinureia
Blood Pressure
Preeclampsia 140/90 mmHg
Severe Preeclampsia 160/110 mmHg
at least two determinations
at least 4 hours apart

Proteinuria
24 hours excretion 300mg
Qualitative Dipstick +1
 Pathophysiology
2 stages :
1. Poor Placentation
2. The consequences hypoxia
 Abnormal Implantation &
Vasculogenesis
Inadequate remodelling of the maternal
vasculature perfusing the intervillous space
placental insufficiency
Normally, fetally derived cytotrophoblasts invade
the maternal uterine spiral arteries
endothelial-like phenotype(high-capacitance &
low resistance ) error insufficiency
Spesific combination of fetal MHC molecules and
maternal NK receptor genes in human risk of
preeclampsia
Endothelial Activation & Dysfunction
Vascular endothelium controlling smooth
muscle tone (dilatation & constriction),
anticoagulant regulation, antiplatelet,
fibrinolytic.
Preeclampsia alteration in circulating
concentration of many markers of endothelial
dysfunction
Maternal status endothelial response to
some factors.
Factor Linking Placental Ischemia and
Hypoxia With the Maternal Syndrome
Angiogenic Factor
Hypoxial placenta pathogenic factors
(antiangiogenic, autoimmune , inflamatory factors)
endothelial dysfunction and other clinical
manifestation
Vascular Endothelial Growth Factor signaling &
Placental Growth Factor (PlGF-1) angiogenesis &
maintain the endothelial cell function.
Flt-1 (sFlt-1) VEGF & PlGF receptors.
sFlt-1 increased free-VEGF & free-PlGF declined
disturbing stimulation of angiogenesis & mantain
endothelial integrity
 Immune Factors and Inflammation
Particle shed from the syncytial surface of the
human placenta Inflammatory response
Preeclampsia increasing particles and has
exaggerated inflammatory response
Agonistic antibody AT1-AA induced by the
production of the cytokine TNF-.
 Increased Endothelin (vasoconstrictor)
Decreased Nitric Oxide (vasodilator)
Increase Oxidative and Endoplasmic Reticulum
Stress peroxynitrites
Risk Factors
 Prediction of Preeclampsia
Uterine Artery Doppler Velocimetry
Biomarker
Angiogenesis-Related Biomarkers
sFlt-1 VEGF&PlGF
Placental Protein-13 and Other Markers
 Management
Antepartum Management
Initial Evaluation
CBC, serum creatinine & liver enzyme levels, urine
protein, severe preeclampsia symptoms
USG evaluation estimated fetal weight & amniotic
fluid index
NST
 Indication of Hospitalization & Delivery
37 0/7 weeks or more of gestation
Suspected abruptio placentae
34 0/7 weeks or more of gestation, plus any of the
following :
Progressive labor or rupture of membranes
USG estimate of fetal weight less than fifth percentile
Oligohydramnions (AFI < 5 cm)
Persistent BPP 6/10 or less ( N : 8/10 10/10 )
 Continued Evaluation
Fetal evaluation ( daily kick count, USG every 3 weeks, amniotic fluid
volume assessment at least once a week). NST twice weekly
Assess BP every antenatal test
Maternal laboratory evaluation CBC and liver enzyme and serum
creatinine level assessment at least one a week.
Have a regular diet with no salt restriction
Beware of severe preeclampsia symptoms (severe headaches, visual
changes, epigastric pain, shortness of breath) come to the hospital
immediately if the develop persistent symptoms, abdominal pain,
contractions, vaginal spotting, rupture of membranes, or decrased
fetal movement.
The develompment of new signs or symptoms of severe preeclampsia
or severe hypertension or evidence of fetal growth restriction and
HELLP syndrome require immediate hospitalization.
 Intrapartum Management
Timing of Delivery
37 0/7 weeks of gestation no abnormal fetal
testing or other severe conditions (premature
rupture of membrane, vaginal bleeding).
< 37 0/7 NICU, Neonatal Respiratory
complication, neonatal death.
 Severe Preeclampsia
Acute & long term complication
Mother pulmonary edema, myocardial infarction,
stroke, ARDS, coagulopathy, severe renal failure, retinal
injury
Fetus complication from exposure to uteroplacental
isufficiency or preterm birth

The clinical course of severe preeclampsia

progressive deterioration of maternal and fetal
conditions if delivery is not pursued.
Delivery is done at or beyond 34 0/7 weeks of
gestational age.
 Indication for Delivery
Preterm severe preeclampsia delivery at
approximately 34 weeks of gestation.
There is some conditions that make the delivery
must be done early
Vaginal delivery can often be accomplished, but
this is less likely with decreasing gestational age.
In preeclampsia, it is sugested that the mode of
delivery does not need to be cesarean delivery.
The mode of delivery should be determined by
fetal gestational age, fetal presentation, cervical
status, and maternal-fetal condition.