Learning Issues

Muhammad Khoiruddin
04011281621139

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Placenta development

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Main Problems

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Classification of HT in Pregnancy

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PRE-ECLAMPSIA
& ECLAMPSIA

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Description
• PE is a pregnancy-specific syndrome (occurring after 20 weeks of
gestation) of reduced organ perfusion, vasospasm, and endothelial
activation characterized by hypertension, proteinuria, and other.
• Untreated PE  convulsion may occur (eclampsia)
• Severe cases  HELLP syndrome

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Etiology and Risk Factor
• Causes:
• Unknown, genetic, endocrine/metabolite, immunologic, utero-placental
ischemia
• Risk Factors:
• Prior history
• BMI >32,3
• Nulliparity
• Age >35 y.o or <18 y.o
• Multifetal pregnancy
• etc

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Clinical Manifestation

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Criteria

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Differential Diagnosis
• Chronic hypertension • Periarteritis nodosa
• Transient hypertension • Obesity
• Chronic renal disease • Epilepsy
• Acute or chronic • Encephalitis
glomerulonephritis • Cerebral aneurysm or tumor
• Coarctation of the aorta • Lupus cerebritis
• Cushing’s disease • Hysteria
• Systemic Lupus Erythematosus

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Normal v. PE condition

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Convulsion (ECLAMPSIA)

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Work Up - Evaluation
• Laboratory:
• Liver and renal function (enzymes, renal clearance, 24-hour urinary protein measurement)
• Imaging – USG to monitor fetal growth
• Special test:
• Assessment of fetal lung maturation
• Invasive hemodynamic monitoring
• Diagnostic Procedures:
• History
• Physical examination (high BP)
• Urinalysis (or dipstick)
• Laboratory assessment

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Therapy (Non-Pharmacologic)
• General Measures
• Specific Measures  the only true treatment is delivery!
• Diet (no specific)
• Activity (bed rest)
• Patient Education

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Therapy (Drug(s) of Choice)
• Glucocorticoid  to encourage fetal lung maturation
• Labetalol or Nifedipine  as conservative
• Prolongation of the gestation
• Improved fetal outcome
• No reduction in catastrophic events such as placental abruption
• Magnesium sulfate (IV)  stabilize BP and reduce the risk of seizures
• Hydralazine (IV)  to lower BP acutely
• Antiplatelet/NSAID  reduce the risk of recurrence or complication (?)

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Common Agents
AGENT MOA DOSE & MAX DOSE SIDE EFFECT
Labetalol 𝛼𝛽 Blocker PO: 100mg, 12 hourly (max: 2400mg) Fatigue, Bradycardia,
IV: 20mg then repeat 40-80mg every 10 Depression
minutes (max: 300mg)
Nifedipine CCB PO: 10mg, 6-8 hourly (max: 120mg) Headache, Hypotension,
Palpitation, Constipation
Methyl dopa Direct PAV PO: 250mg, 8 hourly (max: 2 g) Flushing, Dry Mouth,
Headache
Hydralazine Direct PAV PO: 25mg 8 hourly (max: 300mg) Flushing, Diarrhea,
IV: 5-10mg then repeat after every 10-20 Constipation, Headache
minutes. (max: 20 mg)
Sodium Direct PAV IV: 5mcg/kg/min (max: 10 mcg/kg/min) Metabolite  Cyanide
Nitroprusside
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CI, PC, I
• Contraindications: ACE inhibitors (in pregnancy)
• Precautions: Excessive levels (>10 mEg/L) of Magnesium Sulfate 
respiratory paralysis and cardiac arrest
• Interaction: see individual agents

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Follow Up
• Patient monitoring  increased maternal and fetal surveillance
• Prevention/avoidance  early detection then treatment!
• Possible complication  maternal or fetal (increase in eclampsia)
• Expected outcome

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Primary Prevention
• Folic acid & calcium supplementation
• Fish oil capsules  modify abnormal PG balance
• Periodic monitoring BP and weight gain
• Antioxidants (Vitamin C: 1000mg/day, Vitamin E: 400mg/day)
• Periodic screening:
• Serum uric acid, Doppler: uterine artery and umbilical vein in second
trimester, biophysical testing, USG four weekly, roll over test at 28-32 weeks,
platelet count, urinary calcium, serum fibronectin, urinary protein, serum AT
III, fetal DNA in maternal serum

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Secondary and Tertiary Prevention
• Salt restriction
• Inappropriate diuretic therapy
• Low dose aspirin (60mg)
• Magnesium Sulfate
• Anti-hypertensive

Tertiary: preventing subsequent convulsion in established eclampsia

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Antenatal Care (ANC)

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WHO, 2016
There’re 49 recommendations:
• Nutritional interventions (14)
• Maternal and fetal assessment (13)
• Preventive measures (7)
• Interventions for common physiological symptoms (6)
• Health system interventions to improve the utilization
and quality of antenatal care (9)

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Schedule for visits
WHO is recommending that pregnant
women increase the number of times
they have contact with healthcare
providers throughout their pregnancy
from four to eight.

BPJS policy: four times

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Recommendations
• Nutritional interventions
• Diet
• Supplementation: iron, folic acid, calcium, vitamin A, zinc, micronutrient such as vitamin B6, E, C, D
• Restricts caffeine consumption
• Maternal and fetal assessment
• Anemia
• Asymptomatic bacteriuria
• Intimate partner violence
• Gestational DM
• Tobacco and drugs use
• HIV and sifilis
• Tuberculosis

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Recommendations (con’t)
• Maternal and fetal assessment
• Daily fetal movement counting
• Symphysis-fundal height (SFH) measurement
• Antenatal cardiotocography
• USG scan
• Doppler ultrasound of fetal blood vessels
• Preventive measures
• Antibiotics for asymptomatic bacteriuria (ASB)
• Antibiotc prophylaxis to prevent recurrent UTI
• Antenatal anti-D Immunoglobulin administration
• Preventive anti-helminthic treatment
• Tetanus toxoid vaccination
• Malaria prevention
• Pre-exposure prophylaxis for HIV prevention
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Recommendations (con’t)
• Interventions for common physiological symptoms
• Nausea and vomiting
• Heartburn
• Leg cramps
• Low back and pelvic pain
• Constipation
• Varicose veins and edema

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Recommendations (con’t)
• Health system interventions to improve the utilization and quality of antenatal care
• Woman-held case notes
• Midwife-led continuity of care
• Group antenatal care
• Community-based interventions to improve communication and support
• Task shifting components of antenatal care delivery
• Recruitment and retention of staff in rural and remote areas
• Antenatal care contact schedules

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