Preeclampsia and Diabetes Management in Pregnancy

Medical Disorders with Pregnancy

• Presented by Prof. Dr. Mohamed S. Fahmy, Professor of Obstetrics & Gynecology, Head of the Obstetrics & Gynecology Department, Aswan University.

Hypertensive Disorders with Pregnancy

• Classification:
  • Hypertension: Blood pressure (BP) ≥140/90 mmHg measured twice with a 6-hour interval.
  • Proteinuria: Urinary protein excretion ≥0.3g protein/24 hours or 0.1 g/L.
  • Gestational hypertension: BP ≥140/90 mmHg for the first time during pregnancy after 20 weeks, without proteinuria.
  • Preeclampsia: Gestational hypertension with proteinuria.
  • Eclampsia: Preeclampsia complicated by grand mal seizures and/or coma.
  • HELLP syndrome: Hemolysis (H), Elevated liver enzymes (EL), Low platelet count (LP).
  • Chronic hypertension: Known hypertension before pregnancy or diagnosed for the first time before 20 weeks of pregnancy.
  • Superimposed preeclampsia or eclampsia: New onset of proteinuria in women with chronic hypertension.

Preeclampsia

• Definition: A multisystem disorder of unknown etiology characterized by the development of hypertension (≥140/90 mmHg) and proteinuria after 20 weeks in a previously normotensive, nonproteinuric woman. Preeclamptic features may appear before 20 weeks in some cases, such as hydatidiform mole and acute polyhydramnios.
• Incidence: 5-8%

Preeclampsia Risk Factors

• Primigravida (first-time pregnancy), young or elderly age.
• Family history of hypertension or preeclampsia.
• Placental abnormalities, including hyperplacentosis (excessive exposure to chorionic villi), and placental ischemia.
• Obesity (BMI >35 kg/m²), insulin resistance.
• Pre-existing vascular disease.
• Thrombophilias (e.g., antiphospholipid syndrome, protein C/S deficiency, Factor V Leiden).

Preeclampsia Clinical Types

• Mild: Rise in blood pressure (BP) more than 140/90 mmHg but less than 160 mmHg systolic or 110 mmHg diastolic without significant proteinuria.
• Severe: Persistent systolic BP above or equal to 160 mmHg or diastolic BP above 110 mmHg, protein excretion over 5g/24 hours, Oliguria (<400 mL/24 hours), Platelets <100,000/mm³, Cerebral or visual disturbances, Persistent severe epigastric pain, Retinal hemorrhages, exudates or papilledema. Intrauterine growth restriction of the fetus. Pulmonary edema.

Preeclampsia Symptoms

• Swelling (edema) over the ankles, face, abdominal wall, vulva and even the whole body, appearing in a gradual manner.
• Alarming symptoms:
  • Headache (occipital or frontal).
  • Disturbed sleep.
  • Diminished urinary output (<400 mL in 24 hours).
  • Epigastric pain.
  • Visual disturbances (e.g., blurring, scotomata, dimness, or complete blindness).

Preeclampsia Signs

• Rise of blood pressure
• Abnormal weight gain.
• Edema.
• Pulmonary edema.
• Abdominal examination showing signs of chronic placental insufficiency (scanty liquor or growth retardation of the fetus).

Preeclampsia Investigations

• Urine: Proteinuria is the last feature of preeclampsia to appear.
• Ophthalmoscopic examination.
• Blood values: Serum uric acid, creatinine, abnormal coagulation profile, hepatic enzymes (may be increased).
• Antenatal fetal monitoring: Clinical examination, daily fetal kick count, Ultrasonography (fetal growth and liquor pockets), Cardiotocography, Umbilical artery flow velocimetry, Biophysical profile.

Preeclampsia Complications

• Immediate (Maternal)
  • Eclampsia (convulsions & coma) more in acute instances.
  • Accidental hemorrhage.
  • Oliguria and anuria.
  • Visual impairment and blindness.
  • Pre-term labor.
  • HELLP syndrome.
  • Cerebral hemorrhage.
  • Acute Respiratory Distress Syndrome (ARDS).
• Remote (Maternal)
  • Residual hypertension.
  • Recurrent preeclampsia.
  • Thrombophilia.
  • Chronic renal disease.
• Fetal (related to severity, duration and degree of proteinuria)
  • Intrauterine fetal death.
  • Intrauterine growth restriction due to chronic placental insufficiency.
  • Asphyxia.
  • Prematurity.

Preeclampsia Management

• Primarily empirical & symptomatic, aiming to stabilize hypertension and prevent complications, including eclampsia.
• Objectives: -Stabilize hypertension. -Prevent complications. -Prevent eclampsia. -Optimal time for delivery. -Restoration of maternal health in the puerperium.

Eclampsia

• Definition: Preeclampsia complicated by grand mal seizures (generalized tonic-clonic convulsions) and/or coma.
• Types:
  • Antepartum (70-80%)
  • Intrapartum (15-20%)
  • Postpartum (5-10%, considered the most dangerous)

Eclampsia Stages

• Prodromal: 15-30 seconds, Semi-coma, Severe headache, hallucinations, Twitches in facial, hand and foot muscles, eyeballs rolling.
• Tonic: 30-60 seconds, All body muscle contractions (opisthotonus), cyanosis, respiratory arrest, exhaustive heart failure, hindrance to venous return, limbs stretched.
• Clonic: 60-120 seconds, Intermittent contraction and relaxation.
• Comatose: Minutes to multiple hours. Status eclampticus: Patient shifts from one coma to the next without regaining consciousness.

Eclampsia Differential Diagnosis of Fits

• Epileptic fit of grand mal epilepsy: Past history of epilepsy, absence of pre-eclampsia symptoms.
• Hysterical fit: Not a classic fit, Psychogenic cause
• Cerebral stroke fit: Lateralization, CT scan required
• Strychnine poisoning: History of drug intake.

Eclampsia Treatment

• Prophylaxis: Good control of pre-eclampsia (PE).
• First Aid: At home: IV sedation, transfer to hospital (avoid light & noise). At ICU: Semi-dark, quiet room, side-lying position, VD observation. During fit: IV sedation, anti-convulsants, prevent trauma to airway.

Eclampsia Anti-hypertensive Treatment

• IV Hydralazine (10 mg every 20 minutes, drug of choice).
• IV Labetalol (10 mg every 10 minutes).
• IV sodium nitroprusside, Diazoxide, Nifedipine.
• Avoid Diuretics in cases of heart failure and pre-eclampsia toxins (due to hemoconcentration).

Eclampsia Anti-convulsant Treatment

• MgSO₄ (Magnesium Sulfate): CNS depressant, skeletal muscle relaxant, vasodilation, cerebral dehydration, Initial dose: 4g / 20 min IV, then continuous infusion (dose based on clinical response, toxicity signs - checking for absent ankle and knee reflexes etc.). Antidote: 10 ml of 10% Calcium gluconate.
• Diazepam: Dose: 10-20mg IV, then drip: More rapid, but has more risk for neonatal hypotension and respiratory difficulty.

Eclampsia Intra-partum Control

• Induction of labor (if expected to be rapid): First stage: semi-sitting, analgesia, 125mL/hr fluid, epidural anesthesia. Second stage: forceps for quicker delivery.
• If delivery is delayed > 6hrs or associated indications= Cesarean section (CS).
• Post-partum: Anti-convulsant therapy (1-2 days) + Antihypertensive medications.
• Care of the neonate involves specialized remote care , kidney function & blood pressure monitoring 6-weeks post-partum.

Diabetes with Pregnancy

• Definition: A chronic metabolic disorder characterized by either insulin deficiency (relative or absolute) or due to peripheral tissue resistance (decreased sensitivity) to insulin.

Diabetes with Pregnancy Classification

• Type 1 (IDDM): Young onset, absolute insulin deficiency, autoimmune-related, genetic predisposition, presence of autoantibodies.
• Type 2 (NIDDM): Late onset, overweight, peripheral tissue resistance (skeletal muscle, liver), hyperinsulinemia..
• Gestational Diabetes Mellitus (GDM): Carbohydrate intolerance, develops during the current pregnancy.

Diabetes with Pregnancy Effects on DM

• Pregnancy is diabetogenic: DM may emerge or become harder to control during pregnancy.
• Diabetic complications may worsen (renal and retinal).
• Risk of hypoglycemia is increased.

Diabetes with Pregnancy Complications (Maternal)

• Abortion.
• Pre-term labor.
• Polyhydramnios (excessive amniotic fluid).
• Abruptio placenta (premature separation).
• Placenta previa (placenta covering the cervix).
• Pre-eclampsia (PE).
• Infections (e.g., vulvovaginitis, pyelonephritis).
• Pre-term labor.
• Prolonged or obstructed labor.
• Postpartum hemorrhage (PPH).
• Sepsis.
• Subinvolution of the uterus.
• Pulmonary complications.
• Defective Lactation.

Diabetes with Pregnancy Complications (Fetal)

• Intrauterine fetal death (IUFD).
• Intrauterine growth restriction (IUGR).
• Congenital malformations (e.g., neural tube defects, cardiac defects).
• Macrosomia (excessive fetal size).
• Shoulder dystocia (difficulty during birth).
• Congenital heart disease.
• Birth injuries.
• Polycythemia
• Hypoglycemia, hypothermia
• Hypocalcaemia and tetany
• Hypomagnesaemia

Diabetes with Pregnancy Complications (Neonatal)

• Respiratory distress syndrome (RDS).
• Jaundice.
• Birth injuries..
• Prematurity.
• Hypoglycemia.
• Hypocalcaemia and tetany
• Hypomagnesaemia, Hypothermia (low body temperature)

Diabetes with Pregnancy Investigations

• Screening tests: 1-hour postprandial glucose test (glucola test) - 50 gm of glucose, then measured after 1 hour.
• If >140 mg/dL, further testing.
• Confirmatory test (3 hrs glucose tolerance test (GTT)): 50-75 gm glucose solution given in 300-400 mL water. Measures blood glucose levels at 1 hr, 2 hr, and 3 hrs intervals, in order to diagnose Type 2 diabetes and Gestational diabetes

Diabetes with Pregnancy Management

• Pre-conception management: Maintain HbA1c ≤6%. Control complications and consider adjusting medications before pregnancy.
• In pregnancy. Better control of DM and avoid complications.
• Diet control: Caloric intake 1800-2400 kcal/day (30 kcal/kg/day ±300 kcal in 3rd trimester).
• Insulin therapy: Dosage adjustments as needed.
• Antenatal frequency: Increased frequency for monitoring fetal growth and maternal health (every 2 weeks until week 32), then weekly until week 36 in pregnancy.
• Antenatal fetal surveillance: Regular assessments (fetal kicks, Doppler, CTG, BPP, u/s) to detect potential problems
• Intra-partum control: IV glucose drip for hyperglycemia. Delivery timing based on assessment of fetal maturity to ensure appropriate timing to minimize potential fetal complications and optimize for vaginal delivery.

Anemia with Pregnancy

• Iron deficiency anemia is the most common type of anemia during pregnancy.

Iron Deficiency Anemia with Pregnancy Physiology

• Increased iron demand during pregnancy.
• Insufficient or decreased dietary intake of iron.
• Increased blood loss (e.g., parasitic infestations). Non-pregnant daily absorption is 1-2 mg, Early pregnancy 2-5mg, Late pregnancy 5-6mg.
• WHO recommendation 30-60mg/d for pregnancy with adequate iron stores, 120-240mg/d for pregnancy without adequate iron stores.

Iron Deficiency Anemia with Pregnancy Clinical Picture

• Angular stomatitis.
• Red glazed tongue.
• Brittle nails.
• Splenomegaly.
• Headache.
• Fatigue.

Iron Deficiency Anemia with Pregnancy Investigations

• To diagnose anemia: Hg ≤10.5 g%
• To diagnose iron deficiency: Blood picture (microcytic, hypochromic), Serum iron, and Serum Ferritin.

Iron Deficiency Anemia with Pregnancy Treatment

• Prophylactic: Oral iron preparations (30–60 mg daily), eliminate predisposing factors and treat underlying causes.
• Active treatment: Oral iron (120–240 mg/d), Folic acid. Blood transfusion if severe.