HYPERTENSIVE DISEASE IN PREGNANCY WITH ASSOCIATED NEONATAL OUTCOMES

1. HYPERTENSIVE DISEASE IN PREGNANCY WITH ASSOCIATED NEONATAL OUTCOMES Presented by Dr.Kagema Frank

2. DISCUSSION • 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 • Optimizing fetal outcomes in PE/E • Prevention of PE/E and conclusion

3. 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.

4. 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.

5. 2. DIAGNOSIS OF PE/E Mild PE – • Systolic BP 140 ≤ 160mmHg • Diastolic BP >90 ≤ 110mmHg • Proteinuria > 300mg ≤ 5g/day Severe PE: Multi-organ involvement • Systolic BP >160mmHg • Diastolic BP >110mmHg • Thrombocytopenia <100,000/ul • Pulmonary edema • Oliguria < 500mls/day • Convulsions

6. 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. .

7. 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-

8. 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

9. 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.

10. 5. EFFECTS OF PRE-ECLAMPSIA ON LATE PRETERM FETAL OUTCOMES 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.

11. Effects of PE/E Cont’d 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.

12. Effects of PE/E Cont’d • 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.

13. 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 neuro-protective effect on the preterm infant including cerebral palsy and gross motor dysfunction

14. 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.

15. 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