Pre-eklamsia
Introduction and Facts
Preeclampsia is a serious medical problem and has a high level of complexity. The magnitude of this problem is not only because preeclampsia affects the mother during pregnancy and childbirth, but also causes postpartum problems due to endothelial dysfunction in various organs, such as the risk of cardiometabolic disease and other complications. Preeclampsia is hypertension accompanied by proteinuria in women with gestational age above 20 weeks, with a note that not all women with preeclampsia show edema.
The prevalence of preeclampsia in developed countries is 1.3% - 6%, while in developing countries it is 1.8% - 18%.5,6 The incidence of preeclampsia in Indonesia itself is 128,273/year or about 5.3%. The trend in the last two decades has not seen a significant decrease in the incidence of preeclampsia, in contrast to the incidence of infection which has decreased according to the development of antibiotic findings.
Pathophysiology
Early in pregnancy, cytotrophoblast cells invade the uterine spiral arteries, replacing the endothelial lining of these arteries by destroying the medial, muscular, and neural elastic tissues, respectively. Before the end of the second trimester of pregnancy, the uterine spiral arteries are lined with cytotrophoblasts, and endothelial cells are no longer present in the endometrium or superficial parts of the myometrium. The process of remodeling of the uterine spiral arteries results in the formation of a low-resistance arteriolar system and a significant increase in blood volume supply for the growing needs of the fetus. In preeclampsia, uterine spiral artery invasion is confined to the proximal decidua, with 30% to 50% of spiral arteries from the placental bed spared by endovascular trophoblastic remodeling. The myometrial segment of the artery is anatomically intact and not dilated. The mean external diameter of the uterine spiral arteries in women with preeclampsia was 1.5 times less than the diameter of the same arteries in uncomplicated pregnancies. This failure in the process of vascular remodeling prevents an adequate response to the increased demand for fetal blood supply that occurs during pregnancy. Inappropriate expression of integrins by extravillous cytotrophoblasts may explain the incomplete arterial remodeling that occurs in preeclampsia.
Failure of trophobas invasion in preeclampsia results in decreased uteroplacental perfusion, resulting in a placenta that is progressively ischemic during pregnancy. In addition, placentas in women with preeclampsia show an increased frequency of placental infarcts and morphological changes as evidenced by abnormal cytotrophoblast proliferation. Another empirical evidence supporting the idea that the placenta is the etiology of preeclampsia is the patient's rapid recovery period after delivery.
Vascular endothelial tissue has several important functions, including the function of controlling smooth muscle tone through the release of vasoconstrictor and vasodilator substances, as well as regulation of anticoagulant, antiplatelet, and fibrinolysis functions through the release of different factors. This has led to the idea that the release of factors from the placenta in response to ischemia causes endothelial dysfunction in the maternal circulation. Data from The results of studies regarding endothelial dysfunction as an early pathogenesis of preeclampsia indicate that it is a possible cause of preeclampsia, and not an effect of pregnancy disorders. Furthermore, in women with preeclampsia, pre-existing maternal health problems such as chronic hypertension, diabetes, and hyperlipidemia may predispose to further maternal endothelial damage.
Clinical Symptoms and Complications
Signs and symptoms of preeclampsia are divided into two types, namely based on the clinical picture characterized by excessive weight gain, edema, hypertension, proteinuria and based on subjective symptoms characterized by headache in the frontal area, epigastric pain, visual disturbances: blurred vision, scotoma, diplopia, nausea, vomiting and other cerebral disorders: increased reflexes and restlessness.
Diagnosis
The diagnosis of preeclampsia is based on the presence of pregnancy-induced specific hypertension accompanied by other organ system disorders at gestational age above 20 weeks. Preeclampsia, previously always defined by the presence of hypertension and proteinuria that just occurred in pregnancy (new onset hypertension with proteinuria). Although these two criteria are still the classic definition of preeclampsia, several other women present with hypertension accompanied by other multisystem disorders that indicate a severe condition of preeclampsia even though the patient does not have proteinuria. Meanwhile, edema is no longer used as a diagnostic criterion because it is very common in women with normal pregnancies.
Blood pressure measurement
Recommendation:
1. Examination begins when the patient is calm.
2. We recommend using a mercury sphygmomanometer or its equivalent, which has been validated.
3. Sitting position with cuffs at heart level.
4. Use the appropriate cuff size.
5. Use the Korotkoff sound V in the measurement of diastolic blood pressure.
Determination of proteinuria
Recommendation:
Proteinuria is established if quantitatively the urine protein production is more than 300 mg per 24 hours, but if this cannot be done, the examination can be replaced by a semiquantitative examination using a urine dipstick > 1+
Management and Care
a. Primary Prevention of Preeclampsia
Recommendation:
1. It is necessary to screen the risk of preeclampsia for every pregnant woman from the beginning of her pregnancy
2. Preeclampsia screening examinations other than using the patient's medical history such as the use of biomarkers and ultrasound Doppler Velocimetry cannot be recommended routinely, until the screening method is proven to improve pregnancy outcomes.
Secondary Prevention of Preeclampsia
Recommendation:
1. Rest at home is not recommended for primary prevention of preeclampsia
2. Bed rest is not recommended to improve outcome in pregnant women with hypertension (with or without proteinuria)
3. Salt restriction to prevent preeclampsia and its complications during pregnancy is not recommended
4. The use of low-dose aspirin (75 mg/day) is recommended for the prevention of preeclampsia in women at high risk
5. Low-dose apirine for prevention of preeclampsia should be started before 20 weeks of gestation
6. Calcium supplementation of at least 1 g/day is recommended especially for women with low calcium intake
7. The use of low-dose aspirin and calcium supplementation (at least 1g/day) is recommended for the prevention of preeclampsia in women at high risk of developing preeclampsia.
8. Vitamins C and E are not recommended for the prevention of preeclampsia.
Preeclampsia Management
Expectative Treatment for Preeclampsia without Severe Symptoms
Recommendation:
1. Expectative management is recommended in cases of severe asymptomatic preeclampsia with gestational age <37 weeks with more rigorous maternal and fetal evaluation
2. Strict polyclinical treatment can be carried out in cases of preeclampsia without severe symptoms.
3. Strict evaluations carried out are:
• Daily evaluation of maternal symptoms and fetal movements by the patient
• Evaluation of blood pressure 2 times a week in a polyclinic
• Weekly evaluation of platelet count and liver function
• Regular ultrasound evaluation and fetal well-being (recommended 2 times a week)
• If there are signs of fetal growth restriction, evaluation using Doppler velocimetry of the umbilical artery is recommended
Expectative Treatment in Severe Preeclampsia
Recommendation:
1. Expectative management is recommended in cases of severe preeclampsia with gestational age less than 34 weeks provided the condition of the mother and fetus are stable
2. Expectative management of severe preeclampsia is also recommended to carry out treatment in adequate health facilities with the availability of intensive care for maternal and neonatal
3. For women undergoing expectative treatment of severe preeclampsia, corticosteroid administration is recommended to assist fetal lung maturation
4. Patients with severe preeclampsia are recommended to be hospitalized during expectant care
Administration of Magnesium Sulfate in Severe Preeclampsia
Recommendation:
1. Magnesium sulfate is recommended as first-line therapy for eclampsia
2. Magnesium sulfate is recommended as prophylaxis against eclampsia in patients with severe preeclampsia
3. Magnesium sulfate is the first choice in patients with severe preeclampsia compared to diazepam or phenytoin, to prevent seizures/eclampsia or recurrent seizures.
4. Magnesium sulfate is the first choice in patients with severe preeclampsia compared to diazepam or phenytoin, to prevent seizures/eclampsia or recurrent seizures.
5. Full doses of both intravenous and intramuscular magnesium sulfate are recommended for the prevention and treatment of eclampsia
6. Routine evaluation of serum magnesium levels is not recommended
7. Administration of magnesium sulfate is not recommended to be given routinely to all preeclampsia patients, if there are no worsening symptoms (asymptomatic preeclampsia).
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Administration of Antihypertensives in Severe Preeclampsia
Recommendation:
1. Antihypertensives are recommended in preeclampsia with severe hypertension, or systolic blood pressure = 160 mmHg or diastolic = 110 mmHg
2. Target blood pressure reduction is systolic <160 mmHg and diastolic <110 mmHg
3. Antihypertensives of first choice are short-acting oral nifedipine, hydralazine and parenteral labetalol.
4. Other alternative antihypertensives are nitroglycerin, methyldopa, labetalol
Reference:
1. Perkumpulan Obstetri dan Ginekologi Indonesia Himpunan Kedokteran Feto Maternal. Diagnosis dan Tatalaksana Pre-eklamsia. 2016. Internet [Cited 01/9/2021]. Available from: https://pogi.or.id/publish/download/pnpk-dan-ppk/
2. - Pre-eklamsia. Internet [Cited 01/9/2021]. Available from: http://eprints.undip.ac.id/46835/3/SARAH_DYAANGGARI_AKIP_22010111140188_LAP.KTI_BAB_II.pdf
3. Siti Nur Indah, Ety Apriliana. Hubungan antara Preeklamsia dalam Kehamilan dengan Kejadian Asfiksia pada Bayi Baru Lahir. Internet [Cited 01/9/2021]. Available from: http://juke.kedokteran.unila.ac.id/index.php/majority/article/viewFile/924/738
