OBG512 — Complications in Pregnancy: Lecture Note

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la-NET | ONLINE LEARNING VIDEO PLATFORM FOR POST-SECONDARY & HIGHER INSTITUTION STUDENTS

la-NET | ONLINE LEARNING VIDEO PLATFORM FOR POST-SECONDARY & HIGHER INSTITUTION STUDENTS Course code: OBG 512 Course title: Complications in Pregnancy Course credit load: 1 Unit Series 1: Hypertensive Disorders in Pregnancy • Part 1.1: Classification and Differentiation of Hypertensive Disorders o Sub Part 1.1.1: Forms of hypertensive disorders of pregnancy o Sub Part 1.1.2: Differentiating pre-eclampsia from eclampsia o Sub Part 1.1.3: Effect of pre-eclampsia and eclampsia on maternal and foetal outcome • Part 1.2: Clinical Features and Evaluation of Eclampsia o Sub Part 1.2.1: Signs and symptoms of eclampsia o Sub Part 1.2.2: Evaluation of a patient with eclampsia o Sub Part 1.2.3: Complications of pre-eclampsia and eclampsia • Part 1.3: Management of Pre-eclampsia and Eclampsia o Sub Part 1.3.1: Antihypertensive therapy o Sub Part 1.3.2: Anticonvulsant therapy o Sub Part 1.3.3: Supportive care in management Introduction Picture a woman arriving at the labour ward with a severe headache she initially dismissed as ordinary tiredness, her blood pressure now dangerously elevated. Recognising and managing hypertensive disorders of pregnancy, from the earliest signs of gestational hypertension to the genuine emergency of an eclamptic seizure, is among the most important, life-saving skills in the whole of obstetric practice. This Series lays the essential foundation for the whole of this course on complications in pregnancy, beginning with the hypertensive disorders that remain among the leading causes of maternal death worldwide. The aim of this Series is to equip you with a thorough understanding of the classification, clinical features, evaluation, and management of hypertensive disorders of pregnancy, including pre-eclampsia and eclampsia.

la-NET | ONLINE LEARNING VIDEO PLATFORM FOR POST-SECONDARY & HIGHER INSTITUTION STUDENTS We shall commence this Series by examining the classification of hypertensive disorders of pregnancy and how to differentiate pre-eclampsia from eclampsia. Next, we will consider the clinical features and evaluation of eclampsia. Finally, we will conclude by examining the management of pre-eclampsia and eclampsia, including antihypertensive, anticonvulsant, and supportive care. Series Learning Outcomes Upon completing this Series, you should be able to: • SLO 1.1: list the various forms of hypertensive disorders of pregnancy, • SLO 1.2: differentiate between pre-eclampsia and eclampsia, • SLO 1.3: describe the effect of pre-eclampsia and eclampsia on foetal and maternal outcome, • SLO 1.4: list the signs and symptoms of eclampsia, • SLO 1.5: describe how to evaluate a patient with eclampsia, • SLO 1.6: explain the role of antihypertensives and anticonvulsants in the management of eclamptic patients, and • SLO 1.7: illustrate the role of supportive care in management of patients with these conditions. 1.1 Classification and Differentiation of Hypertensive Disorders 1.1.1 Forms of hypertensive disorders of pregnancy Hypertensive disorders of pregnancy are classified into four principal categories: chronic hypertension (present before pregnancy or diagnosed before 20 weeks of gestation), gestational hypertension (new-onset hypertension after 20 weeks without proteinuria or other features of pre-eclampsia), pre-eclampsia (new-onset hypertension after 20 weeks with proteinuria or other evidence of maternal organ dysfunction), and chronic hypertension with superimposed pre-eclampsia (pre-existing hypertension in which new features of pre-eclampsia subsequently develop). Correctly classifying a woman's specific hypertensive disorder carries genuine, direct implications for the intensity of antenatal surveillance required, the anticipated clinical course, and the specific management approach most appropriate, meaning careful, accurate classification at the point of diagnosis represents a genuinely essential first step in the safe management of any pregnant woman presenting with elevated blood pressure.

la-NET | ONLINE LEARNING VIDEO PLATFORM FOR POST-SECONDARY & HIGHER INSTITUTION STUDENTS Fill in the blank: Gestational hypertension is new-onset hypertension after 20 weeks without ________ or other features of pre-eclampsia. Chronic hypertension with superimposed pre-eclampsia describes pre-existing hypertension in which new features of pre-eclampsia subsequently ________. 1.1.2 Differentiating pre-eclampsia from eclampsia Pre-eclampsia is defined as new-onset hypertension after 20 weeks of gestation accompanied by proteinuria or other evidence of maternal organ dysfunction, including renal impairment, liver dysfunction, neurological features, hematological complications, or uteroplacental dysfunction, representing a multisystem disorder rather than an isolated elevation of blood pressure alone. Eclampsia is specifically defined as the occurrence of seizures in a woman with pre-eclampsia, not attributable to any other identifiable cause, representing a genuinely serious progression and complication of the underlying pre-eclamptic process, with the transition from pre-eclampsia to eclampsia sometimes occurring with alarming rapidity, and, in a genuinely important minority of cases, occurring without the classic warning signs typically expected to precede it. Fill in the blank: Pre-eclampsia is a multisystem disorder involving new-onset hypertension with proteinuria or other evidence of maternal organ ________. Eclampsia is specifically defined as the occurrence of ________ in a woman with pre-eclampsia, not attributable to any other cause. 1.1.3 Effect of pre-eclampsia and eclampsia on maternal and foetal outcome Pre-eclampsia and eclampsia carry substantial risk to maternal health, including progression to eclampsia itself, HELLP syndrome (haemolysis, elevated liver enzymes, and low platelets), placental abruption, disseminated intravascular coagulation, stroke, and, in the most severe cases, maternal death, with pre-eclampsia and eclampsia together remaining among the leading direct causes of maternal mortality worldwide and in Nigeria specifically. Foetal outcomes associated with pre-eclampsia and eclampsia include foetal growth restriction (reflecting placental insufficiency from the underlying disease process), preterm birth (whether spontaneous or, more commonly, medically indicated given the severity of the maternal condition), and an increased risk of stillbirth, meaning the specific timing of delivery in these conditions always requires a genuinely careful balance between maternal and foetal risk. Fill in the blank: HELLP syndrome comprises haemolysis, elevated liver enzymes, and low ________. The timing of delivery in pre-eclampsia and eclampsia always requires a genuinely careful balance between maternal and ________ risk. Category Defining Features Chronic Hypertension Hypertension present before pregnancy or diagnosed before 20 weeks of gestation; persists beyond 12 weeks postpartum.

la-NET | ONLINE LEARNING VIDEO PLATFORM FOR POST-SECONDARY & HIGHER INSTITUTION STUDENTS Category Defining Features Gestational Hypertension New-onset hypertension after 20 weeks of gestation without proteinuria or systemic features of preeclampsia; resolves postpartum. Preeclampsia/Eclampsia Hypertension after 20 weeks with proteinuria or evidence of systemic involvement (renal, hepatic, neurological, hematological); eclampsia refers to seizures in a woman with preeclampsia. Chronic Hypertension with Superimposed Preeclampsia Women with chronic hypertension who develop new-onset proteinuria or systemic features consistent with preeclampsia. Table 1.1: Classification of hypertensive disorders of pregnancy. Pilot questions 1.1 1. List the various forms of hypertensive disorders of pregnancy. (Linked to SLO 1.1) 2. Explain why accurate classification of hypertensive disorders matters clinically. (Linked to SLO 1.1) 3. Differentiate between pre-eclampsia and eclampsia. (Linked to SLO 1.2) 4. Describe the maternal complications of pre-eclampsia and eclampsia. (Linked to SLO 1.3) 5. Describe the foetal outcomes associated with pre-eclampsia and eclampsia. (Linked to SLO 1.3) 1.2 Clinical Features and Evaluation of Eclampsia 1.2.1 Signs and symptoms of eclampsia Warning signs and symptoms that may precede eclamptic seizures include severe headache (often described as unlike any headache previously experienced), visual disturbance (blurred vision, flashing lights, or, in severe cases, temporary loss of vision), epigastric or right upper quadrant pain (reflecting liver involvement), and hyperreflexia with clonus on examination, each representing a specific, recognised warning sign warranting urgent clinical attention. The eclamptic seizure itself typically presents as a generalised tonic-clonic seizure, though it is genuinely important to recognise that a proportion of eclamptic seizures occur without any clearly preceding warning signs, and that eclampsia can occur antepartum, intrapartum, or, less commonly recognised, postpartum, meaning ongoing vigilance for these specific warning signs should continue throughout the entire peripartum period, not solely during pregnancy itself.

la-NET | ONLINE LEARNING VIDEO PLATFORM FOR POST-SECONDARY & HIGHER INSTITUTION STUDENTS Fill in the blank: Warning signs preceding eclamptic seizures include severe headache, visual disturbance, and epigastric or right upper quadrant pain reflecting ________ involvement. Eclampsia can occur antepartum, intrapartum, or, less commonly recognised, ________. 1.2.2 Evaluation of a patient with eclampsia Evaluation of a woman with eclampsia proceeds simultaneously with initial resuscitation rather than delaying treatment, including assessment of airway, breathing, and circulation, blood pressure measurement, and neurological assessment, alongside urgent laboratory investigation including full blood count, liver and renal function tests, coagulation studies, and urinalysis for proteinuria, together confirming the diagnosis and assessing the severity of associated multisystem involvement. Foetal assessment (where the pregnancy has not yet been delivered) including continuous foetal heart rate monitoring should proceed alongside maternal evaluation and stabilisation, though genuine maternal stabilisation must always take clear priority over foetal assessment or delivery, given that effective maternal resuscitation itself directly benefits foetal wellbeing through restored uteroplacental perfusion. Fill in the blank: Evaluation of eclampsia includes urgent laboratory investigation including full blood count, liver and renal function tests, and ________ studies. Maternal stabilisation must always take clear priority over foetal assessment, given that effective resuscitation itself benefits foetal wellbeing through restored uteroplacental ________. 1.2.3 Complications of pre-eclampsia and eclampsia Complications of severe pre-eclampsia and eclampsia include HELLP syndrome, disseminated intravascular coagulation, acute kidney injury, pulmonary oedema, cerebral haemorrhage, and, in the most severe cases, maternal death, with each specific complication requiring its own targeted assessment and management alongside the

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