Pre-eclampsia Prevention, Prediction and Possibilities PDF

Preface xi
Acknowledgements xiii
Author xv
Part
1 GENERAL ASPECTS OF PRE-ECLAMPSIA 1
1 Introduction 3
General aspects of pre-eclampsia 3
What is pre-eclampsia? 4
What is obstetric vasculopathy? 4
Part
2 POSSIBILITIES IN AETIOLOGY OF PRE-ECLAMPSIA 7
2 Immunology of pre-eclampsia 9
Immune tolerance and pre-eclampsia 9
Types of pre-eclampsia based on immunology 9
First few days of placentation and pre-eclampsia 10
The autonomous tight unit 10
Uterine glands and placentation 10
Uterine milk 11
Uterine gland knockout cells 11
The crosstalk 12
References 12
3 Endothelial cell dysfunction and pre-eclampsia 15
Introduction 15
The phenomenon of endothelial cell activation 16
Circulating markers of endothelial activation 16
Endothelial activation and prostaglandins 16
Plasminogen and allied procoagulant activity: A manifestation of endothelial cell activation 17
Antiphospholipid antibodies act through procoagulant mechanism 17
Endothelial cell adhesion molecule disturbances 18
VEGF 18
Clinical bearings 18
Endothelin 19
vi Contents
Other molecules contributing to endothelial cell activation 19
Immunological antibodies 19
Cytokines 19
Formed elements in blood 20
“Toxins” 20
List of Abbreviations 20
References 20
4 Oxidative stress and pre-eclampsia 23
Introduction 23
What is oxidative stress? 23
What is a free radical? 23
Oxygen: A double-edged sword 24
The mischief of free radicals in vascular walls 25
Lipid peroxides: The agents of oxidative stress 25
Our basic study 28
Lipid metabolism in normal pregnancy and in pre-eclampsia 28
Hypertriglyceridemia and pre-eclampsia 31
Small dense LDL phenotype in pre-eclampsia 31
Placental lipid peroxidation 32
Transition metals in lipid peroxidation 34
Clinical manifestations 35
Reperfusion 35
Innate maternal reducing systems 37
The family of free radicals 38
Vascular endothelium and oxidative stress 38
Inefficient second wave of trophoblastic invasion 39
Production of vascular endothelial growth factors 40
Nitric oxide in pre-eclampsia 41
Nitric oxide and endothelial cells 41
Placental atherosis in pre-eclampsia 42
Extracellular reducing systems 42
Uric acid: The powerhouse reductant 43
Policeman-to-riot model to understand uric acid 43
Limitations of reducing systems 44
Inconsistency of reducing systems 45
The ideal reducing system 45
Exercise and prevention of pre-eclampsia 45
The beauty of lysophosphotidyl choline 46
References 47
5 Metabolic syndrome and pre-eclampsia 51
What is metabolic syndrome? 51
Metabolic syndrome and hypertension 51
Metabolic changes in normal pregnancy 52
Basal metabolic rate 52
Proteins and amino acids 53
Carbohydrates 53
Lipids 53
Diagnosis of metabolic syndrome 54
Metabolic syndrome and pre-eclampsia 54
References 54
Contents vii
6 The genetics of pre-eclampsia 57
Basis for reviewing the role of genetics in pre-eclampsia 57
Challenges to the genetic studies in pre-eclampsia 58
Mammalian studies 59
Application of genetic models 59
Examining associations 59
Foetal contributions: Any? 59
Immunology and genetics 60
Epigenetics and pre-eclampsia 61
References 61
Part
3 PREDICTION 63
7 Prediction of pre-eclampsia 65
Introduction 65
Challenges to tests for prediction in pre-eclampsia 65
Need for multiple tests 65
Assessing the quality of tests in prediction of pre-eclampsia 65
Overview of the types of tests 66
Clinical bearings of negative and positive tests 66
An ideal test 66
Clinical tests 66
Mid-trimester blood pressure 66
The roll-over test 67
Hand-grip test 67
Maternal weight gain in pregnancy 67
Urinary tests 67
Microalbuminuria 67
Urinary calcium 68
Calcium-to-creatinine ratio 68
Kallikrein 68
Haematological indices 68
Cellular components in prediction of pre-eclampsia 68
Leucocytes 68
Platelets and platelet activation 68
Uric acid 69
Fibronectin 70
β-hCG 70
Epidemiological indices in pre-eclampsia prediction 70
Colour Doppler in pre-eclampsia prediction: The game changer 71
Review of indices 71
Doppler indices with biomarkers 72
The diastolic notch 72
What is diastolic notch? 72
Practical problem with using colour Doppler and biomarker in combination 73
Notch Depth Index 74
Doppler indices for the discontinuation of preventive measures 75
Identifying low-risk subjects in the first trimester 76
The future: Nanoparticles including exosomes 76
References 77
viii Contents
Part 4 PREVENTION 81
8 Prevention of pre-eclampsia 83
Introduction 83
What is the difference between disease and derangement? 83
Which subjects may benefit? 85
Salt restriction 85
Diuretics 85
Antihypertensives 86
Calcium supplementation 86
Other trace elements and micronutrients 87
Aspirin for the prevention of pre-eclampsia 87
Possible mechanism of action of aspirin 87
Aspirin: Review of literature 88
What dose of aspirin: 75 mg or 150 mg? 88
Misgivings and fears about aspirin 89
Aspirin timing 89
References 89
Part 5 SYSTEMIC MANIFESTATIONS 93
9 Central nervous system 95
Changes in the CNS 95
Pathological lesions in pre-eclampsia 95
Brain 96
Posterior leukoencephalopathy syndrome 96
Psychiatric complications following obstetric vasculopathies: Any correlation? 96
References 96
10 Cardiovascular system 99
Changes in cardiac functions 99
Stroke volume and heart rate 99
How does the heart increase its cardiac output? 99
Vascular response to increase cardiac output 100
Oscillatory pressure and propulsive pressure 100
Peripheral vascular resistance 101
Changes in venous system 101
References 102
11 Haematological system 103
Introduction 103
Alteration in coagulation factors (other than platelets) and procoagulants 103
Alteration in other cellular components of blood 103
Review of coagulation alterations in pre-eclampsia 104
Platelets in normal and pre-eclamptic pregnancies 104
Concept of competence alteration (efficiency) of platelets 105
Platelet activation and thromboxane A2 production 105
References 106
12 Hepatobiliary system 109
Introduction 109
Pathological changes in the liver 109
Liver in the HELLP syndrome 110
References 110
Contents ix
13 Ophthalmic system 113
Introduction 113
The peripheral pathogenesis of ophthalmic changes in pre-eclampsia 113
The central pathogenesis of ophthalmic changes in pre-eclampsia 114
Visual alterations of special mention – recurrent and unilateral 114
References 114
14 Renal system 117
Introduction 117
Brief outline of renal changes in pregnancy 117
Vulnerability of renal system 117
Special features of renal failure complicating pre-eclampsia 118
Renal lesions 119
Are kidney changes in pre-eclampsia – pathognomonic? 119
Gross changes in the kidneys 119
On microscopy 119
Renal function alterations in pre-eclampsia 121
Renal handling of proteins in pre-eclampsia 122
Handling of urinary excretion of proteins in pre-eclampsia 122
Renin-angiotensin system in pre-eclampsia 122
References 123
Part
6 CLINICAL FEATURES OF PRE-ECLAMPSIA 125
15 Clinical features 127
Introduction 127
Classification 127
Hypertension 128
Proteinuria 128
Oedema 129
Grades of severity of pre-eclampsia 129
References 129
Part
7 TR TR TREATMENT OF PRE-ECLAMPSIA 131
16 Treatment of pre-eclampsia 133
Introduction 133
Management goals in pre-eclampsia 133
Early diagnosis and alert surveillance 133
Do women with pre-eclampsia need admission? 134
Management on hospitalization 134
Antihypertensives 135
Does mild pre-eclampsia need antihypertensives? 135
Challenges before treating pre-eclampsia with antihypertensives 135
Which antihypertensive? 136
Mono therapy versus multi-drug therapy 136
Drugs and their dosage schedules 137
When to stop antihypertensives 137
Induction of labour in PIH 137
37 weeks 138
Induction of labour in eclampsia 138
x Contents
Induction of labour in severe pre-eclampsia 138
Induction of labour in pregnancy for foetal reasons 138
Case study in CPR 139
Analysis of the case study 143
The need for involving a neonatologist 144
Readiness of the maternal system for labour induction in PIH 144
Methods of the induction of labour 144
Trachleodynamics in the induction of labour 144
Prostaglandins 145
Dose 145
Foley catheters in induction of labour 146
Other methods of labour induction 146
Caesarean section in PIH 146
Post-delivery care 147
Postpartum haemorrhage (PPH) 147
Blood pressure 147
Coagulation failure 147
Renal failure 148
Pulmonary oedema 148
References 148
Index 151
Pre-eclampsia Prevention, Prediction and Possibilities PDF Ebook

Dr. Pankaj Desai is one of the best known academicians and teachers in obstetrics and gynecology in India. All his twelve books have proved to be best-sellers, one of which was awarded the best book award in the subject. A prolific writer, he has contributed 43 chapters to different text books internationally and nationally. His outstanding academic contributions in the subject have been acknowledged and honored with 7 gold medals and 60 orations. An extremely popular teacher that he is, he has delivered 717 guest lectures in different parts of India and the world at the time of this book going for print. He has published 107 research papers till date, 9 of which have been awarded best research paper prizes. His website www.drpankajdesai.com has become an extremely popular portal for students and practitioners of the subject seeking references and up-to-date knowledge of the subject. It has invited nearly 200000 hits by the time of this publication. His blogs on different academic and non-academic aspects being published on the net as Dr. Pankaj Desai’s blogs have also become very popular inviting more than 30,000 reads as of now. He was recently felicitated by his large number of students and was called The Best Teacher of The century!