Cardiovascular Journal of Africa: Vol 27 No 2 (March/April 2016)

CARDIOVASCULAR JOURNAL OF AFRICA • Volume 27, No 2, March/April 2016

AFRICA

109

Patients with pre-eclampsia may describe new-onset headache

that is frontal, throbbing or similar to migraine headache.

They may also have visual disturbances, including scintillations

and scotoma, which has been linked to cerebral vasospasm.

Gastrointestinal complaints, such as epigastric pain, may be

moderate to severe in intensity and due to hepatic swelling

and inflammation, with stretch of the liver capsule. Rapidly

increasing or non-dependant oedema may be a symptom of

developing pre-eclampsia. In addition, rapid weight gain as a

result of oedema due to capillary leak, as well as renal sodium and

fluid retention could be a pointer to pre-eclampsia. New-onset

seizures in pregnancy suggest pre-eclampsia–eclampsia, but

primary neurological disorders must always be excluded.

Signs the physician must look out for

Pre-eclampsia is a multi-systemic disease with various physical

signs. Oedema can be seen in non-dependent areas such as

the face and hands, apart from the dependent areas. Maternal

systolic blood pressure above 160 mmHg or diastolic blood

pressure above 110 mmHg can occur and denote severe disease.

In measuring the blood pressure, women should be made

to sit quietly for five to 10 minutes before each blood pressure

measurement, and blood pressure should be measured in lateral

recumbency with the cuff at the level of the heart. Korotokoff

sounds I and V should be used to define the systolic and diastolic

blood pressure, respectively. In about 5% of pregnant women, an

exaggerated gap exists between the fourth and fifth Korotokoff

sounds with the fifth sound approaching zero. In this type of

case, the fourth sound may more closely approximate the true

diastolic blood pressure.

Signs of secondary hypertension such as buffalo hump, wide

purple abdominal striae suggesting glucocorticoid excess, systolic

bruit heard over the abdomen or in the flanks suggesting renal

artery stenosis, and radio-femoral delay or diminished pulses in

the lower versus upper extremities suggesting aortic co-arctation

should be looked for. The presence of a fourth heart sound

on auscultation is not a normal finding in pregnancy and may

suggest left ventricular hypertrophy from chronic hypertension.

Carotid bruits may also reflect atherosclerotic disease due to

longstanding hypertension. In addition, retinal changes of

chronic hypertension may be noted. Retinal vasospasm and

retinal oedema, which may manifest as severely impaired vision,

generally reflects pre-eclampsia.

In pre-eclampsia right upper-quadrant abdominal tenderness

stemming from hepatic swelling and capsular stretch may be

seen. Although brisk or hyperactive reflexes are common during

pregnancy, clonus is a sign of neuromuscular irritability that

usually reflects severe pre-eclampsia.

Laboratory investigations the physician must order

Laboratory investigations to evaluate chronic hypertension

include testing for target-organ damage, and to exclude

secondary causes of hypertension and co-morbid factors. For

chronic hypertension in the first trimester, it is very useful to

obtain a full blood count, electrolyte, urea and creatinine levels,

liver enzyme concentrations and testing for proteinuria. These

serve as baseline values to be referred to later in the pregnancy if

there is a concern regarding superimposed pre-eclampsia.

Serum lipids usually increase during pregnancy and therefore

measurement should be deferred until the postpartum period.

Also, the increase in endogenous corticosteroids levels during

normal pregnancy makes it difficult to evaluate for secondary

hypertension due to adrenal corticosteroid excess.

Useful blood tests when evaluating eclampsia and

pre-eclampsia include urinalysis, a full blood count, serum

electrolyte levels, urea and creatinine 24-hour urinary protein

excretion, and serum uric acid, liver enzyme and bilirubin levels.

Follow up

The long-term implications of having a pregnancy complicated

by pre-eclampsia or hypertension have been highlighted above. It

is important that pregnant women with hypertensive disease be

given every opportunity to attend appropriate follow-up care in

order to prevent long-term premature morbidity and mortality.

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