2. u Hypertensive diseases affect 1 in 10 pregnancies → Very common
u • Preeclampsia is the 2nd most common cause of maternal death in
Egypt.
u What is the first…?
u • Hypertensive disorders in pregnancy:
u 1. Chronic hypertension
u 2. Gestational hypertension
u 3. Preeclampsia
3. DEFINITIONS
Preeclampsia
• Hypertension arising for the first time after 20 weeks pregnancy
associated with proteinuria or other features of severe
preeclampsia.
• Blood pressures → normal within 6 weeks postpartum.
Gestational Hypertension
• Hypertension occurring for the first time after 20 weeks of
pregnancy
with NO proteinuria or other features of preeclampsia.
4. Chronic Hypertension
• HTN present before pregnancy OR
• HTN diagnosed before 20 weeks of pregnancy OR
• HTN that persists for > 3 months after delivery.
Chronic Hypertension with Superimposed Preeclampsia
Chronic HTN + preeclampsia
• Severe increase in blood pressure with proteinuria and other features
of severe preeclampsia.
5. What is hypertension….?
• Blood pressure ≥ 140 mmHg systole OR ≥ 90 mmHg diastole
• Measured at least twice
• At least 4 hours apart
What is proteinuria….?
• ≥ 300 mg protein in urine collected over 24 hours.
6.
7. PREECLAMPSIA
• Pregnancy-specific multisystem disorder
– >20 weeks: HTN + proteinuria OR other features of severe preeclampsia.
• Pathophysiology
– 1st trimester: abnormal trophoblastic invasion of spiral arteries → placental
ischemia.
– Release of placental factors from ischemic placenta:
• Vascular endothelial cell dysfunction → edema - proteinuria
• Vasoconstriction → HTN
• Intravascular coagulation → ischemia - decrease platelets
8. Grades of Preeclampsia
Mild preeclampsia
• HTN < 160/110 Proteinuria
Severe preeclampsia: Any one of the following:
• Severe HTN: ≥ 160 systole OR ≥ 110 systole OR
• Any of the features of severe preeclampsia
9. Features of severe preeclampsia
• Persistent headache
• Blurring of vision ,Nausea & vomiting
• Epigastric & Rt upper abdominal pain
• Pulmonary edema
• elevated Liver enzymes
• Elevated serum creatinine
• Fetal growth restriction or fetal death
• Pulmonary edema
• Oliguria
10. RISK FACTORS
Age > 40 years
• Obesity
• 1st pregnancy
• Pregnancy interval > 10 years
• Twins
• past History of HTN with pregnancy
• Family history of PE
• Chronic HTN
• Other diseases: DM – Systemic lupus –Chronic kidney disease
11. Prevention of PE
• Aspirin once daily Throughout pregnancy
From 1st trimester
13. Management of Preeclampsia
“ Delivery is the Only Cure ”
• Decision of delivery depends on:
– Gestational age → Avoid prematurity.
– Maternal condition → Severity of disease.
– Fetal condition → (avoid fetal hypoxia – death)
14. Management of Mild Preeclampsia
At ≥ 37 weeks: Delivery by induction of labor or CS.
< 37 weeks: Expectant management:
• Hospital admission for initial assessment
• Regular assessment of BP (4 times/day)
• Daily weight measurement.
• Follow up of danger signs ???
• Blood tests (CBC – liver – kidney function): 2 times /week
• Fetal assessment: daily kick count – CTG – ultrasound
• Antihypertensive drugs to control BP (moderate & severe)
• Dexamethasone for lung maturity (if delivery is needed before 34 weeks)
15. Management of severe preeclampsia
Control of blood pressure+ Prevention of
eclampsia+ Delivery
16. Prevention of eclampsia:
• Magnesium Sulphate
– Loading dose 4-6 gm in 100 ml ringer solution IV over 20 minutes
– Maintenance: 1-2 gm / hour for 24 hours.
• Patient monitoring during magnesium Sulphate treatment:
– Respiratory rate (> 16/minute)
– Knee jerk reflex (present)
– Urine output (> 30 ml/hour)
17. Eclampsia
Eclampsia: Tonic clonic convulsions associated with preeclampsia
Timing: Antepartum – intrapartum – postpartum
Stages of eclampsia:
1. Prodrome: Muscle twitches – altered conscious level
2. Tonic stage (20 seconds): generalized muscle contraction
3. Tonic-clonic stage (60 seconds): Alternating muscle contraction and relaxation –
starts in the face and extends to the body – loss or respiration – tongue biting –
trauma –involuntary passage of urine or stool.
4. Coma: patient is breathing but unconscious.
5. Postictal stage: confusion – agitation.
18. Management of eclampsia
1. Call for help
2. Protect airways: – Oropharyngeal airway ± Suction
– O2 supplementation – left lateral position
3. Control convulsion: magnesium sulphate infusion.
4. Control of BP: antihypertensive medications
5. Fetal assessment: after stabilization of maternal condition
6. Delivery: induction of labour or CS
20. Gestational hypertension is:
1. Hypertension & proteinuria before 20 weeks
2. Hypertension & proteinuria after 20 weeks
3. Hypertension without proteinuria before 20
weeks
4. Hypertension without proteinuria after 20 weeks
21. Management of eclampsia at 31 weeks pregnancy
should include all of the following except:
1. Magnesium sulphate
2. Assessment of the fetal condition
3. Protection of the airway
4. Antihypertensive treatment
22. All of the following are features of severe preeclampsia
except:
1. Severe persistent headache
2. Epigastric pain
3. Elevated liver enzymes
4. Low platelets
5. Severe anemia
