PRINCIPLES OF MANAGEMENT OF
PRE-ECLAMPSIA/ECLAMPSIA
BY
DR .A.A.SOBANDE.FRCOG
Professor/Consultant Obstetrician

INTRODUCTION
• Hypertensive disorders are the most common
medical complication of pregnancy
• It complicates up to 10% of pregnancies
• It is a leading cause of maternal and perinatal
morbidity and mortality worldwide
Rates are rising because of the older, more obese
obstetric population with medical issues

Principle
• Generalization that is accepted as true and
that can be used as a basis for reasoning or
conduct
• Rule
• Norm

Management of pre-eclampsia
•Adequate and proper antenatal care is the most
important in the management of pre-eclampsia.
•Maternal antenatal monitoring includes
identification of women at high risk, early detection
by recognition of the clinical signs and symptoms,
and progression of the condition to severe state.
•After diagnosis, subsequent treatment depends on
the results of initial maternal and fetal assessment

Principles of management of
preeclampsia
Admission to hospital
Stabilization of hypertension
Request necessary investigations
Close fetomaternal monitoring
Prevent eclampsia
Delivery as at when appropriate
Post natal care including counseling on future
pregnancies/risks/family planning.

DEFINITIONS OF HYPERTENSION
• Blood pressure (BP) should be measured thrice,
with the average of the 2nd and 3rd values taken
as the BP for the visit
• Hypertension in pregnancy is systolic blood
pressure (sBP)>140mmHg and /or diastolic blood
pressure (dBP)>90mmHg.
• Severe hypertension is sBP >160mmHg and/or
dBP>110mmHg
• White-coat effect is observed when BP is
>140/90mmHg in the hospital but <135/85mmHg
at home

Measurement and definition of
Proteinuria
• In early pregnancy to detect pre-existing renal
disease and at >20 weeks to screen for pre-
eclampsia in at risk patients
• Screening is by dip-stick testing with low
sensitivity (55%) but reasonable specificity
(84%)
• A negative or trace result should not exclude
further investigation.

Measurement of Proteinuria
• Quantification by 24-hr collection is often
inaccurate.
• Now replaced by spot urine sample
• Protein to creatinine ratio of >30mg/mmol
represent significant proteinuria in singleton
pregnancy and >40mg/mmol in multiples

Classification of hypertensive disorders
of pregnancy
• 1 Pre-existing hypertension(1-3%)
• 2. Gestational hypertension (5-6%)
• Pre-eclampsia /eclampsia (2-8%)
• Others

Adverse conditions and severe complications
of preeclampsia
• Organ system affected Adverse conditions Severe complications
• ( risk of severe comp) (that warrant delivery)
• CNS .Headache/visual Eclampsia
• symptoms PRES
• Cortical blindness
• Retinal detachment
• GCS <13
• Stroke,TIA,RIND
• uncontrolled severe bp
• over 12hrs despite 3 anti
• hypertensive agents
• PRES-(posterior reversible leukoenchepalopathy syndrome)
• RIND(reversible neurological deficit< 48hrs)
•

Adverse conditions and severe
complications of preeclampsia
Organ system affected Adverse conditions Severe complications
(increase risk of SC) (that warrant delivery)
• Cardiorespiratory Chest pain/dyspnoea Oxygen saturation<90%
• Oxygen saturation<97%. Need for >50%oxygen>1H
• Intubation other than CS
• Pulmonary oedema
• Positive inotropic support
• Myocardial infarction/ischaemia
• Haematological Elevated WBC count Platelet count <50 x109/L
• Elevated INR or aPTT Transfusion of blood prod
• Low platelet count
• Renal Elevated serum creatinine Acute kidney injury
• Elevated serum uric acid New indication for dialys

Adverse conditions and severe
complications of preeclampsia
Organ system affected Adverse conditions Severe complications
(that increses risk of SC) ( that warrant delivery)
Hepatic Nausea and vomiting Hepatic dysfunction(iNR
RUQ or epigastric pain >2 in absence of warfarin
Elevated serun AST,ALT Hepatic haematoma or
LDH or bilirubin rupture
Feto-placental Non-reassuring FHR Abruption with evidence
IUGR of maternal/fetal compr
Oligohydramnios Stillbirth
Absence or reversed end-diastolic
flow by Doppler velocimetry

Diagnostic and therapeutic considerations
• Pre-existing or chronic hypertension
• Must be differentiated from white –coat effect
(about 30% of early pregnanacies)
• Associated with the following
• Super-imposed preeclampsia=20%
• Abruption (1-2%)
• Preterm delivery (33%)
• IUGR (15%)
• NICU admission (50%)

Diagnostic and therapeutic
considerations
• The white –coat effect in early pregnancy is associated with
40% chance of superimposed gestational hypertension and
8% chance of pre-eclampsia
• More than 95% of women with pre-existing hypertension
have essential hypertension
• Need to investigate thoroughly
• .(urinalysis,serum creatinine,potassium,FBS, ECG)

Gestational hypertension
• Appears at >20weeks
• Risks depend on gestational age at
presentation and progression to pre-eclampsia
• About 35% at <34 weeks will develop pre-
eclampsia over an average of 5 weeks
• Women with prior gestational hypertension
are likely to have recurrence(21%)
• Women with prior pre-eclampsia may develop
gestational hypertension(22%)

Classification of hypertension in
pregnancy.
• •Mild hypertension diastolic blood pressure
90–99 mmHg, systolic blood pressure 140–149
mmHg.
• • Moderate hypertension diastolic blood
pressure 100–109 mmHg, systolic blood
pressure 150–159 mmHg.
• • Severe hypertension diastolic blood
pressure 110 mmHg or greater, systolic blood
pressure 160 mmHg or greater.

MANAGEMENT OF GESTATIONAL
HYPERTENSION
Degree of
hypertension
Mild hypertension Moderate
hypertension
Severe
hypertension
Admit to hospital No (Yes) No (Yes) Yes,until blood
pressure is 150/100
or lower
Treat No With oral labetolol
as first line .keep bp
at systolic <150 and
diastolic at 80-100
mmHg
With oral labetolol
as first line .keep bp
at systolic <150 and
diastolic at 80-100
mmHg
Measure blood
pressure
Not less than once
a week
At least twice
weekly
At least four times a
day
Test for proteinuria At each visit At each visit Daily

Timing of delivery
• Best at 37 weeks
• Labour induction decreases poor maternal
outcome and it is cost saving
• Expectant care at 34-36 weeks may decrease
neonatal respiratory morbidity
• At <34 weeks, there is insufficient evidence to
make recommendation.

Pre-eclampsia
• Defined as gestational hypertension with proteinuria or
one/more adverse conditions or severe complications listed in
previous slide
Factors independently associated with adverse maternal
outcome
- Preterm preeclampsia
- - chest pain/dyspnoea
- -abnormal oxygen saturation/platelet count/creatinine/AST.
- DEGREE OF PROTEINUIA NOT ASSOCIATED WITH SHORT TERM
ADVERSE PREGNANCY OUTCOME.

PRE-ECLAMPSIA
• However,the disease can develop for the first
time after delivery
• Or- worsen rather than improve during the
post natal period.
• It is advisable that all post partum patients
become educated about symptoms suggestive
of new or worsening preeclampsia after
leaving the hospital

DIAGNOSIS
• ACOG says that Proteinuria ,or elevated
protein in urine should not be considered the
single criterion besides new-onset
hypertension, in diagnosing preeclampsia
• Equal weight should be given to reduced
platelet count, renal insufficiency, severe
headache, heart-lung compromise and ,
impared liver function.

DIAGNOSIS
• Any of these ,concurrent with new-onset
hypertension at 20 weeks of pregnancy or
beyond is enough to establish
preeclampsia,even in the absence of
proteinuria
• Reviews of maternal mortality data have
shown that waiting for proteinuria to present
can result in delayed intervention or missed
diagnosis.,as not all women with preeclampsia
develop proteinuria

Predicting pre-eclampsia
• Demographics and family history
• -maternal age >40years
• -family history of preeclampsia(mum or sister)
• -family history of early-onset cardiovascular
disease

Predicting pre-eclampsia
• Past medical or obstetric history
• -Previous pre-eclampsia (*)
• -Antiphospholipid antibody syndrome(*)
• -Pre existing medical condition (s)
• -Pre existing hypertension or booking dBP>90
• -Pre existing renal disease or booking proteinuria
• -Pre existing diabetes mellitus
• Heritable thrombophilias
• Non-smoking
• Previous miscarriage at <10 weeks with same partner.

Risk makers for preeclampsia
• Current pregnancy (First trimester)
• Multiple pregnancy(*)
• Overweight/obesity
• First ongoing pregnancy
• New partner
• Reproductive technologies
• Inter-pregnancy interval>10years
• Booking sBP>130mmHg or dBP>90mmHg
• GTD, Abnormal PAPP-A.
• Vaginal bleeding in early pregnancy

Risk makers for pre-eclampsia
• Second or third trimester
• Gestational hypertension
• Abnormal AFP, hCG, inh A or E3
• Excessive weight gain in pregnancy
• Infection during pregnancy (UTI, periodontal
disease)
• Abnormal uterine artery Doppler
• IUGR

Predicting preeclampsia
• No single test predicts pre-eclampsia
sufficiently to be recommeded for use in
clinical practice to improve outcome.
• THE CONFIDENTIAL ENQUIRY INTO MATERNAL
DEATH HAVE RELATED UNDERAPPRECIATION
OF RISK IN PRE-ECLAMPSIA TO
POTENTIALLYAVOIDABLE DEATHS.

MANAGEMENT OF PET
Degree of
hypertension
Mild hypertension Moderate
hypertension
Severe
hypertension
Admit to hospital Yes Yes Yes
Treat No With oral labetolol
as first line .keep bp
at systolic <150 and
diastolic at 80-100
mmHg
With oral/IV
labetolol as first line
.keep bp at systolic
<150 and diastolic
at 80-100 mmHg
Measure blood
presssure
At least four times a
day
At least four times a
day
More than 4 times
a day depending on
clincal circumstance
Test for proteinuria Do not repeat
quantification
Do not repeat
quantification
Do not repeat
quantification

Timing of delivery
• Refers to pregnancy prolongation following a
period of observation and stabilisation
• Only about 40% of women are eligible
• Should be offered only in experienced centres
where neonates can be cared for (secondary
or tertiary care centre)

Timing of delivery
• Expectant care at<24 weeks is associated with
substanticl maternal complication rates
(including death) (27-71%) and perinatal
mortality (80%)]
• Termination of pregnancy should be discussed

Timing of delivery
• At 24- 33 weeks + 6 days
• Associated with lower rates of maternal
complications (5%) and fewer neonatal
complications despite poorer fetal growth
• Average pregnancy prolongation is 2 weeks
• At 34-36 weeks + 6 days
• Expectant management appears to decrease
neonatal respiratory distress syndrome.

Indications for delivery
• Term gestation
• Severe maternal complications
• Stillbirth or non-reassuring fetal monitoring

Most commonly used agents for
treating BP>160/110
Agent Dosage Onset Peak Duration Comments
Labetalol Start with 20mgIV 5mins 30mins 4hrs Best avoided in women
repeat 20-80mg IV with asthma or heart
q 30min.maximum failure
of 300mg(then switch
to oral tablets
Nifedipine 5-10mg cap or 5-10mins 30mins -6hrs
10mg tab orally
every 30 mins
Hydralazine .Start with 5mgIV 5mins 30mins
repeat 5-10mgIV
every 30mins
ORAL LABETALOL HAS BEEN RECOMMENDED AS AN INITIAL THERAPY FOR SEVERE
HYPERTENSION.(NICE GUIDELINE )

Doses of commonly used drugs to
treat BP149-159/99-109
Agent Dosage Comments
Aldomet 250-500mg po-qid
( max 2g/D)
Labetalol 100-400mg po bid-tid
(max 1200mg/D)
Nifedipine Slow –release preparation
20-60mg po OD
(maximun 120mg /day)
No compelling evidence that antihypertensives are associated with neuro-
developmental effects.
Gestational hypertension and pre-eclamapsia can be associated with an increase in
adverse paediatric neurodevelopmental effects(inattention,aggresion)

Other considerations
• Most cases of severe pregnancy hypertension
are not associated with clear end-organ
dysfunction(e g eclampsia),so BP can be
lowered over hours
• MgS04 may lower BP transiently 30mins after
loading dose
• If Nifedipine is used as antihypertensive,it may
be prudent to administer MgS04 over 20mins
rather than 5mins.
• Antenatal corticosteroids and MgS04 for fetal

USE OF CORTICOSTEROIDS
• Corticosteroids for fetal lung maturation
delivery is anticipated within 7 days
• • give two doses of betamethasone* 12 mg
intramuscularly 24 hours apart in women
between 24 and 34 weeks
• • consider giving two doses of
betamethasone* 12 mg intramuscularly 24
hours apart in women between 35 and 36
weeks.
• DON’T GIVE STEROIDS TO TREAT HELLP

Fetal monitoring
Mild/moderate gestational
hypertension
• Ultrasound scan for fetal growth and amniotic
fluid volume assessment at gestational age
<34 weeks.
• If results are normal, there is no need for
repeat
• After 34 weeks, routine ultrasound is not
advocated unless there is in indication
• CTG can be performed if there is abnormal
fetal activity

Severe gestational
hypertension/Preeclampsia
• Perform CTG at diagnosis
• Carry out ultrasound for fetal growth and
amniotic fluid assessment at diagnosis
• Ultrasound can be performed every two
weeks and CTG weekly

Care plan to be recorded
• -Time and nature of future fetal monitoring
• Fetal indication for delivery and if and when
corticosteroid should be given
• When discussion with neonatologist and
anaesthetists should be take place and what
decisions should be made.

Magnesium sulphate
• Magnesium sulphate (MgS04 (4 g intravenously (IV) halves the
risk of recurrent eclampsia
• Recurrent seizures should be treated with another 2-4-g
IVdose
• MgS04 more than halves the eclampsia occurrence in women
with pre-eclampsia
• Abruption risk is also decreased
• 100 women with pre-eclampsia must be treated to prevent
one seizure,GUIDELINES agree that only women with severe
pre-eclampsia be treated.

Caesarean section vs induction of
labour
• Choose mode of delivery for women with
severe hypertension, severe pre-eclampsia or
eclampsia according to the clinical
circumstances and the woman's preference.

MANAGEMENT OF LABOUR
• Hourly BP check in mild/moderate GH
• ½ hrly in severe hypertension
• Do not routinely limit the duration of the
second stage of labour:
• Recommend operative birth in the second
stage of labour for women with severe
hypertension whose hypertension has not
responded to initial treatment.
rd

Fluid management
• Intravenous fluid intake should be
minimized.(80mls/hr if there is no ongoing
bleeding)
• Use 0.9% Normal saline/Ringers Lactate
Better to avoid colloids(albumin/haemacel)

Management of coagulation disorders before
delivery
• Platelet transfusion is recommeded for counts
<20x 109/L,20-49x109/L prior to CS or >50
x109/L ( with excessive bleeding, platelet
dysfunction.

PREVENTION OF PREECLAMPSIA
• Several randomised trials reported the use of various
methods to reduce the rate or severity or both of pre-
eclampsia.
• Include protein and salt restriction,zinc,magnesium, fish
oil, vit C, E supplement.
• Cochrane review showed benefit of calcium
supplimentation for preeclampsia prevention in women
with low dietary intake is unclear (Knight 2000)
• Even though these trial had limited sample sizes, results
showed a minimum to no benefit (Sibai 1998)
• Observational studies suggest that heparin reduces
recurrent preeclampsia in women with thrombophilia
(Kupferminc 2001)

Eclampsia
• Preceded by severe pre-eclampsia in majority
of cases( beware of atypical cases)
Mortality higher in antepartum eclampsia
• If treated early and adequately, mortality
should be towards zero.

Principles of management of
Eclampsia
Maintain airway, breathing & circulatiion - Control B.P
Oxygen administration 8-10L/min -Request for investigations
Arrest convulsion - Delivery within 6-8hrs
Ventilatory support -Prevent complications
Prevention of injury - Post partum care ( intensive)

Causes of death
• -Cardiac failure
• -Pulmonary oedama
• -Cerebral haemorrage/oedema
• -Adult respiratory distress syndrome
• -Acute renal failure
• -Cardiopulmonary arrest
• -Pulmonary embolisn
• -Puerperal sepsis

Prognosis
• -Long interval between onset of fit and
commencement of treatment (delay)
• -Antepartum eclampsia
• -Coma between fits
• -Fits more than 10
• sBP>200mmHg
• -Temp >102 degrees F
• -Oliguria
• -Jaundice

RISKS IN FUTURE PREGNANCY
Gestational
hypertension
Pre-eclampsia Severe pre-
eclampsia/eclampsi
a,HELLP synrome
Gestational
hypertension
16-47% 13-53%
Pre-eclampsia 2-7% (16%). If birth was needed
before
34 weeks risk is
about 25%.
If birth was needed
before
28 weeks risk is
about 55%
Cardiovascular
disease
Increased risk of
hypertension and
its complications
Increased risk of
hypertension and
its complications
Increased risk of
hypertension and
its complications

Indications for referral to critical care
levels
Level 3 care Severe pre-eclampsia and needing ventilation
Level 2 care Eclampsia
HELLP syndrome
Haemorrhage
Hyperkalaemia
Severe oliguria
Coagulation support
Intravenous antihypertensive treatment
Intial stabilisation of severe hypertension
Evidence of cardiac failure
Abnormal neurology
Pre-eclampsia with mild to moderate hypertension

Post-natal investigation,monitoring
and treatment
In women with gestational hypertension who
have given birth, measure blood pressure:
• daily for the first 2 days after birth
• at least once between day 3 and day 5
after birth
• as clinically indicated if antihypertensive
treatment is changed after birth.

Post-partum management
• Continue use of antenatal antihypertensive
treatment
• Consider reducing the antihypertensive
treatment if BP<130/80mmHg
• Stop methy-dopa within 2 days of delivery if
on the treatment
• Start antihypertensive if BP>150/100mmHg
postnatally
• Follow up patients appropriately until 6-8
weeks post partum

Post-natal investigation,monitoring
and treatment
• With those not on antihypertensives
• Measure BP qid while woman is in hospital
• At least once daily after discharge
• Start antihypertensive if BP>150/100
• Check all investigations results before
discharge.

Patients education
 •Patients should be made aware of the need to
seek immediate advice from a healthcare
professional if they experience symptoms of pre-
eclampsia.
 -severe headache
 •-problems with vision, such as blurring or
flashing before the eyes
 •-severe pain just below the ribs
 •-vomiting

CONCLUSION
-Identifying at Risk Patients during antenatal
booking is Key to reducing the incidence and
complications of the disease
-Delivery should be discussed in patients
presenting before 24 weeks of gestation
-Eclamptic /preeclamptic patients with one end
organ insult should be transferred to High
Dependency Unit

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