A case presented to the Dept of OBGYNE PHMC LP as

1. Under Pressure:
A Case of Pre-
eclampsia Severe
Ellen A. Nano, MD
Emergency Medicine
OB-GYNE Rotator, July 2021

2. • To discuss a case of pre-eclampsia seen at the
emergency department
• To discuss the management done at the emergency
room
SPECIFIC
OBJECTIVES

3. J.B
32 year old
G3P1 (1011)
Single
Filipino
Roman Catholic
Resides in Las Piñas City
Admitted last July 17,
2021
GENERAL DATA

4. Hypogastric Pain
CHIEF COMPLAINT

5. No Hypertension
No Diabetes
No Bronchial Asthma
No history of any accident or
operation
PAST MEDICAL/SURGICAL
HISTORY

6. No Hypertension
No Diabetes
No Bronchial Asthma
No history of any accident or
operation
FAMILY MEDICAL HISTORY

7. Non smoker
Non alcoholic beverage drinker
Denies illicit drug use
Online Seller
Cohabitating with a 33 years old Overseas Filipino
Worker
PERSONAL AND SOCIAL
HISTORY

8. Menarche: 13 years old
Interval: regular
Duration: 7 days
Amount: 4-5 moderately soaked pads
Symptoms: No dysmenorrhea
MENSTRUAL HISTORY

9. First Sexual Contact at 25 years old
Three sexual partners
No dyspareunia, No history of STI
No OCP used
Pap smear not done
GYNECOLOGIC HISTORY

10. G3P1 (1011)
LMP: October 20, 2020
AOG: 36 3/7 by Ultrasound
EDD: August 10, 2021
Pre-Natal check up: Lying-in 7x
No history of any disease or infection during
the whole pregnancy
OB HISTORY

11. G3P1 (1011)
OB HISTORY
G Year AOG Manner of
Delivery
Place of Delivery Birth
Weight
Complications
1 2016 Full term
Male
Spontaneous
Vaginal Delivery
East Avenue
Medical Center
unrecalled None
2 2019 Incomplete
Abortion
Completion
Curettage
Ospital ng
Muntinlupa
3 PRESENT PREGNANCY

12. HISTORY OF PRESENT
PREGNANCY
4 WEEKS
AOG
 (+) Amenorrhea
 Pregnancy test:
positive
 Consult done at
a lying-in clinic
 Given with OB
multivitamins
and Ferrous
Sulfate once a
day
12
WEEKS
AOG
 First
Transabdominal
ultrasound: 17 2/7
weeks AOG
 Work ups done:
normal
 Unremarkable
prenatal check ups
32
WEEKS
AOG
 75 g OGTT done
with NORMAL
result
 NO history of
infection

13. HISTORY OF PRESENT
PREGNANCY
20 hours
PTC
•Sudden onset of Hypogastric pain, + Nausea, No headache, No dizziness
•No medication taken
•Sought consult to a lying-in
18 hours PTC
•BP elevated at 170/110 mmhg
•Given with Nifedipine 30mg/tab PO (1st dose)
•Repeat BP after 30 minutes = 130/100 mmhg
•Given with Nifedipine 30mg/tab PO (2nd dose)
•Repeat BP after 30 minutes = 120/90 mmhg
11 hours PTC
•Advised transfer to tertiary hospital for further evaluation and management

14. PHYSICAL EXAMINATION
GENERAL SURVEY Awake, ambulatory, conversant and not in cardiorespiratory distress
Pre-pregnancy Wt: 60kg ht: 156cm BMI: 24.7
VITAL SIGNS Blood Pressure: 180/140 mmhg Heart Rate: 96 bpm
Respiratory Rate: 19 cpm Temperature: 36.5°C
MENTAL STATUS Conversant, oriented to time, place, and person
SKIN Brown skinned, soft, warm to touch with good skin turgor. No lesions.

15. PHYSICAL EXAMINATION
HEAD AND NECK Symmetrical, normocephalic head, no deformities; no lesions
EENT Anicteric sclerae, pink palpebral conjunctivae
CHEST AND LUNGS Symmetrical chest expansion, clear breath sounds, no retractions
CARDIOVASCULAR Adynamic precordium, normal rate and regular rhythm, no murmurs
ABDOMEN Globular, gravid, (+) linea nigra, (+) striae gravidarum
Fetal heart tone: 140s
Fundic height: 24cm
Estimated fetal weight: 1800 – 2000g
Uterine contractions: every 11 minutes, moderate, lasting for 40-60
seconds
LEOPOLDS MANEUVER
LM1: soft doughy mass,
LM2: hard convex structure on maternal right, small irregular mobile
parts on maternal left
LM3: hard round ballotable mass
LM4: not assessed

16. PHYSICAL EXAMINATION
PELVIC EXAM Inspection:
Normal looking external genitalia.
No ulcers, scars, abnormal discharge, atrophy, masses, varicosities,
abnormal hair distribution. Vaginal wall smooth, no irregularities or
masses.
Speculum Examination:
Cervix is pink, smooth, no discharge
Internal Examination: (done after Loading dose of MgS04)
Posterior , 1 cm dilated beginning effacement, (+) bag of water,
cephalic, floating
EXTREMITIES No deformities, no lesions, good muscle tone, no cyanosis or edema,
full and equal pulses

17. G3P1 (1011) PREGNANCY UTERINE 36 3/7 WEEK
AGE OF GESTATION BY UTZ,
CEPHALIC IN PRETERM LABOR;
PREECLAMPSIA WITH SEVERE FEATURES
INITIAL IMPRESSION

18. COURSE AT EMERGENCY
ROOM
BP: 160/110 mmhg (initially at the triage)
Repeat BP 180/140 mmhg (at ER)
Hydralazine 5mg/IV was given
Repeat BP after 15 minutes 170/100 mmhg
Hydralazine 10mg/IV was given
MgSo4 4g Slow IV push Loading dose
Dexamethasone 6mg IM
Indwelling Foley Catheter inserted
CBC c PC, Blood typing , Urinalysis, BUN, Creatinine,
SGPT/SGOT, LDH, COVID RTPCR, 24H urine protein
Upon Arrival at ER
(MAP = 150)
15 minutes at ER
(-) headache
(-) dizziness
(-) nausea/vomiting
(-) abdominal pain

19. COURSE AT EMERGENCY
ROOM
Repeat BP 170/100 mmhg (at ER)
Hydralazine 5mg/IV was given
Maintenance drip: MgSO4 20g + D5LR 1L to run at 100cc/hr
at 2g/hr
Repeat BP after 15 minutes 170/100 mmhg
Hydralazine 5mg/IV was given
MgSo4 4g Slow IV push Loading dose
Repeat BP after 15 minutes 180/100 mmhg
Start Nicardipine drip: 10mg Nicardipine + 90 cc D5W to run
at 1mg/hr to be titrated if 1mg/hr until with SBP of 150
IVF: D5LR 1L x KVO
30 minutes at ER
(-) headache
(-) dizziness
(-) nausea/vomiting
(-) abdominal pain
45 minutes at ER
(-) headache
(-) dizziness
(-) nausea/vomiting
(-) abdominal pain
1 hour at ER
(-) headache
(-) dizziness
(-) nausea/vomiting
(-) abdominal pain

20. COURSE AT EMERGENCY
ROOM
Results Normal value
Red blood cell 4.77 4.50-5.50
Hematocrit 0.40 0.37-0.47
Hemoglobin 134 110-150
White blood cell 14.37 4.50-10.00
Segmenters 0.58 0.50-0.70
Eosinophils 0.01 0.00-0.05
Lymphocytes 0.34 0.20-0.40
Monocytes 0.07 0.00-0.07
Platelet count 261 150-400
MCV 84.70 80-100
MCH 28.10 26-34
MCHC 332 320-360
Results Normal value
BUN 4.9 2.5-6.4
Creatinine 69 49-90
AST 67 15-37
ALT 62.80 14-59
Lactate
Dehydrogenase
346 135-214
Blood Typing O Positive

21. COURSE AT EMERGENCY
ROOM
URINALYSIS Result Normal value
Color Yellow Straw-Dark
yellow
Transparency Turbid Clear
Specific gravity 1.030 1.005-1.025
pH 6.0 5.00-7.00
Protein Trace Negative
Glucose Negative Negative
RBC 3-5 0-3
Pus cells 1-3 0-5
Epithelial cellss Moderate
Bacteria Many

22. COURSE IN THE LABOR
ROOM
PX Hooked to fetal monitor
Admission test done: Reactive
Nicardipine drip continued
1st Hour
Afebrile
No subjective
complaints
BP 180/100
Nicardipine drip:
10mg Nicardipine +
90 cc D5W to run at
1mg/hr
BP Range: 140/80-
150/100

23. COURSE IN THE LABOR
ROOM
For BPS with doppler velocimetry 36 3/7
weeks AOG
On the 8th Hour
Afebrile
No subjective
complaints
BP = 140/80
HR = 97bpm
RR = 18 cpm
O2sat = 98%
Nicardipine drip at
1mg/hr
Mgso4 drip:
Ongoing
IMPRESSION
Pregnancy Uterine 32 weeks 6 days by Fetal Biometry, Live, Singleton,
Cephalic Presentation
Placenta Anterior Grade 3
Adequate Amniotic Fluid Volume
Estimated Fetal weight is at low limits of Normal for Age of Gestation
(2087 grams)
Biophysical Profile Score 8/8

24. COURSE IN THE LABOR
ROOM
For Stat CS for Preeclampsia with severe features under
RA-SAB
Cefazolin 2g IV as loading dose
On the 13th Hour
Afebrile
+ HEADACHE
+ HEMATURIA
BP = 150/100
HR = 92 bpm
RR = 18 cpm
O2sat = 98%
Nicardipine drip at
1mg/hr
Mgso4 drip:
Ongoing
IE: posterior, 2 cm
dilated, beginning
effacement, + BOW,
floating
Results Normal value
BUN 4.3 2.5-6.4
Creatinine 60 49-90
AST 67 15-37
ALT 66 14-59

25. COURSE IN THE LABOR
ROOM
OUTCOME:
Delivered to a live preterm, cephalic baby
boy, 36 weeks SGA, 1814g; AS 9,9
On the 15th Hour

26. POST PARTUM COURSE IN THE
WARDS

MgSO4 drip: 1 L PNSS+20g MgSO4: Infuse 50cc (1g) /hr via
solusetx 24hours
Post Partum blood pressure ranges: 130-140/80-90
Patient was discharged on the 4th hospital day
24 hours urine
protein
1620.30 Less than
149.1mg/24
hours

27. G3P2 (1112) PREGNANCY UTERINE DELIVERED
TO A LIVE PRETERM, CEPHALIC,
BABY BOY 36 WEEKS,
SGA (1814 g, APGAR SCORE 9,9)
RIMARY LOW TRANSVERSE CESAREAN SECTIO
FOR PREECLAMPSIA WITH SEVERE FEATURES
UNDER RA-SAB
POST-OPERATIVE
DIAGNOSIS

28. DIFFERENTIAL DIAGNOSIS
Rule In Rule Out
Gestational Hypertension >20 weeks
Elevated blood pressure
(+) proteinuria
Chronic Hypertension Elevated blood pressure Non Hypertensive
> 20weeks
Chronic Hypertension with
superimposed pre eclampsia
Elevated blood pressure
(+) proteinuria
Non Hypertensive
> 20 weeks
Pre eclampsia >20 weeks
Elevated blood pressure
(+) proteinuria
CANNOT TOTALLY RULE OUT
Eclampsia >20 weeks
Elevated blood pressure
(+) proteinuria
No seizure

29. - Complicates 10-20% of pregnancies
- Elevation of BP ≥140 mmHg systolic and/or ≥90 mmHg
diastolic, on two occasions at least 6 hours apart
HYPERTENSION IN
PREGNANCY

30. Parturients with high blood pressure fall into four
categories, which include:
•Gestational hypertension
•Preeclampsia-eclampsia
•Chronic hypertension or pre-pregnant hypertension
•Preeclampsia superimposed on chronic hypertension

31. Chronic HTN with
superimposed
preeclampsia
Chronic HTN Preeclampsia Gestational
Hypertension
Hypertension
In Pregnancy
<20 weeks
age of
gestation
>20 weeks
age of
gestation
Proteinuria Proteinuria
New or
Increased
Proteinuria
No
Proteinuria

32. Chronic Hypertension Chronic HTN with
superimposed preeclampsia
Gestational
Hypertension
Preeclampsia
• Systolic blood
pressure of
>140mmHg or a
diastolic blood
pressure of >90mmHg
• Existed prior to
pregnancy
• Diagnosed before the
20th week of gestation
• Persists longer than
12 weeks after
delivery
• + new onset or sudden
increase of Proteinuria in
hypertensive patients
• BP >140/90
mmhg after 20
weeks of
geatation in
previously
normotensive
women
• BP >140/90mmHg on 2
occasions at least 4 hours
apart after 20 weeks AOG in
women with previously
normal blood pressure OR >
160/110mmHg
+
Proteinuria
• >300mg/24 hours urine
collection OR
• Protein:Creatinine> 0.3
• +1 Dipstick Reading

33. Thrombocytopenia Platelet count <100,000uL
Renal insufficiency Serum creatinine >1.1mg/dL or doubling
of serum creatinine concentration in the
absence of other renal disease
Impaired liver function Liver transaminases twice the normal
symptoms: RUQ pain/epigastric
Pulmonary Edema
Cerebral or visual symptoms
Or in the absence of proteinuria, New-onset hypertension
with new onset of any of the following:
Preeclampsia

34. PATHOPHYSIOLOGY
SPIRAL
ARTERIES
- Delivers
blood
NARROW
- Less blood delivered
POORLY PERFUSED
PLACENTA
- Intrauterine Growth
Restriction
- Fetal Death
- Release of Pro
Inflammatory
Proteins
NORMAL
• Maternal maladaptation to
Cardiovascular changes
• Genetic/Immunologic Factors
• Defective Trophoblastic Invasion

35. PATHOPHYSIOLOGY
ENDOTHELIAL CELL DYSFUNCTION
LOCAL VASOPASM
GLOMERULAR DAMAGE
• Oliguria
• Proteinuria
• Blurred vision
• Flashing lights
• Scotoma
• Injury and swelling
• Elevated Liver enzymes
• Abdominal pain (RUQ and Epigastric)

36. PATHOPHYSIOLOGY
ENDOTHELIAL CELL DYSFUNCTION
ACTIVATION OF COAGULATION
FORMATION OF THROMBI
~ use of platelets
H emolysis
E levated
L iver Enzymes
L ow
P latelet

37. PATHOPHYSIOLOGY
ENDOTHELIAL CELL DYSFUNCTION
CAPILLARY LEAK
MORE PERMEABLE
TISSUES
GENERALIZED EDEMA
PULMONARY EDEMA
CEREBRAL EDEMA

38. Risk factors include:
• Maternal age >40 years old
• Hypertension
• Diabetes
• Renal disease
• Collagen vascular disease
• Multiple gestation

40. • Diagnostics:
• CBC
• Creatinine
• Alanine and aspartate aminotransferase concentrations
• Lactate dehydrogenase level
• Protein in urine
• Protein/creatinine ratio

41. Goals
1.Early identification of worsening preeclampsia
2.Development of a management plan for timely
delivery
Further management depends on:
1. Preeclampsia severity
2. Gestational age
3. Condition of the cervix
MANAGEMENT

42. Objectives in the management of preeclampsia with severe features
 Reduce severity OR prevent progression
 Prevent convulsions
 Control severe hypertension
 Optimum time of delivery
 Detect and appropriately treat end-organ damage
 Completely restore the health of the mother
MANAGEMENT

43. Emergent Therapy for Acute-onset Severe
Hypertension in pregnancy
Drug Dose and Route Precaution & adverse
effect
Labetalol
- Selective a and
nonselective b
antagonist
10-20mg IV, Then 20-80mg q20-30 mins
Maximum dose: 300mg;
For infusion 1-2mg/min/IV
Considered a first line agent
Tachycardia is less common
and fewer side effects
CI: Asthma, heart disease,
or congestive heart
Hydralazine
- Arterial Vasodilator
5mg IV or IM, Then 5-10mg q20-40 mins;
Once BP is controlled, repeat every 3 hours
For Infusion: 0.5-10mg/hr
If no success with 20mg IV(25mg IV ACOG) or
30mg IM, consider another drug
High doses leads to
maternal hypotension,
headache, fetal distress
Methyldopa
- Central a adrenergic
receptor agonists
4-6hr onset of duration
250-500mg PO BID-TID

44. Emergent Therapy for Acute-onset Severe
Hypertension in pregnancy
Drug Dose and Route Precaution & adverse
effect
Nifedipine
- Calcium channel
blocker
10-20mg tab, repeat in 30 minutes if needed,
then
10-20mg tab q2-6 hours
May observe reflex
tachycardia and headaches
Nicardipine IV D5W 90ml + 10mg Nicardipine in soluset
(concentration 0.1mg/mL)
Start drip at 10ugtts/min (equivalent to 1mg/hr)
Titrate every hour (increments of 1mg/hr)
*IV infusion site must be changed every 12
hours
Thiazide Diuretics
(2nd line)
Depends on the agent Can be used in pregnancy
dose adjustment to minimize
adverse effects and risks
such as hypokalemia

45. Prevent Convulsions: Magnesium sulfate
First line treatment & prophylaxis for eclampsia
Decreases level of acetylcholine in nerve terminals
Fetal neuroprotection in <32 weeks in the setting of imminent preterm birth
therapeutic range of MgSO4 is 4-7 mg/dl
MANAGEMENT
MAGNESIUM SULFATE DOSE
1. Loading Dose: 4 g. slow IV push over 5-10 mins and 10 g deep IM (5 g each buttock)
then 5 g. IM every 4 hours until 24 hours after delivery
OR
2. Loading Dose: 4 g IV slow IV push over 5-10 mins
IV infusion of 1-2 g infuse in a rate of 50-100cc/hour via infusion pump or soluset
2. Continue for 24 hours after delivery
3. Given for severe preeclampsia for 24 hours during expectant management

46. MANAGEMENT
What to monitor while on MgSO4:
Urine output less than 20cc/hr
Patellar reflex
RR less than 12/min (respiratory depression)
Serum Magnesium levels should be monitored
*IV Calcium Gluconate-(ANTIDOTE for MgSO4 toxicity)

47. MANAGEMENT
What to monitor while on MgSO4:
Urine output less than 20cc/hr
Patellar reflex
RR less than 12/min (respiratory depression)
Serum Magnesium levels should be monitored
*IV Calcium Gluconate-(ANTIDOTE for MgSO4 toxicity)

48. MANAGEMENT
Consideration for delivery:
Termination of pregnancy is the only cure for
preeclampsia

49. INDICATIONS FOR
DELIVERY
MATERNAL INDICATIONS
• Recurrent severe hypertension
• Recurrent symptoms of preeclampsia
• Progressive renal insufficiency
• Persistent thrombocytopenia or HELLP syndrome
• Pulmonary edema
• Eclampsia
• Suspected abruptio placenta
• Progressive labor or rupture of membranes
FETAL INDICATIONS
• Gestational weeks of 34 weeks
• Severe fetal growth restriction (<5thpercentile)
• Persistent oligohydramnios
• Biophysical profile of 4/10 or less on at least 2 occasions 6 hours apart
• Reversed End Diastolic Flow on umbilical artery doppler studies
• Recurrent variable or late decelerations
• Fetal death

50. POSTPARTUM CARE
Laboratory values initially worsen postpartum
Decreasing platelet count (24-48 hours postpartum)
Serum LDH concentration peaks at 24-48 hours postpartum
Decreases by 4th postpartum day

51. Counseling for future pregnancies:
higher risk to develop hypertension in future pregnancies
nulliparas (before 30 weeks)-recurrence risk of 40 %
Previous Preeclampsia delivered at 37 weeks, 23 percent
recurrence

52. Prevention of Preeclampsia
ASPIRIN Should be given <16 weeks AOG (50 – 150 mg)
CALCIUM High dose supplementation 1500 -2000mg/day

53. 12 steps approach in patient treatment
1.Anticipate and make the diagnosis
2.Assess the maternal condition
3.Assess the fetal condition: deliver sooner or later?
4.Control BP
5.Prevent seizures with MgSO4
6.Manage fluid and electrolytes
7.Exercise judicious hemotherapy
8.Manage labor and delivery
9.Optimize perinatal care
10.Intensively treat the postpartum patient
11.Remain alert to the development of multi organ system failure
12.Counsel about future pregnancies

54. Thank You!

55. Any questions?
Thank You!