Pre eclampsia

1. HYPERTENSIVE DISORDERS OF PREGNANCY
LEARNING OBJECTIVES:
•Classify different types of hypertensive disorders in
pregnancy.
•Demonstrate ability to diagnose and provide immediate
care to woman with pre-eclampsia and eclampsia.
•Understand PE/E management

2. PRESENTATION OUTLINE
 Introduction
 Important signs
 Classification of hypertensive disorders of pregnancy
 Chronic hypertension
 Gestational hypertension
 Pre-eclampsia
 Preeclampsia without severe features
 pre-eclampsia with severe features
 Eclampsia
• Risk categorization in ANC and risk reduction with Aspirin

3. Introduction
• Hypertensive disorders of pregnancy are among the leading causes of maternal & foetal
morbidity & mortality
• Efforts to promote prevention, proper diagnosis & treatment are needed to reverse trend
• The 4 major hypertensive disorders of pregnancy are:
1. Chronic hypertension
2. Gestational hypertension
3. Pre-eclampsia / Eclampsia / HELLP syndrome
4. Pre-eclampsia superimposed on chronic hypertension

4. Introduction cont’d
• Differentiating these disorders requires:
Careful evaluation of a detailed patient’s history
Thorough physical examination
Appropriate laboratory testing
Appropriate imaging specifically ultrasonography
• Proper diagnosis is crucial to initiate appropriate treatment to reduce
potential harm to mother & foetus

5. Classification of Hypertensive Disorders of Pregnancy
Probable Diagnosis Systolic
(mm Hg)
Diastolic
(mm Hg)
Other Signs and Symptoms
Normal range 90-139 and 60-89
Chronic
Hypertension ≥140 and/or ≥90
Pre-pregnancy or
< 20 weeks of pregnancy No Proteinuria
Gestational
Hypertension
≥140 and/or ≥90
≥ 20 weeks of pregnancy No feature of
Pre-eclampsia No proteinuria
No systemic signs and symptoms
Pre-eclampsia
without severe
features
≥140 but
≤ 159 and/or
≥90 but
≤ 109
After 20 weeks of pregnancy
Proteinuria ≥2+ on dipstick or
≥ 300 mg of protein/24-hour urine
collection but protein may also be
negative in case of non proteinuric PE
No organ dysfunction (no symptoms,
normal laboratory and u/s findings)
Pre- Eclampsia with
severe features ≥160 and/or ≥110
Any degree of hypertension with organ
dysfunction which may manifest in any
of the following symptoms
 Headache, nausea, vomiting
 Blurred vision
 Oliguria
 Upper abdominal pain
 Pulmonary oedema
 Abnormal Labs (CBC, RFT, LFTs and or
U/S findings)
Eclampsia ≥140 and/or ≥90
- Convulsions or
- Coma (unconscious)
- No other neurological cause of
convulsions
- May or may not have severe
pre- eclampsia features

6. Chronic (preexisting) hypertension
• Hypertension diagnosed before pregnancy or before 20 weeks of gestation
• Or hypertension diagnosed during pregnancy & persists for at least 12
weeks post-delivery
• It can be primary or secondary to a variety of medical disorders

7. Chronic (preexisting) hypertension
MANAGEMENT
• Lifestyle modifications for controlling hypertension such as:
- No alcohol
- Regular moderate exercise, brisk walking for 30 minutes at least 3 times a week
- Smoking cessation
 Regular monitoring especially for blood pressure, urine test and for foetal movements at each visit
 Aim to bring BP <140/90 mmHg
 Consider delivery if BP is persistently high
 Switch to chronic antihypertensive medication or start
- Methyldopa 250 mg 8 hourly, increase as necessary (max dose 750 mg 8 hourly) and/or
- Nifedipine 20-40 mg every 12 hours
 If BP is not controlled or any sign of pre-eclampsia: refer to hospital for farther management

8. Gestational hypertension
• New onset of hypertension after 20 weeks of gestation in a previously
normotensive individual
AND
• No proteinuria
• No severe features of preeclampsia or no evidence of end organ damage
• That is: no thrombocytopenia, renal insufficiency, elevated liver
transaminases, pulmonary oedema, cerebral or visual symptoms etc.

9. Pre-eclampsia
• Preeclampsia is a multisystem progressive disorder
• Characterized by new onset of hypertension after 20 weeks of gestation or postpartum in
a previously normotensive mother
AND
• Proteinuria (≥300 mg per 24-hour urine collection or protein: creatinine ratio ≥0.3, or urine
dipstick reading ≥2+)
OR
• In the absence of proteinuria, new-onset hypertension with new onset of any of the severe
features pre-eclampsia : thrombocytopenia, renal insufficiency, pulmonary oedema etc

10. Pre-eclampsia classification
Current classification
Pre-eclampsia with severe features
• Pre-eclampsia without severe
features
Previous classification
• Mild pre-eclampsia
• Severe pre-eclampsia

11. HOW TO RULE OUT SEVERE FEATURES
• The severe features can be:
Symptoms
Physical examination findings
Laboratory findings
Imaging findings

12. Pre-eclampsia with severe features
 Any of these findings in a patient with preeclampsia:
• Doubling of serum creatinine concentration in absence of other renal disease
• Systolic BP ≥160 mmHg or diastolic BP≥110 mmHg on ≥2 occasions
• Impaired liver function as indicated by elevated liver transaminases at least
twice upper limit or severe persistent RUQ or epigastric pain unresponsive to
medication & not accounted for by alternative diagnoses, or both
• Progressive renal insufficiency (serum creatinine >1.1 mg/dL or 90 µmol/L)

13. Pre-eclampsia with severe features cont’d
• Thrombocytopenia (platelet count <100,000/µL) with or without
DIC, hemolysis
• Pulmonary oedema (SPO2 < 90%)
• Persistent cerebral or visual disturbances
• Neurological complications*
• Uteroplacental dysfunction (IUGR, abnormal umbilical artery
Doppler wave form or stillbirth)
*Including eclampsia, altered mental status, blindness, stroke, hyperreflexia when accompanied by clonus, severe headaches, & persistent, visual scotomata

14. Chronic hypertension with superimposed
preeclampsia*
• Any of these findings in a patient with chronic hypertension:
• A sudden increase in BP that was previously well-controlled
• Or an escalation of antihypertensive therapy to control BP
• New onset of proteinuria
• Or sudden increase in proteinuria in a patient with known
proteinuria before or early in pregnancy
*Precise diagnosis is often challenging. High clinical suspicion is warranted due to increase in maternal & foetal-neonatal risks associated with superimposed preeclampsia

15. Chronic hypertension with superimposed
preeclampsia with severe features
• Any of these findings in a patient with chronic hypertension and
superimposed preeclampsia:
Systolic BP ≥160 mmHg or diastolic BP ≥110 mmHg despite escalation
of antihypertensive therapy
Thrombocytopenia (platelet count <100,000/microL)
Impaired liver function as indicated by elevated liver transaminase >2X
normal or severe persistent RUQ or epigastric pain unresponsive to
medication & not accounted for by alternative diagnoses, or both

16. Chronic hypertension with superimposed
preeclampsia with severe features Cont’d
New-onset or worsening renal insufficiency (serum
creatinine >1.1 mg/dL or 90 µmol/L)
Pulmonary oedema (SPO2 < 90%)
Persistent cerebral or visual disturbances

17. Eclampsia
• In a patient with preeclampsia, generalized seizures that cannot be
attributed to other causes
NB: some mothers have normal blood pressures after convulsions
• The belief that pre-eclampsia progresses from “mild” to “severe” to
eclampsia is not always true
• Mothers can convulsive without prior warning & with non severe BP

18. Pathogenesis and pathophysiology of
preeclampsia
• How does preeclampsia come about?

19. Defective placentation is the primary defect in
pre-eclampsia
Moffett, Nature Reviews l Immunology 2002

20. Stage 1: Poor
placentation
Stage 2: Systemic
Inflammation
Pre-eclampsia : a two stage disorder

21. Management of Pre-eclampsia
• The goals of management of pre-eclampsia are:
Prevention or control of seizures / convulsions / fits (eclampsia)
Control of hypertension
Delivery of the placenta (baby)
Post delivery and long term follow up
Prevention of recurrence

22. 1. Prevention and /or control of seizures
 Drug of choice is magnesium sulphate
 Mechanism for anticonvulsant effect not clearly defined
Loading dose: total of 14g
 IV 4g of 20% followed by IM 5g of 50% with 1 ml of 2% lignocaine in each
buttock
 Draw 8 mL of a 50% MgSO4 and add 12 mL of water for injection or normal
saline: this is equal to 4 g of 20% MgSO4
 Give the solution as a slow IV bolus over 20 minute

23. Dosing of magnesium sulphate
Maintenance dose:
• IM 5g of 50% with 1 ml of 2% lignocaine 4 hourly in alternate buttocks for 24 hours from
delivery or convulsion whichever occurred last
• If a patient convulses again while receiving MgSO4, give IV 2g of 20% & continue with
maintenance dose
• Clinical assessment for magnesium toxicity should be every 1 to 2 hours
• Maintenance dose is only given or continued when:
Patellar reflex is present
Respiratory rate exceeds 12 breaths/minute,
Urine output exceeds 100 mL over four hours

24. Signs of magnesium toxicity & antidote
 Toxicity correlates with the serum magnesium concentration
• Loss of deep tendon reflexes occurs at or 3.5 to 5.0 mmol/L
• Respiratory paralysis at 5.0 to 6.5 mmol/L
• Cardiac conduction is altered at >7.5 mmol/L
• Cardiac arrest occurs at >12.5 mmol/L
 Antidote:
• Calcium gluconate 15 to 30 mL of a 10% solution (1500 to 3000 mg) IV over 2 to 5
minutes
• Calcium chloride 5 to 10 mL of a 10% solution (500 to 1000 mg) IV over 2 to 5
minutes is an alternative but is more irritating & likely to cause tissue necrosis in
case of extravasation

25. Dosing of MgSO4 in renal insufficiency
• MgSO4 is excreted by kidneys
• Patients with renal insufficiency should receive a standard loading dose, since
their volume of distribution is not altered, but a reduced maintenance dose
• If serum creatinine is >1.1 and <2.5 mg/dL, maintenance dose of 1 g/hour*
• If serum creatinine is ≥2.5 mg/dL or magnesium sulphate toxicity is present, no
maintenance dose
In Uganda half the maintenance dose is given
* This is applicable if maintenance dose is IV infusion. In Uganda where we use IM, the maintenance is halved (2.5g of 50%)

26. 2. Control or treatment of hypertension
• Threshold for treatment of hypertension in pregnancy is a SBP ≥140 mmHg
and/or a DBP ≥90 mmHg1, 2
• This applies whether hypertension is chronic, gestational, or due to pre-
eclampsia1
• Antihypertensive medications do not prevent eclampsia or disease progression
• Intended to prevent end organ damage mainly CVA / stroke
• Hypertension is classified as severe (BP≥160/110mmHg) or non severe (BP
≥140/90 mmHg to 159/109mmHg)
1 Tahlak, M. (2021). A literature review and best practice advice for second and third trimester risk stratification, monitoring, and management of pre-
eclampsia
2Tita, A. T., et al (2022). Treatment for mild chronic hypertension during pregnancy. New England Journal of Medicine.

27. Treatment of severe hypertension
• Severe hypertension is systolic BP≥160 mmHg & / or diastolic
BP≥110mmHg)
• Should be confirmed with a repeat measurement within 15 minutes
• Should be treated promptly (within 30 to 60 minutes)
• Should be lowered gradually over hours to days
• Drugs of choice are IV labetalol or IV hydralazine or immediate
release oral nifedipine1
• Do not use sublingual nifedipine
• Target blood pressure is 130-139 mmHg systolic
80-89mmHg diastolic
1Croke, L. M. (2019). Gestational hypertension and preeclampsia: a practice bulletin from ACOG. American family physician, 100(10), 649-650.

28. Treatment of severe hypertension
Hydralazine
 Hydralazine 5 mg IV bolus every 30 minutes until dBP is down to <110
mmHg and systolic< 160 mmHg
 Maximum dose 30mg in 24 hours
 Once blood pressure is reduced to non-severe levels (lower than
160/110mmHg), ongoing treatment should be continued using oral
medication
Labetalol (Trandate):
 Give Labetalol 20 mg in slow IV over 2 minutes. Double the dose every 20
minutes until dBP is <110 mmHg (total dose not to exceed 300mg in 24
hours).

29. Treatment of non severe (mild) hypertension
• Non severe hypertension is systolic BP ≥140 mmHg to 159
mmHg and / or diastolic BP ≥90 mmHg to 109 mmHg
• Drugs of choice are oral labetalol, nifedipine, or methyldopa
or a combination
• Dosages should be titrated accordingly with response
• Should be lowered gradually over hours to days
• Target blood pressure is (130-139)/80-89 mmHg

30. 3. Delivery of the placenta (baby)
• Ultimate or definitive treatment of pre-eclampsia is delivery
• Timing of delivery is the most difficult decision in management of pre-eclampsia
• Delivery minimizes risk of serious maternal & foetal complications
• Maternal complications include cerebral haemorrhage, hepatic rupture, renal
failure, pulmonary oedema, seizure, thrombocytopenia, myocardial infarction,
stroke, acute respiratory distress syndrome, retinal injury, or abruptio placentae
• Foetal complications, include growth restriction & foetal demise
• Except foetal growth restriction, any of these life-threatening complications can
occur suddenly

31. Delivery of the placenta (baby)
 Decision to deliver is based on:
• Gestational age
• Maternal condition
• Foetal condition
• Severity of pre-eclampsia
 For pregnancies at ≥37 WOG, initiate delivery within 24 hours irrespective of
severity of disease
 For others, determine if there is an indication for immediate delivery

32. Delivery of the placenta (baby)
 If there is no indication for immediate delivery:
• For mothers at 34WOG to 36W6D, offer expectant management if
there is no evidence of maternal and / or foetal compromise
• For mothers at 26WOG to 33W6D, offer expectant management if
there is no evidence of maternal and / or foetal compromise
• For Eclampsia delivery should occur within 12 hours
• Preeclampsia with severe Features, delivery plan should be
initiated within 24 hours

33. Indications for immediate delivery / contraindications
for expectant management
• Abnormal neurological features (eclampsia, stroke,
intractable persistent severe headache unresponsive
to analgesia, visual symptoms)
• Repeated episodes of severe hypertension despite
use of three antihypertensive drugs
• Pulmonary oedema
• Worsening thrombocytopenia <100,000 or need for
transfusion
• Worsening labs in severe range
• Haemodynamic instability
• Non reassuring foetal status (abnormal NST,
Oligohydramnios, low BPP, IUGR, absent / reduced
EDFV on UA Doppler)
• No expectation for survival at diagnosis e.g. extreme
prematurity
• Abruption placentae, PPROM
• Myocardial infarction or cardiomyopathy
• HELLP syndrome, AKI
• Persistent epigastric / RUQ pain unresponsive to med
• Maternal request for delivery

34. Expectant management of preeclampsia
• Most patients with preeclampsia with severe features are delivered promptly to
prevent maternal & foetal complications
• Preeclampsia is progressive & no medical treatment to prevent progression
exists except MgSO4 to prevent eclampsia
• Delivery is always in the best interest of the mother
• However, preterm delivery may not always be in the best interest of the
newborn
• Delaying delivery to increase fetal maturity & reduce neonatal morbidity &
mortality can be considered under certain circumstances

35. Expectant management of preeclampsia cont’d
• The risk of expectant management
• severe maternal end-organ damage
• Fetal progressive growth restriction & demise
• Shared decision-making weighing risks & benefits of expectant management
• No direct maternal benefit from expectant management
• Mother is taking a significant risk to her own health to delay delivery
• Decision should be clearly documented & revisited at regular intervals
• There must be no absolute contraindication to expectant management

36. Components of expectant management for pre-
eclampsia with severe features
• Inpatient care until delivery
• Daily maternal & foetal assessment for
indication of immediate delivery
• Daily laboratory tests (PLT, AST, ALT,
serum creatinine at minimum)
• Blood pressure control as discussed
• Magnesium sulphate as discussed
• Corticosteroid for those <34 WOG
• Daily CTG if available
• Monitor fluid input and output
• Twice weekly obstetric USS for BPP,
UA Doppler studies, NST, foetal
growth
• Deliver immediately if indications for
immediate delivery develop

37. Components of expectant management for pre-eclampsia
without severe features
• Admit and investigate then Outpatient care
• Weekly follow-up in ANC at minimum by a
medical officer
• Assess for development of severe
symptoms
• BP control as discussed
• Weekly laboratory tests (Platelets, AST,
ALT, serum creatinine at minimum)
• Weekly obstetric USS for BPP, UA Doppler
studies, NST, foetal growth
• Corticosteroid for those <34 WOG
• Teach mother to monitor foetal movement
& return immediately if reduced
• Daily home BP monitoring if feasible &
when to return
• If severe features develop, admit &
deliver immediately
• If no severe features develop, deliver at
37WOG
• Strict bedrest is not recommended

38. Summary of approach to a pregnant woman with
hypertension
• Thorough history to look for severe features
• Thorough physical exam to look for severe features
• Laboratory investigation to look for severe features
• Obstetric ultrasound scan for foetal growth and foetal well being
• Determine if patient has pre-eclampsia
• If patient has pre-eclampsia determine if its with or without severe features
• Give MgSO4 prophylaxis or control seizures if present

39. Summary of approach to a pregnant woman
with hypertension cont’d
• Treat hypertension appropriately
• Determine if at term or not
• If at term, deliver immediately (initiate delivery within 24 hours)
• If not at term, determine if there is indication for immediate delivery
• If no indication for immediate delivery, offer expectant management
• Terminate expectant management if indication for immediate delivery
develops
• If no indication for immediate delivery develops, deliver at 37 weeks

40. Intrapartum care
• Route of delivery is based on standard obstetric indication
• Pre-eclampsia or eclampsia is not an absolute indication for C-section
• Decision to expedite delivery, does not mandate immediate caesarean birth
• Continuous maternal-foetal monitoring is indicated intrapartum
• Strict fluid input and output monitoring
• Limit fluid intake to 80mls per hour
• Neural axial labour analgesia can be safely provided

41. Postpartum care
• Close monitoring of vital signs for at least 3 days
• Some patients will require longer monitoring
• Continued follow-up is needed until all signs & symptoms of preeclampsia resolve
• Repeat laboratory tests (platelet count, creatinine, liver transaminases) daily until two consecutive
sets of data are normal or trending to normal
• Complete MgSO4
• Adjust antihypertensive therapy accordingly
• Some patients will have to be discharged on antihypertensive medications, which
are discontinued when BP returns to normal

42. Postpartum care cont’d
• Tapering of antihypertensive is favoured over abrupt total stoppage
• Blood pressure should continued to be monitored after stopping antihypertensive
• Unless unstable, mothers can be discharged on day 5 post delivery
• Review at 1 week, 6 weeks and 12 weeks postpartum
• Some mothers may require more frequent follow up
• Repeat labs at each of those follow ups
• Additional work up such as cardiac echo, ECG will vary from one patient to
another

43. Long term complications
Pre-eclampsia survivors are at an increase risk of the following
Recurrent pre-eclampsia, fetal growth restriction, preterm delivery, abruptio
placentae, and stillbirth in subsequent pregnancy (The GREAT Obstetric
syndrome)
Chronic hypertension, cardiovascular disease (CVD, including coronary heart
disease, stroke, and heart failure)
Chronic kidney disease
Diabetes mellitus
Depression, anxiety and PTSD

44. Complications continued
 Mothers should be educated on these & strategies to reduce risk of complications
Regular screening for HTN, CVD, CKD, DM, PTSD, Depression, etc.
Regular BP monitoring
Appropriate weight
Healthy diet
Exercise
Preconception optimisation

45. Risk factors for preeclampsia
High risk factors
• Previous pregnancy with preeclampsia, especially
early onset and with an adverse outcome
• Multifetal gestation
• Chronic hypertension
• Type 1 or 2 diabetes mellitus
• Chronic kidney disease
• Autoimmune disease with potential vascular
complications (antiphospholipid syndrome,
systemic lupus erythematosus)
Moderate risk factors
• Nulliparity
• Obesity (body mass index >30 kg/m2)
• Family history of preeclampsia in mother or sister
• Advanced maternal age (≥35 years)
• Previous adverse pregnancy outcome e.g.,
stillbirth, IUGR, abruption placentae etc.
• Interval >10 years between pregnancies
• Change of partner
• In vitro conception

46. Antenatal prevention or risk reduction of
preeclampsia
• Administer low dose aspirin 150mg once daily for a mother with any one of
the high-risk factors or a mother with any two of the moderate risk
mothers
• Start from 11 weeks of gestation but before 16 weeks of gestation
• Preferably taken at night
• Stop the aspirin at 36 weeks of gestation
• Calcium can also be given to population of low dietary calcium intake

47. Mechanism of action of aspirin

48. References
1. Essential Maternal and Newborn Clinical Care Guidelines for Uganda, May 2022
2. Tita, A. T., Szychowski, J. M., Boggess, K., Dugoff, L., Sibai, B., Lawrence, K., ... & Andrews, W. W. (2022). Treatment
for mild chronic hypertension during pregnancy. New England Journal of Medicine.
3. Magee, L. A., et al (2022). The 2021 International Society for the Study of Hypertension in Pregnancy classification,
diagnosis & management recommendations for international practice. Pregnancy Hypertension, 27, 148-169
4. Poon, L. C., Magee, L. A., Verlohren, S., Shennan, A., von Dadelszen, P., Sheiner, E., ... & Hod, M. (2021). A literature
review and best practice advice for second and third trimester risk stratification, monitoring, and management of pre-
eclampsia: Compiled by the Pregnancy and Non-Communicable Diseases Committee of FIGO (the International
Federation of Gynecology and Obstetrics).
5. Croke, L. M. (2019). Gestational hypertension and preeclampsia: a practice bulletin from ACOG. American family
physician, 100(10), 649-650.
6. Group, T. M. T. C. (2002). Do women with pre-eclampsia, and their babies, benefit from magnesium sulphate? The
Magpie Trial: a randomised placebo-controlled trial. The Lancet, 359(9321), 1877-1890

49. Thank you