Preeclampsia is defined as new onset hypertension and proteinuria after 20 weeks of gestation. It can progress to eclampsia, which is characterized by seizures in addition to the symptoms of preeclampsia. Magnesium sulfate is the primary treatment for preventing seizures in women with eclampsia, as it is more effective than other anticonvulsants like diazepam or phenytoin. Care of women with eclampsia involves prevention of seizures, management of hypertension, and evaluation for prompt delivery of the fetus once the mother is stabilized.

1. DR. SUMIT KAMBLE
SENIOR RESIDENT
DEPT. OF NEUROLOGY
GMC, KOTA

2. PREECLAMPSIA
New onset of hypertension and proteinuria after
20 weeks of gestation in a previously
normotensive woman
Criteria for the diagnosis of preeclampsia
Systolic blood pressure ≥140 mmHg
Or
Diastolic blood pressure ≥90 mmHg
And
Proteinuria ≥0.3 grams in a 24-hour urine
specimen
 Sibai b et al. Preeclampsia. Lancet.2005;365:785-799

3. Eclampsia –
 Occurrence of one or more generalized
convulsions and/or coma in the setting of
preeclampsia and in the absence of other
neurologic conditions.
 Sibai b et al. ACOG. Diagnosis, prevention and mm of eclampsia;.2005;402-410

4.  Eclamptic seizure occurs in 2-3 % of
severely preeclamptic women not receiving
anti-seizure prophylaxis;
 Incidence of eclampsia in developing
countries varies widely: from 6 to 157 cases
per 10,000 deliveries

5.  Approximately one maternal death due to
eclampsia per 100,000 live births
 case-fatality rate of 6.4 deaths per 10,000 cases
 Geographic variation in the incidence of hypertension in pregnancy. World Health
Organization International Collaborative Study of Hypertensive Disorders of Pregnancy.
Am J Obstet Gynecol 1988; 158:80.
 Lubarsky SL, Barton JR, Friedman SA, et al. Late postpartum eclampsia revisited. Obstet
Gynecol 1994; 83:502

6.  Nulliparity
 Preeclampsia in a previous pregnancy
 Age >40 years or <18 years
 Family history of preeclampsia
 Chronic hypertension
 Chronic renal disease
 Antiphospholipid antibody syndrome or inherited
thrombophilia
 Vascular or connective tissue disease
 Diabetes mellitus (pregestational and gestational)
 Multifetal gestationHigh
 body mass index

7.  Black race
 Hydrops fetalis
 Unexplained fetal growth restriction
 Fetal growth restriction,
 abruptio placentae, or fetal demise in a previous
pregnancy
 Prolonged interpregnancy interval
 Partner related factors (new partner, limted sperm
exposure [eg, previous use of barrier contraception])
 Hydatidiform mole
 Susceptibility genes

8.  Symptoms:
 •Headache
 •Visual disturbance
 •Epigastric pain
 •Nausea
 •Restlessness
 •Swelling
 •Poor urine output
 signs:
 •Agitation
 •Hyperreflexia
 •Facial &peripheral
oedema
 •Rt upper quadrant
tendernes

9.  Features of pre-eclampsia plus one the
following:
 – Systolic bp>160 mmHg
 –Diastolic bp>110mHg
 –Proteinuria> 5g per 24 hours
 –Cerebral or visual disturbances: headache, tinnitus,
 –Oliguria< 500ml per 24 hours, creatinine>1.2mg/dl
 –Epigastric pain
 –Pulmonary oedema
 –Heamolysis, elevated liver enzymes and low platalet syndrome=
HELLP syndrome
 –Fetal criteria-IUGR, oligohydro, fetal death
 ACOG,PracticeBull.2002

10.  •Cerebrovascular accidents
 •Hypertensive encephalopathy
 •Seizure disorder
 •Previously undiagnosed brain tumors
 •Metastatic gestational trophoblastic disease
 •Metabolic diseases- hyponatremia, hypoglysemia
 •Reversible posterior leukoencephalopathy
syndrome
 •Cerebral vasculitis
 Sibai E. Diagnosis and management of eclampsia. ACOG 2005

11.  Headache- temporal, frontal, occipital, or
diffuse
 Generalized hyperreflexia; sustained ankle
clonus may be present.
 Visual symptoms - include blurred vision,
flashing lights (photopsia), and scotomata .
Diplopia or amaurosis fugax may also occur.
 Cortical blindness is rare .

12.  Blindness related to retinal pathology, optic
nerve damage, retinal artery spasm, and
retinal ischemia, may be permanent
 Seizures
 Posterior reversible leukoencephalopathy
syndrome (PRES)
 Stroke leading to death or disability is the
most serious complication

13.  Cerebral overregulation results in vasospasm
of cerebral arteries, underperfusion of the
brain, localized ischemia/infarction, and
cytotoxic (intracellular) edema.
 Loss of autoregulation of cerebral blood flow
(ie, hypertensive encephalopathy) results in
hyperperfusion, endothelial damage, and
vasogenic (extracellular) edema.
 Morriss MC, Twickler DM, Hatab MR, et al. Cerebral blood flow and cranial
magnetic resonance imaging in eclampsia and severe preeclampsia. Obstet
Gynecol 1997; 89:56

14.  General principles-
 The immediate issues in caring for an
eclamptic woman include:
1. Prevention of maternal hypoxia and trauma
2. Management of severe hypertension, if
present
3. Prevention of recurrent seizures
4. Evaluation for prompt delivery.

15.  Maternal assessment should include:–
History and examination: BP, weight gain,
edema, sensorium
–Serial or continuous blood pressure
monitoring
–Urinanalysis for proteinuria
–quantification for degree of severity

16. –Blood test include
•Platelet count and morphology, CBC
•Haemocoagulation system: PT, aPTT
•Uric acid, creatinin, electrolytes for renal
function
•Serum uric acid –useful early and for
progression
•Hepatic enzymes (AST,ALT,GGT)& bilirubin
–Fluid balance –urine output, CVP, SP02 etc
–ECG

17.  •Cerebral imaging is not necessary for the
diagnosis and management of most women
with eclampsia.
 •Cerebral imaging findings in eclampsia are
similar to those found in patients with
hypertensive encephalopathy.

18.  Cerebral imaging is indicated :-
 •focal neurologic deficits
 •prolonged coma
 •atypical presentation for eclampsia:
 •onset before 20 weeks of gestation or
 •more than 48 hours after delivery
 •eclampsia refractory to adequate mgso4 therapy
 Sibai BM. Hypertension and Obstetrics. Churchill Livingstone. 2002

19.  •Fetal monitoring:–
-Cardiotocography–for acceleration, loss of
variability or decelerations
–Fetal ultrasound -may be useful for fetal size and
morphology, amniotic fluid volume estimation
–Placental and fetal blood flow measurement of
uterine artery and main fetal Doppler
velocimetry(including diastolic flow)

20. Treatment required when:–
Systolic bp> 160 mm Hg or
Diastolic bp> 110 mm Hg
Hydralazine: agent of choice(5-10mg IV
max30)
–Causes direct arteriolar vasodilation
–Improves renal and uteroplacental blood flow

21. •Labetalol: causes rapid decrease in arterial
bp without compromising uteroplacental flow
–May cross placenta but fetal complications
rare
–20-40mg every 30min for a max of 220mg
IV

22. Nifedipine: oral 10-20mg every 30min for a
max of 50mg
-causes direct relaxation of arteriolar smooth
muscle
–Maintains uterine perfusion
–Can cause uterine muscle relaxation
–increase risk of post partum haemorrhage–
Relative contra-indication with use of Mg

23. •Sodium nitroprusside: hypertensive
emergencies but should be avoided due to
safety concern
•Nitroglycerin : useful especially when
pulmonary oedema complicates situation
WHO recommmendations for prevention and treatment of PEC & EC 2011

24.  Reasonable goal is systolic BP of 140 to 155
mmHg and diastolic BP of 90 to 105 mmHg.
 In women with extremely severe
hypertension (≥180/120 mmHg), a diastolic
goal of 100 to 105 mmHg should be achieved
within two to six hours, with the maximum
initial (within 10 to 20 minutes) fall in BP not
exceeding 25 percent of the presenting value
 Vaughan CJ, Delanty N. Hypertensive emergencies. Lancet 2000; 356:411.
 Ledingham JG, Rajagopalan B. Cerebral complications in the treatment of accelerated
hypertension. Q J Med 1979; 48:25

25.  Use of antihypertensive agents to control
mildly elevated blood pressure in the setting
of preeclampsia/eclampsia has not been
shown to alter the course of the disease, nor
to diminish perinatal morbidity or mortality.
 Sibai BM. Treatment of hypertension in pregnant women. N Engl J Med 1996; 335:257.
 von Dadelszen P, Ornstein MP, Bull SB, et al. Fall in mean arterial pressure and fetal growth
restriction in pregnancy hypertension: a meta-analysis. Lancet 2000; 355:87.
 Magee LA, Ornstein MP, von Dadelszen P. Fortnightly review: management of hypertension in
pregnancy. BMJ 1999; 318:1332.

26. •Airway protection
•Maintain oxygenation(O2 inhalation via mask)
•Control of seizures–Continued convulsions may
indicate other cerebral pathology–Management
may involve treatment cerebral oedema
•Delivery of fetus when mother is in stable
condition, even in some situation CS is needed
acutely

27. •Magnesium sulphate: -anticonvulsant of choice
–Action by:
•antagonism of calcium and hence decreased
systemic and cerebral vasospasm
•Increase release of PGI2 by vascular endothelium
–Other effects in parturient include:
•Tocolysis
•Decreased cathecholamine release
•Mild antihypertensive
•Increases renal and uterine blood flow

28. –Renaly excreted–so reduce dose in renal
failure
–Therapeutic level 4-7 mEq/l ; must monitor
for toxicity
–Repeated seizures despite therapeutic levels
need to consider other anticonvulasnts.

29. Regimen Loading Dose Maintenance Dose
Pritchard
(Intramuscular)
4gm IV over 3-5 min
f/b 10gm deep IM(5gm
each buttock)
5gm IM 4 hourly in
alternate buttock
Zuspan or Sibai
(Intravenous)
4gm IV over 15-20
min.
1-2gm/hr IV infusion
4/2/2015Dutta’s. Hypertensive disorder of pregnancy: 17 29

30. •Hypotension, flushing, slurred speech,
drowsiness, double vision
•Absent reflexes
•Respiratory paralysis
•Conduction (heart) disturbances
•Cardiac arrest–Calcium Gluconate 1G slow
push –10 min

31.  An additional benefit of magnesium
sulfate therapy is in women expected to have
a preterm delivery within 24 hours have
consistently demonstrated a decreased risk of
cerebral palsy and severe motor dysfunction
in offspring
 Crowther CA, Hiller JE, Doyle LW, et al. Effect of magnesium sulfate given for neuroprotection before
preterm birth: a randomized controlled trial. JAMA 2003; 290:2669.
 Rouse DJ, Hirtz DG, Thom E, et al. A randomized, controlled trial of magnesium sulfate for the
prevention of cerebral palsy. N Engl J Med 2008; 359:895.

32. • Additional bolus of 2 grams of magnesium
sulfate over 15 to 20 minutes, with careful
monitoring for signs of magnesium toxicity.
• Phenytoin : effective in pre-eclampsia
–Central anticonvulsant activity
–No effect on uterine tone, fetal HR or neonatal
tone
•Diazepam: effective especially if needed acutely
but causes fetal/ neonatal
complications(depression of muscle tone and
breath centre)

33.  The Eclampsia Trial Collaborative Group
conducted two prospective trials
 The primary outcome measures were the
rates of recurrent seizures and maternal
death.
 Magnesium sulfate was significantly more
effective than either diazepam or phenytoin:
 Which anticonvulsant for women with eclampsia? Evidence from the Collaborative Eclampsia Trial.
Lancet 1995; 345:1455.

34.  Additional advantages of magnesium sulfate therapy
include lower cost, ease of administration and less
sedation .
 Magnesium also appears to selectively increase
cerebral blood flow and oxygen consumption in
women with preeclampsia
 Belfort MA, Moise KJ Jr. Effect of magnesium sulfate on maternal brain blood flow in
preeclampsia: a randomized, placebo-controlled study. Am J Obstet Gynecol 1992; 167:661.

35. Cerebrovascularsyndromes and preeclampsia
RCVS (postpartum
angiopathy)
RPLS
Preeclampsia,
severe
Ischemic
stroke
Reversible vasogenic
edema, subarachnoid
hemorrhage
Thunderclap
headache,
reversible cerebral
vasoconstriction
Intracerebral
hemorrhage

36.  Most common causes of both ischemic and
hemorrhagic stroke in pregnancy.
 The most frequent cerebrovascular disturbance
associated with eclampsia is a reversible
encephalopathy.
 Women with preeclampsia are at risk for stroke
and cardiovascular disease well after the
postpartum period and child bearing years. The
relative risks ranged from 1.39 to 5.08.
B. J. Wilson, M. S. Watson, G. J. Prescott et al., “Hypertensive diseases of pregnancy and risk of
hypertension and stroke in later life: results from cohort study,” British Medical Journal, vol.
326, no. 7394, pp. 845–849, 2003

37. -Preeclampsia/eclampsia commonly associated
with ischemic stroke of arterial origin [36
percent])
-Intracerebral hemorrhage [55 percent]) but less
frequently with cerebral venous thrombosis (13
of 136 cases [10 percent])
Cantu-Brito C, Arauz A, Aburto Y, et al. Cerebrovascular complications during pregnancy and postpartum:
clinical and prognosis observations in 240 Hispanic women. Eur J Neurol 2011; 18:819

38.  Is a clinical radiologic syndrome of
heterogeneous etiologies that are grouped
together because of similar findings on
neuroimaging studies
 RPLS may occur in the setting of preeclampsia
due to impaired cerebral autoregulation from
endothelial damage.

39.  Autoregulatory failure Endothelial dysfunction
vasodilatation capillar leakage
hyperperfusion disruption BBB
Vasogenic edeoma

40. Clinical presentation
 Headaches
 Altered consciousness
 Visual disturbances
 Seizures - are usually generalized tonic
clonic; they may begin focally.

41.  Other risk factors-
 Acute and chronic renal failure
 Immunosuppressive agents and cytotoxic drugs
 Hemolytic and uremic syndrome
 Collagen vascular disorders
 leukemia
 Behcets syndrome
 TTP
 HIV
 Acute intermittent prophyria
 Hypercalcemia,hypomagnesmia
 Contrast media exposure
 Cryoglobulinemia

42.  Some suggest that PRES (typical clinical syndrome
and neuroimaging findings) could be considered an
indicator of eclampsia, even when the other
features of eclampsia (proteinuria, hypertension)
are not present.
Br J Obstet Gynaecol 1997 Oct;104(10):1165-72

43. FLAIR images show high signal symmetrically involving bilateral
parieto-occipital, posterior frontal, and temporo-occipital regions

44.  The classical presentation of RCVS, also
known as Call Fleming Syndrome, is a
thunderclap headache, with or without
additional neurologic signs.
 Diagnostic imaging reveals multifocal
segmental vasoconstriction of the cerebral
arteries, which usually resolves within days to
weeks.

45.  Calcium channel blockers may be initiated,
such as nimodipine or verapamil, although
caution should be employed to maintain
cerebral perfusion in watershed regions of a
constricted artery.
 The primary difference between RPLS and
RCVS is in the clinical symptoms.
 L.H. Calabrese, D.W. Dodick, T. J. Schwedt, and A. B. Singhal, “Narrative review: reversible cerebral
vasoconstriction syndromes,” Annals of Internal Medicine, vol. 146, no. 1, pp. 34– 44, 2007.

46.  There is nearly a 4-fold odds of developing
hypertension (OR 3.7, 95% CI 2.70–5.05)
 2-fold risk of ischemic heart disease (OR
2.16, 95% CI 1.86–2.52) in women with
preeclampsia.
 For fatal and nonfatal stroke, relative risks
ranged from 1.39 to 5.08.
 Children may also be at increased risk for
neurological problems and stroke.

47.  There was a significant reduction in the rate of
preeclampsia with low dose aspirin started at 16
weeks gestation or earlier in women identified as
moderate or high risk.
 Vitamin D deficiency has recently emerged as an
important potentially modifiable risk factor for
both preeclampsia and stroke.
 E. Bujold, S. Roberge, Y. Lacasse et al., “Prevention of preeclampsia and intrauterine growth restriction with aspirin started in early
pregnancy: a metaanalysis,” Obstetrics and Gynecology, vol. 116, no. 2 PART 1, pp. 402–414, 2010.