4. Objectives
By end of this class participants will able to:
discuss about hypertensive disorder in pregnancy.
explain about eclampsia, its incidence, risk factors, etiology and
clinical features of eclampsia.
explain about the investigation done in eclampsia
recognise its complication and prognosis
discuss the management of eclampsia
5. HYPERTENSIVE DISORDER IN PREGNANCY
• One of the common complications of
pregnancy and contributes significantly to
maternal and perinatal morbidity and mortality
• Diagnosed by any onset of the following,
Systolic blood pressure of 140mm of Hg or
more, diastolic blood pressure of 90 mm of
Hg or more,
6. Contd.
Rise of systolic BP of at least 30 mm of Hg or
more, or rise in diastolic BP of at least 15mm
of Hg over the previously known BP.
This should be evident at least on two
occasions, at least 6 hours apart.
(Konar, 2015)
7. Contd…
• Hypertension may appear for the first
time during pregnancy as direct result of
the gravid state or as assign of underlying
pathology which may be preexisting.
9. ECLAMPSIA
Introduction
• Eclampsia is derived from Greek word
meaning “ like a flash of lightening.”
• It may occur abruptly without any warning
manifestations.
• In majority over (80%), it is preceded by
features of Pre-eclampsia.
(Konar, 2015)
10.
11. Contd …
• Pre-eclampsia when complicated with
grandmal seizures (generalized tonic- clonic
convulsion) and/or coma is called Eclampsia.
• It may occur in patients who have
preeclampsia superimposed on essential
hypertension or chronic nephritis
12. INCIDENCE
• In developed countries: its prevalence is Few.
• In developing countries (rural ): High and
contribute to maternal death.
• Hypertensive disorders of pregnancy cause 14% of
all maternal deaths globally, approximately 42,000
each year. The majority of morbidity and mortality is
associated with pre-eclampsia and eclampsia.
(Vodusen N, 2019 n.d)
13. Contd.
• Hospital incidence in India: 1 in 500 to 1 in 30.
(Konar, 2015)
• More common in primigravida: 75%
• 5 times more in twins.
• 50% occurs between 36th week and term.
(Konar, 2015)
14. • Eclampsia was the second leading direct cause of
Maternal Mortality in Nepal which has increased
from 12 % in 1998 to 21 %in 2008/09.
(Nepal Maternal Mortality and Morbidity
Study, 2008/2009).
15. Hypertensive disorders in Pregnancy is identified
to be the second leading cause of MMR in Nepal
which has decreased from 21% in 2076-77, 19%
in 2078-79 to 20% in 2079-80.
- (Annual Report 2079-80)
16.
17. Risk factors
Elderly and young primigravida
Family history of pre-eclampsia and
eclampsia
Poor and under privileged sector
Hereditary
18. Risk Factors
Pregnancy complication such as
hydatidiform mole, multiple pregnancy,
polyhydramnios and Rh- incompatibility
Medical disorder; hypertension,
nephritis, diabetes
19. • A retrospective study was conducted by Das. S
et.al in 2017 to study the incidence and riskfactors
of pre-eclampsia in Paropakar Maternity &
Women’s Hospital among 4820 pregnant woman
of age 15 to 38 revealed that 1.8% had diagnosis
of pre-eclampsia. Among them 12%were older
than 35 years and 67.7% were primiparous.
20. ETIOLOGY:
• Exact cause is unknown.
• Abnormal placental action
• Immunological factors; presence of foreign protein,
pre-existing diabetes, lupus.
26. CLINICAL FEATURES
Symptoms:
• Headache
• Edema
• Visual disturbances, such as blurred vision
• Anxiety, amnesia
• Abdominal pain, especially in the upper right
area of the belly
• Decreased urine output
27. SIGNS:
• Abnormal weight gain
• Raise in blood pressure
• Tachycardia
• Tachypnea
• Crepitus or wheeze
• Hyperreflexia
• Seizures
• Loss of consciousness
28. INVESTIGATIONS
A. Blood test
Hematology :- (Hemoglobin, Complete blood
count and BT/ CT)
Biochemistry:-(Liver function test, Renal function
test, Fasting blood sugar & Serum uric acid &
Coagulation profile)
29. Contd..
B. Urine Test
Urinalysis:- RE/ME & Culture
Urinary protein 24 hrs and urine albumin.
C. Ophthalmoscopy
D. Obstetric scan
E. CT- Brain & Abdomen
F. Cardiotocography
G. ECG
30. COMPLICATIONS
MATERNAL COMPLICATIONS
• Injuries; tongue bite, injuries due to fall from bed,
bed sore.
• Pulmonary complication; edema, pneumonia,
adult respiratory distress syndrome and embolism
• Hyperpyrexia
• Cardiac failure
32. FETAL COMPLICATIONS
• Prematurity
• Intrauterine asphyxia
• Trauma due to operative delivery
33. PROGNOSIS
Maternal mortality:
• Varies from 2-30% ( more in rural)
• If treated early, even less than 2%
Fetal Mortality:
• Very high of about 30-50%
35. A) GENERAL MANAGEMENT
• Shout for help
• Put patients in left lateral recumbent position
as much as possible to lessen the effects of
vena caval compression.
• Maintain oral airway
• Provide oxygen inhalation- 8-10 L/min by
non-breather mask.
• Start IV lines; one or two wide bore cannulas,
provide IV fluids( crystalloids) or colloids.
36. Contd….
• Insert Foley's Catheter with urometer and
monitor urine output hourly.
• Monitor oxygen saturation( SPO2).
• Take vital signs every half hourly.
• Oropharnygeal suctioning
• Give antibiotic to prevent secondary infection
e.g. inj. ampicillin 500 mg IV 6 hourly.
provide diuretics to prevent pulmonary edema
37. B) SPECIFIC MANAGEMENT
1. Anticonvulsant
A. MAGNESIUM SULPHATE is the drug of
choice.
• Exact mechanism of action is unclear
• Reduce neuro-muscular irritability
• Cerebral vaso dilation
• Dilate uterine arteries
38. Contd ..
Administration of magnesium sulphate
50% MgSO4 1 ampoule= 1gm= 2ml
I. Loading dose
First step
Take 4gm MgSO ₄ IV as 20% solution
• Take 20ml syringe
• Draw 4 ampoules of MgSO ₄ 50% =8ml=4gm
• Add 12ml distilled water for injection to make
it 20%
• Give slowly IV over 5min.
40. Step 2
Follow promptly with 10gm ad 50% MgSO ₄ deep
IM
• Take two 10ml syringes
• Draw 5 ampules of MgSO ₄ 50%=10ml=5gm
into each syringes
• Add 1ml of 2% lignocaine in each syringe
• Give deep IM in each buttocks
• If further fits occur, give further 2 ampules of
MgSO ₄ 50%=4ml=2gm IV slowely over 5min.
Contd..
42. II. Maintenance dose
5gm as 50% MgSO ₄ deep IM in alternate buttocks
every 4 hourly.
• Take 10ml syringe
• Draw 5 ampoules of MgSO ₄ 50%=10ml=5gm into
the syringe.
• Add 1ml of 2% lignocaine in that syringe.
• Give deep IM in alternate buttocks every 4 hourly.
• Continue same treatment for 24 hours after delivery
or the last convulsion, whichever in the last.
Contd..
43. Toxicity of MgSO ₄
• Before repeating and in every 1 hour, always
monitor for toxicity.
• Withhold or delay if any of the following signs
seen .
-Respiratory rate < 16/min.
-Patellar reflex absent.
-Urine output <30ml/hour.
Contd..
44. Management for toxicity of MgSO ₄
Patellar reflex absent Urine output
<30ml/hour
Respiratory rate <
16/min
• Withhold MgSO₄.
• Check patellar reflex
every hour and start
MgSO ₄ after returning
reflex.
• Withhold
MgSO₄.
• Start R/L IV
1l(2pint) in
8hours.
• Withhold MgSO₄.
• Start bag and mask
ventilation.
• Administer calcium
gluconate 1gm(10%
10 ml) in 10min.
44
45. Contd.
B. Diazepam(When Magnesium Sulphate is not
available)
• Loading dose=10mg I/V over 2mins.
• If convulsion recur, repeat loading dose.
• Maintenance dose=40mg in 500ml I/V fluids.
• DO NOT GIVE more than 100mg/24hrs.
• Can be GIVEN rectally.
• Inj. Flumazenil 0.2mg in 2ml. IV over 15
seconds. (Antidote)
46. 2. Anti Hypertensive Drugs
• If Diastolic Blood Pressure (DBP) is ≥110
mmHg or more give antihypertensive drugs.
• Inj. HYDRALAZINE 5mg IV slowly every 20
mins until BP is lowered.
• Repeat hourly as needed or give 12.5 mg IM
every 2 hourly.
• Inj. Labatolol or Nifedipine can be given.( If
Hydralizine is not available)
47. Contd..
• NIFEDIPINE 5mg sublingual (SL)
• If response is inadequate, it can be repeated
after 10mins.
Or
• Labetolol 10 mg I/ V
• After 10 min.Labetolol 20 mg iv (If DBP,
remains above 110 mm of Hg
48. 3. Diuretics: the most commonly used diuretics are
furosemide (lasix) 40mg orally after breakfast for 5
days in a week.
The compelling reasons for its use are:-
cardiac failure
pulmonary edema
massive edema not relieve by rest and producing
discomfort
Contd..
49. C) OBSTETRICAL MANAGEMENT
I) Fits are controlled;
a) Baby mature: delivery should be done.
• If the cervix is favorable and there is no
contraindication of vaginal delivery, surgical
induction by lower rupture of membrane is
done.
• Oxytocin drip may be added.
50. Contd..
• When the cervix is unfavorable, cervical
ripening with PGE2 gel of Pessary should be
achieved before ARM.
• If the cervix is unfavorable and/or there is
obstetric contraindication of vaginal delivery,
cesarean section is done.
51. Contd..
b)Baby Premature (<37 weeks):-
• Delivery is recommended in a set up with
neonatal intensive care unit (NICU).
• Corticosteroid is given if pregnancy is < 34
weeks for fetal lung maturity. Inj.
Dexamethasone 6mg for 4 doses at 12 hours
apart is prescribed.
52. Contd..
c. Baby death:
• The preeclamptic process gradually subsides
and eventually expulsion of fetus occurs
otherwise induction is started.
53. II. Fits are not controlled
• If the fits are not controlled with
anticonvulsant within in a reasonable period
(6-8hrs),termination of pregnancy should be
done.
• If the cervix is unfavorable and / or there is
obstetrical contraindication of vaginal delivery,
caesarean section is done.
54. Contd..
During labour:
• In absence of any contraindication to vaginal
delivery, as soon as labour should be well
established, ARM should be done to accelerate
the labor.
• Second stage should be curtailed by forceps,
Vacuum or craniotomy if the baby is dead.
55. Contd..
Management in puerperium
• The patient is to be watched closely for at least
48 hours in which convulsions usually occurs.
• Antihypertensive drugs should be continued if
the BP is high (systolic ≥ 150mm Hg or diastolic
≥ 100mm Hg).
• Nefidipine 10mg at every 6 hours until BP
remains below the hypertensive levels for at least
48 hours.
56. Contd..
• In breastfeeding women, labetalol, Nifedipine
or Enalapril may used on discharge.
• Methyldopa is avoided due to the risks of
postpartum depression.
59. References
1. Awasthi, M. S. (2017). Essential Textbook of
Midwifery Nursing Part –I (1sted.).
Samikshya publication Pvt .Ltd. Kathmandu,
Nepal.
2. Fraser, D. M. & Cooper, M. A. (2011). Myles
textbook for Midwives ( 15th ed.). Churchill
Livingstone; Edinburgh
3. Konar, H. (2015). DC Dutta’s Textbook of
Obstetrics. (8th ed.). Jaypee Brothers Medical
Publishers(P)Ltd. New Delhi, India.
60. Contd.
4. Ranabhat, R. D. & Mahat, H. N. (2017). A Text Book
of Midwifery and Reproductive Health (1sted). National
Center for Health Profession Education. Kathmandu
Nepal.
5.WHO, UNFPA, UNICEF and World Bank (2004).
Integrated management of pregnancy and
childbirth(IMPAC): Managing complications in
pregnancy and child birth: aguide for midwives and
doctors.
6.Ghimire, S. (2016). Eclampsia: Feto-Maternal
Outcomes in A Tertiary Care Centre in Eastern Nepal. J
Nepal Med Assoc, 54(201), 24-8.
61. 7. Shrestha, D. R. (2012). Reproductive Health; National
and International Perspective (2nd ed.). Lalitpur; Nepal.
Sigma General Offset Press.
8. Vousden N, Lawley E, Seed PT, Gidiri MF, Goudar S,
Sandall J, Chappell LC, Shennan AH; CRADLE Trial
Collaborative Group. Incidence of eclampsia and related
complications across 10 low- and middle-resource
geographical regions: Secondary analysis of a cluster
randomised controlled trial. PLoS Med. 2019 Mar
29;16(3):e1002775. doi: 10.1371/journal.pmed.1002775.
PMID: 30925157; PMCID: PMC6440614.
62. • Das S, Das R, Bajracharya R, Baral G,
Jabegu B, Odland JØ, Odland ML.
Incidence and Risk Factors of Pre-
Eclampsia in the Paropakar Maternity and
Women's Hospital, Nepal: A Retrospective
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