This document defines and describes hypertensive disorders in pregnancy including pre-eclampsia, eclampsia, and HELLP syndrome. It discusses their definitions, epidemiology, etiology, symptoms, risk factors, signs, diagnosis, investigations, treatment including magnesium sulfate administration and delivery approaches, complications, nursing management of severe preeclampsia/eclampsia, postpartum care, and HELLP syndrome including its possible pathophysiology, signs and symptoms, evaluation, management of hypertension and prevention of convulsions.

1. Pre-eclampsia,
Eclampsia and HELLP
syndrome

2. Definitions of hypertensive disorders in
pregnancy
• Hypertension in pregnancy: A condition characterized by
diastolic Bp > 90mmHg on two consecutive readings after 20
weeks gestation
• Pre-eclampsia: “A disorder associated with pregnancy consisting
of hypertension, proteinuria (2+) and new-onset dependent
oedema, most commonly after 20 weeks of gestation”.
•Mild to moderate pre-eclampsia: as above, no further symptoms

3. Definitions of hypertensive disorders in
pregnancy
• Severe pre-eclampsia: A condition characterized by blood
pressure > 90mmHg, proteinuria 3+ or more and one or
more signs and symptoms
• Eclampsia: A condition characterized by Bp > 90 mmHg,
proteinuria 2+ or more, convulsions, other signs and
symptoms of severe preeclampsia.
“pre eclampsia complicated with seizures”

4. Epidemiology
Incidence
 Pre-eclampsia: 6-8% of pregnancies
 Eclampsia: 0.05-0.2%
Mortality and morbidity
Maternal: 8-36% most frequently related to seizure activity
Foetal: 13-30% most frequently related to iatrogenic prematurity

5. Aetiology
Exact pathophysiology unknown
Possible causes-
o Dysfunction of the uteroplacental bed leading to
vasoconstriction, platelet aggregation and hypercoagulability
o Vasospasm, micro thrombi, implantation problems,
hypertension etc

6. Symptoms
Headache
Oedema
Visual disturbance
Focal neurology, fits, anxiety, amnesia
Abdominal pain
SOBOE- shortness of breath on exhaustion
Decreased urine output
None

7. Risk factors
Low socioeconomic class
Multiple foetuses, or hydatid
Maternal age <20 or >35yrs
Primipara
Gestational or pre-gestational DM
Renal disease
Family history- four times the risk

8. Signs
Hypertension
Tachycardia and tachypnoea
Crepitations or wheeze on auscultation
Neurological deficit
Hyperreflexia
Petechiae, intracranial haemorrhage
Generalised oedema
Small uterus for dates

9. Diagnosis
Hypertension
- Systolic > 140mmHg
or 30mm above pre-pregnancy
- Diastolic > 90 mmHg
or 15mm above pre-pregnancy
Two abnormal measurements, on two occasions, more than
6 hours apart

10. Diagnosis
Measuring blood pressure:
The woman should be resting and lying at 45-degree angle
The blood pressure cuff should be of appropriate size
Cuff should be placed at level of heart
Multiple readings should be used to confirm diagnosis
Manual sphygmomanometers are preferable to automated
ones
Use a stethoscope

11. Investigations
Liver functional tests – liver enzymes (ALT/AST)↑
Urinalysis- proteinuria greater than 2+
Blood tests- Platelets ↓, bilirubin ↑
Haemolysis (burst red blood cells on blood slide, serum
haemolytic)
Check patella reflexes
Foetal US

12. Investigations
 Coagulation profile
 Bedside clotting test (Draw about 2 mls of venous blood in a
syringe and keep warm at 37 C (in a closed fist). Check every 2
minutes if clot has formed.
◦ Coagulopathy if clot formation takes more than 7-10 minutes
 Check for clonus (Move the pts foot upwards rapidly, this may
be followed by beating of the foot if clonus is present)
 CT head

13. Treatment
ABC, for seizures
Hypertension alone- not true pre-eclampsia but need follow-up
Hypertension and proteinuria- pre-eclampsia must be ruled out
Severe pre-eclampsia-as if eclampsia, careful BP control, MgSO4,
delivery.

14. Complications/prognosis
Permanent neuro damage
Renal insufficiency
Abruption
HELLP syndrome
Death
25% of eclamptics will be so in future pregnancies
Increased risk of essential hypertension

15. Eclampsia & severe preeclampsia

16. Differential diagnosis
Epilepsy Cerebral malaria Meningitis
History of epilepsy Fever Headache
No elevated Bp Blood slide positive Fever
No proteinuria No proteinuria Stiff neck
No elevated Bp Positive lumbar puncture
No proteinuria
No elevated Bp

17. Principles of management
 Stabilise mother and then deliver the fetus
◦Treat and prevent fits
◦Treat blood pressure
◦Attention to fluid balance
◦Be ware of and prevent complications

18. Management
Fitting or unconscious patient
 Call for help
 Position in left lateral tilt
 Airway : open , maintain airway, suction if necessary
 Recovery position
- Circulation: pulse, Bp, IV access
- Give magnesium sulphate1 litre Ringer’s lactate or
normal saline in 12 hours

19. Management
Prevention of convulsions
Magnesium sulphate halves the risk of eclampsia in
women with severe pre-eclampsia
Used in the same diose as in eclampsia
There is commitment to delivery in severe preeclampsia

20. Management
oMagnesium is the drug of choice
oSuperior to any other drug preparation in preventing/ reducing
the risk of recurrence of convulsions
o20% 0r 50% concentration available
o20% preferred for IV route (more dilute but greater volume)
o50% preferred for IM route (less dilute and smaller volume)

21. Management
Magnesium sulphate dosage
Loading dose
IV 4g 20% solution slowly over 15 minutes
And
10g 50% IM (5g in each buttock with 1 ml 2% Lignocaine)
soon after loading dose
Then
Maintenance dose
5g IM 4 hourly

22. Management
NB: IV maintenance dose of 1g 20% per hour/ 24 hours should only be applied if IV pump is
available to avoid toxicity and complications
Route Dose If you only have 50% solution
available: vial containing 5 g in 10
ml (1g/2ml)
20% solution: to make 10 ml of 20 ml
solution, add 4ml of 50 % solution to
6ml of NS (normal saline)
IM 5g 10ml and 1 ml of 2% lignocaine Not applicable
IV 4g 8ml + 12mls NS 20ml
2g 4ml + 6mls NS 10 ml

23. Management
 If unable to give IV, give loading dose IM only
 If convulsions recur, give an additional 2-4g IV over 10-15
minutes
◦Give lower dose (2g) if patient is small and/or weight is
less than 70 kgs
 If dilution is required for IV route use normal saline NOT
Lignocaine

24. Management
Magnesium sulphate toxicity
• Do not give the next dose of MgSO4 if:
◦Absent knee jerk
◦Urine output is less than 100mls in the last 4 hours
◦Respiratory rate is < 16 breaths per minute
•If respiratory rate is < 16 breaths/minute STOP magnesium
and give calcium gluconate (10%) 1 g IV over minutes

25. Management
Treating high blood pressure
A. None-severe hypertension: Bp 140-159/90-109 mmHg
◦Increased risk of haemorrhagic stroke
◦Goal: Lower levels of SBP 140-150/ DBP 90-100
◦Safe drugs: Methyldopa, nifedipine, labetolol and other
adrenoceptor blockers (metopronolol, pindilol, propranolol)

26. Management
Treating high blood pressures cont.
B. Severe hypertension: BP >/= 160/110 mmHg
◦Increased risk of intracerebral haemorrhage
◦Goal: Lower to levels of SBP 140-150/ DBP 90-100 at a rate of
10-20 mmHg every 10-20 mins
◦Safe drugs: Hydralazine, nifedipine, labetolol
◦NB: Avoid precipitous fall in Bp

27. Management
Considerations
 Give Nifedipine orally
 Atenolol may cause fetal growth restrictions
 ACE 1 and 2 inhibitors are contraindicated
 Avoid Labetolol in severe asthmatic women
 Diazoxide, Ketanserin, Nimodipine and MgSO4 should not be used
to reduce Bp
 Sodium Nitroprusside is not recommended for routine use, may
cause risk of fetal cyanide toxicity and maternal paradoxical
bradycardia

28. Nursing management
Fluid management in severe preeclampsia/eclampsia
 Fluid restriction: Keep them dry
 Capillaries are “leaky” therefore control fluid input to
reduce the risk of pulmonary edema
 Restrict IV fluids to 1mg/kg/hr or 80 mls/hour
 Monitor appropriately via use of appropriate monitoring
chart and catheterize if necessary

29. Delivery
Assess pregnancy and assess the cervix
Vaginal delivery or C/S?
Vaginal delivery
◦If no maternal or fetal distress, no obstetric contraindication and
cervix is favourable.
◦Delivery should occur within 12 hours after onset of fits.
◦Pain relief during labour can be provided by opiods or by use of
lumbar epidural analgesia (platelet count >/= 100million

30. Delivery
Caesarean section cont.
◦ If repeated fits, fetal distress , unfavourable cervix and other obstetric indication.
◦ Stabilize patient first!
 Regional anaesthesia (spinal) is preferred for C/S in preeclampsia
◦ Risk of haematoma in the absence of coagulation abnormalities is very low
(platelets >/= 100 million/l
◦ Hypotension is less common in healthy women

31. Delivery
Caesarean section cont.
General anaesthesia is indicated:
◦Coagulopathy
◦Pulmonary oedema
◦Eclampsia
◦Other cerebral oedema, reduced levels of consciousness
MgSO4 may potentiate non-depolarizing muscle relaxants

32. Delivery
Caesarean section cont.
Measures should be taken to ablate the potentially fatal hypertensive
response to intubation in women with eclampsia by using drugs such as:
Alfentil / Fentanyl
MgSO4
IV Lignocaine
Esmolol

33. After delivery
•Continue with MgSO4 for 24 hours after delivery or after last fit.
•Monitor until diuresis occurs.
•MgSO4 does not reverse or prevent the progression of the
disease and is not used as an anti-hypertensive
•Up to 44% of eclampsia occurs in the postpartum period.
•Do not be in a hurry to discharge home

34. NB:
1. Pedal oedema is a common symptom in normal
pregnancy
2. There is no evidence that:
◦Low salt intake will reduce pedal oedema or treat
preeclampsia
◦The use of furosemide or low dose dopamine for management
of oliguria in a woman with normal renal function is beneficial.
3. MgSO4 is excreted in breast milk but is safe for breast fed
infants.

35. HELLP SYNDROME

36. What is HELLP?
WEINSTEIN(1982) HELLP
H → HEMOLYSIS
EL → ELEVATED LIVER ENZYMES
LP → LOW PLATELETS

37. Incidence

38. Possible pathophysiology
CAUSALAGENTS : Increase in volume., Fetal presence / decidual cell?,
Vasospasm?, Deficient vascular repair?, Idiopathic?
↓
Vasculo-endothelial Disorder
↓
Platelet Agregation/Consumption
↓
Fibrin Activation/Consumption
↓
Selective organic Isquemia/insuficiency
↓
Variable Manifestations

39. Differential diagnosis
Erythrocytic morphology
Platelet disorders
Renal compromise
Hepatic disorders
Immunologic disorders
Genetic disorders

40. Signs & symptoms
oExcessive body weight increase .
oPulse pressure increase.
oSystole pressure > 140 mmHg, but diastole pressure < 90 mmHg.
oOphthalmic disorders
- Minor alterations
- Cortical blindness (amaurosis)
- Retinal detachment
- Vitreous hemorrhage.

41. Elevation of Biomarkers:
-HCG
-Maternal alfa-fetal protein
-Serum Haptoglobin

42. The presence of these disorders in an hypertensive woman
with epigastric and/or right hypochondrial pain, nausea,
vomiting; as well as hemolysis, will help in making the
right diagnosis.

43. Management
1. Anticipate the diagnosis
2. Evaluate the maternal condition
3. Evaluate the fetal condition
4. Control the hypertension
5. Prophylaxis of convulsions with MgSO4
6. Water and electrolyte balance
7. Hemotherapy
8. Management of labor and delivery
9. Optimize perinatal care
10.Intensive postpartum treatment of the patient
11.Be alert for multiple organ failure
12.Advise on future pregnancy

44. Evaluating fetal well-being
Determine the gestational age.
Evaluate fetal well-being: Non-stress test, Tolerance to
contracction test and/or biophysical profile.
Use corticosteroids between 24 and 34 weeks to improve
fetal pulmonary maturity/neonatal pulmonary function as
well as maternal and perinatal results.

45. Controlling the hypertension
 80-85% of patients with HELLP need control of their BP to
avoid significant maternal and perinatal morbidity and
mortality.
Treat systolic BP when>150mmHg and avoid placental
hypoperfusion maintaining the diastolic BP not less than 80-
90 mmHg.

46. Hypertensive medications
Hydralazine: Bolus of 5-10 mg IV every 20-40 min. If uneffective
or unavailable, use labetalol, nifedipine o sodium nitroprussiate.
Labetalol: Initial bolus of 20 mg IV, with increases in dosage until
a satisfactory BP is obtained or up to maximum dose of 300 mg.
Nifedipine oral (not sublingual) at usual dosage.

47. Hypertensive medications
Sodium Nitroprussiate
◦fast acting hypotensive agent (venous and arterial)
◦can be used in an hypertinsive crisis when all other hypotensive
drugs have failed
◦Loading dose: 0,25 μg/kg/min, increasing upto 10 μg/kg/min.
◦Above this dose there is a greater risk of cyanide intoxication of the
fetus.
◦When using, remember it’s photosensitivty and severe rebound
effect.

48. Preventing convulsions
MgSO4
Initial bolus of 4-6g IV, followed by a continous infusion at 1,5-4g/h,
individualized according to the patient.
Continue 48 hours or more postpartum until clinical and laboratory
signs of improvement are obtained.
If contraindications of MgSO4 exist, use Phenytoin.
Loading dose: 15 mg/kg at 40 mg/min with continous monitoring of
the cardiac function and BP every 5 minutes.
The therapeutic range is 10-20 μg/ml.

49. Management of labour and delivery
When considering termination of gestation in a patient with
HELLP, determine:
◦Gestational age.
◦Maternal and fetal conditions.
◦Fetal presentation.
◦Cervical maturity

50. Optimizing perinatal care
 The main risk for the fetus in pregnancies with HELLP is it´s
prematurity.
 The use of corticosteroids decreases the morbidity associated
with pulmonary immaturity in preterm babies.
 Delivery should be in a center with capability of treating these
children with a major risk of cardiopulmonary instability.

51. Advising on future pregnancies
 The risk of recurrence of
preeclampsia and /or eclampsia is
42-43% and for HELLP syndrome 19-
27%.
 The risk of recurrence of preterm
delivery is high, about 61%.1

52. Conclusion
HELLP Syndrome and its management still poses a problem
in modern obstetrics
Precise diagnosis and early treatment with non-mineral
corticosteroides such as Dexamethasone may help achieve
favorable maternal and perinatal results.