Pre eclampsia, Eclampsia

1. Hypertensive Disorders
in Pregnancy
Dr. Massam,

2. Objectives
By the end of this session, students are expected to
be able to:
• Define the terms pre-eclampsia and eclampsia
• Identify risk factors for pre-eclampsia and
eclampsia
• Classify pre-eclampsia based on clinical features
• Describe management of a woman with pre-
eclampsia and eclampsia
• Describe complications of pre-eclampsia and
eclampsia

3. Introduction
• Hypertensive disorders in pregnancy refers to
elevation of blood pressure (BP) of 140/90
mmHg or greater, measured on two occasions
at least four hours apart during pregnancy.
• Is an elevated systolic BP >30mmHg, or
diastolic BP 15mmHg from the baseline
warrant close observation during pregnancy.

4. • Gestation hypertension - Blood pressure
elevation after 20 weeks of gestation without
proteinuria or systemic findings including
thrombocytopenia impaired liver function,
new development of renal insufficient,
pulmonary edema and new onset of cerebral
or visual disturbance.
• It can also be referred as an evidence of pre-
eclampsia/eclampsia and hypertension that
resolves by 12 weeks of postpartum period.

5. Pre-Eclampsia
• Raised blood pressure in pregnancy, when BP
>140/90 mmHg with the presence of protein in
urine more than 300mg in a 24 hour urine
collection and oedema or proteinuria of 0.3
grams or greater in a 24 hour urine specimen or
persistent 1+ (30mg/dL on dipstick)
• The diagnosis requires two such abnormal BP
measurements, recorded at least six hours apart

7. The clinical classification of pre-eclampsia
• Depends on the level of blood pressure for
management purpose.
• But proteinuria is more significant than blood
pressure to predict fetal outcome.

8. Mild Pre-eclampsia
• This includes cases of sustained rise of
blood pressure of more than 140 -
<160/90 - <110 mm Hg without significant
proteinuria.
• May be asymptomatic
• Protein in urine is 1+ or less, less than 5
grams in a 24 hour urine collection
• No symptoms of imminent eclampsia

9. Severe Pre-eclampsia (Features)
1. A persistent systolic blood pressure of >160
mm Hg or diastolic pressure of >110 mm Hg.
2. Protein excretion of >5 gm/24 hr or > 3+ on
urine dipstick.
3. Oliguria (<400 ml/24 hr).
4. Platelet count < 100,000/mm3.
1. HELLP syndrome. (Haemolysis, Elevated Liver
enzymes, Low Platelet count (Platelet count <100
x 109/L))
• HELLP syndrome, especially with
thrombocytopaenia

10. 6. Cerebral disturbances (Headache, visual
disturbance, evidence of cerebral complications,
brisk patellar reflexes and clonus)
7. Persistent severe epigastric or right upper
quadrant pain.

11. 8. Retinal hemorrhages, exudates or papilledema.
9. Intrauterine growth restriction of the fetus.
10. Pulmonary edema.

12. • From the prognostic point of view, a diastolic rise
of blood pressure is more important than the
systolic rise.
• Moreover, convulsions may occur even with
moderate rise of blood pressure; conversely,
even with alarming high rise of pressure, the
pregnancy may have an uneventful outcome.
• This calls for a strict vigilance whenever the
blood pressure is raised to the pre-eclamptic
level or even before that.

13. Imminent Eclampsia
• Elevation of BP (in pregnant women) above
160/110mmHg accompanied by blurring of vision,
vomiting, epigastric pain and severe and
persistent headache.

14. Eclampsia
• Convulsions occurring in a woman with
established pre-eclampsia in the absence
of any other neurological or metabolic
cause.
• Note that eclampsia may occur without
warning signs of imminent eclampsia.

15. ...
• Many view eclampsia as continuous spectrum
with mild PIH at one end and eclampsia at the
other.
• It is the 3rd leading cause of maternal morbidity
and mortality worldwide.
• It is responsible for approx 15% of maternal
deaths in USA.
• Hypertension related to pre-
eclampsia/eclampsia would usually resolve
within 12wks postpartum.

16. Risk Factors for Pre-Eclampsia and
Eclampsia
• Primigravida
• 85% of pre-eclampsia occur in primigravidas
• Increased placental tissue for gestational age
-Resulting from Hydatiform moles, twin pregnancies, etc.
• Family history of pre-eclampsia
• Pre-existing hypertension
• Renal diseases
• Diabetes mellitus
• Rhesus isoimmunization
• Obesity
• Extreme maternal age

17. Risk Factors for Pre-Eclampsia and
Eclampsia
• Change of partner
• Nonimmune/ autoimmune fetal hydrops
• Hydatiform mole (size of placenta)
• African-American race
• Thyroid disease
NOTE:Women who smoke cigarettes have a lower
risk of pre-eclampsia than non-smokers.

18. What Causes Pre-eclampsia ?
• Abnormal Placentation
• Release of inflammatory
mediators
• Endothelial cell damage
• Maternal reaction

19. The Endothelial Cell
• Vasospasm
• Leaky vessels
• Platelets activated
• Coagulation starts
• Reduced blood flow
• Tissue hypoxia

20. Differential Diagnosis
CNS manifestations
• Epilepsy
• Complicated malaria
• Head injury
• Migraine
• Meningitis
• Encephalitis
• Space-occupying lesions
(brain tumor, abscess)
• Hypertensive disease
(hypertensive
encephalopathy,
pheochromocytoma)
Proteinuria
• Urinary infection
• Severe anaemia
• Heart failure
• Difficult labor
• Blood in urine (trauma
due to catheter or
schistosomiasis)
OTHERS
• Gastroenteritis
• Hepatitis
• Acute fatty liver
• Appendicitis

21. INVESTIGATIONS
• Total Blood Count
• Hematocrit
• Platelet- reduced
• Coagulation profile (PT, aPTT)
• WBC may increase due to liver damage
• LFT and RFT
• Increased uric acid and creatinine
• Raised ALAT and ASAT
• 24hrs urine for proteins
• Serum lactate dehydrogenase(LDH)
• Biophysical test-
• poor placental perfusion
• Oligohydramnios
• Fetal movement
• CTG with deceleration
• Obstetric USS (R/O IUGR)

22. MANAGEMENT
• The most effective therapy is delivery of the
fetus and the placenta.
• But this may not be in the best interest of the
fetus.
• The decision may be biased by disease severity,
fetal maturity, maternal and fetal condition, and
cervical status.

23. Management of Pre-eclampsia
• Objectives are:
1.To stabilise hypertension and to prevent its
progression to severe pre-eclampsia.
2.To prevent the complications
3.To prevent eclampsia
4.Delivery of a healthy baby in optimal time.
5.Restoration of the health of the mother in
puerperium.

24. Management of Mild - Moderate Pre-eclampsia
• GA of 40 weeks or more delivery is indicated.
• GA of 37–40 weeks
• Very unfavorable cx (any GA) – bed rest
―antepartum fetal surveillance
―blood pressure measurement every 4–6 hours
―daily assessment of patellar reflexes, weight gain, proteinuria,
and other symptoms (pt warned of the symptoms)
―FBP & levels of serum transaminases, lactate dehydrogenase,
& uric acid should be checked weekly
― delivery must be accomplished by 37 to 38 wks
Antihypertensive therapy begins when diastolic is105 and
systolic is 160 mmHg.
Favorable cervix INDUCE
Unfavorable cervix pre
induction cervical ripening agents

25. ...
Mild–Moderate Pre-Eclampsia before 37 Weeks
of Gestation Age:
• Manage as outpatient if patient is compliant and
can be followed closely
• Provide antihypertensives: Methyldopa
(Aldomet), etc.
• Rest at home
• Monitor foetal well-being

26. Management of Severe Pre-eclampsia
Usually delivered promptly
to prevent maternal and
fetal complications, but
what about preterm fetus??
• continued poor perfusion of major maternal organs
• potential risk for severe end organ damage i.e. brain,
liver, kidneys, placenta/fetus
• hematologic and vascular systems damage
The risks of
prolonging pregnancy
are
All women with the GA of 34
weeks or more should be
delivered promptly.

27. GA<34 Weeks
• Glucocorticoids administered with an effort to delay the
delivery for 48hrs.
• BUT, delivery is indicated in women with
– Very premature fetuses
– Rapidly worsening disease
– Non reassuring fetal heart status
– Oligohydramnios
– Severe IUGR
• Mother for expectant management must be stable,
adequate urine output, essentially normal laboratory
values (exclusive exception of mildly elevated LFT) &
hypertension that can be controlled.

28. Management of Severe Pre-eclampsia
• Note: Patients with severe pre-eclampsia and severe
eclampsia should be managed in the hospital by a doctor
• Control of hypertension
– Methyldopa is safe in pregnancy.
– Hydralazine used for acute reduction.
• The goal is to bring BP around 140/90
• IV bolus at a dose of 5–10 mg, the doze can be
repeated in 15-20mins if necessary
• Effective in the prevention of cerebral hemorrhage

29. Control of hypertension cont…
– Labetalol
• 5–20 mg by slow IV push
• doses (10, 20, 40, 80, etc) every 10
minutes up to a maximum dose of 220 mg
– Nifedipine ( NOT sublingual)
• 10 mg PO every 15-30 minutes with a
maximum of 3 doses
• Often used in pospartum period to control
the BP
ACE inhibitors are contraindicated as may
cause oligohydramnios, still birth, neonatal
renal failure, or bony malformations!

30. Control/Prevent fits by giving MAGNESIUM
SULFATE
• All patients with severe pre-eclampsia should receive
prophylaxis for seizures i.e. magnesium sulfate.
• Therapy is started at the beginning of labor or prior to
cesarean section and continued 24 hours postpartum.

31. • Mode of actions include of MgSO4
– vasodilatation of the cerebral vasculature
– inhibition of platelet aggregation
– protection of endothelial cells from damage by
free radicals
– prevention of calcium ion entry into ischemic
cells, decreasing the release of acetylcholine
at motor end plates within the neuromuscular
junction
– competitive antagonist to the glutamate N-
methyl-D-aspartate receptor (which is
epileptogenic).

32. • Loading dose of magnesium sulfate of 4 g
intravenously over 5 minutes
• 5 g intramuscularly into each buttock (mixed with
1mL of 2% lignocaine).
• Maintenance dose 5 g magnesium sulfate + 1
mL lignocaine 2% IM every 4 hours into
alternate buttocks.
• Continue treatment with magnesium sulfate for
24 hours after delivery or the last convulsion,
whichever occurs last.

33. Remember the MgSO4 toxicity...
• The following features of Mg toxicity should be
monitored:
– Loss of patellar reflexes
– Shortness of breath RSP 16 per min
– Cardiac arrest
– Reduced urinary output( 30mls per hour over
4hrs)
• Several studies carried out comparing
magnesium with placebo, and risk eclampsia
was more then halved with magnesium sulfate.
• Also decreased risk of abruption seen.

34. MAGNESIUM SULFATE cont…
• Calcium gluconate (1 g iv over 5 to 10 minutes) for
symptoms of magnesium toxicity. (Antidot for
MgSO4 toxicity)
• Urine output should be monitored - at least
30mls/hr, as well as fluid input of 50-125 ml/hr
maintained.
• The contraindications to the use magnesium sulfate
include:-
– Renal insufficiency
– Myasthenia gravis (precipitate a severe
myasthenic crisis)
– Concurrent use with calcium channel blockers
(hypotension)
– Symptoms of hypermagnesemia

35. • Choose the METHODS OF DELIVERY
– Normal vaginal delivery is beneficial if there are no
contraindications.
• If the cervix is favorable, intravenous oxytocin is
given
• Induction with prostaglandin or cervical
osmotic pressure may be required
• Amniotomy performed
• Close, continuous maternal-fetal monitoring
• Assisted 2nd stage
• Active management of 3rd stage (Do not give
ergometrine, find out why?)
Deliver vaginally if SVD is anticipated to
complete in 8 hours only.

36. –Caesarian section is reserved for:
• Deeply unconscious or uncooperative
patients
• If vaginal delivery is unlikely in 6-8hrs
from the 1st eclamptic seizure
• Nonreassuring fetal heart rate tracings
or severe IUGR
• Failure of the cervix to dilate
• Worsening signs and symptoms
• Obstetric indications

37. Management of Eclampsia
• If seizure is witnessed maintain airway patency
and prevention of aspiration by:
– Roll patient to her left side
– Protect airway and provide oxygen
– Suctioning of the oral cavity
– Pulse oximetry
– Use of side rails on the bed

38. • Magnesium sulfate intravenously
beginning with 5 g over 5 min followed by
maintenance dose.
• Fetal monitoring may be instituted when
the maternal airway and seizures
are under control.
• Definitive management is delivery
irrespective of gestational age, but when
the mother is stable!

39. • Control of blood pressure is essential to avoid
complications such as CVA.
• May initiate with hydralazine or/and labetolol as
described previously.
• Only when the mother is safe enough to
undergo surgery may cesarean delivery be
considered.

40. ...
• Steps to effect vaginal delivery are used
initially with less common morbidity.
• Induction with oxytocin may be considered
if both the mother and the baby are stable.

41. Postpartum Care
– Maternal vital signs, fluid input and output
should be monitored closely.
– Continue with magnesium sulfate at least
24hrs.
– Liver function tests and platelet counts must
be performed to document decreasing values
prior to hospital discharge.
– Elevated blood pressure may be controlled
with nifedipine or labetalol .

42. – Oliguric patients unresponsive to fluid
challenge will benefit from low dose
Dopamine.
– Counsel about risk of recurrence; advice on
contraception and early booking before
discharge.
– See the patient weekly if high blood pressure
on discharge.
– Long term follow-up for neurological
assessment.

43. Complications/Prognosis
• Permanent neural damage
• Hepatic and Renal insufficiency
• Pulmonary edema
• Abruption placenta
• DIC
• Death (abruptio, aspiration pneumonia, &
cardiopulmonary arrest)
• 25% of eclamptics will be so in future pregnancies
• Increased risk of essential hypertension, Ischemic
Heart Disease, and venous thromboembolism
• HELLP syndrome

44. Complications
Pre-eclampsia can produce complications in many
different systems.
1. Cardiovascular System
• Haematological changes – HELLP syndrome
may lead to disseminated intravascular
coagulopathy.
2. Kidneys
• Acute renal failure (oliguria or anuria)

45. 3. Brain
• Cerebral oedema
• Infarction, cerebral haemorrhage
• Blindness, possibly due to retinal artery vasospasms
and retinal detachment
• Fever from 39ºC and above (considered a grave sign).
• Coma – may be a result of Cerebral Vascular Accident
(CVA)

46. 4. Respiratory
• Pulmonary oedema and cyanosis
5. Reduced utero-placental perfusion
• May be due to increased vasospasms and perfusion
and acute artherosis
6. Oligohydramnion
7. Foetal complications
• Intrauterine growth restriction, foetal distress,
intrauterine foetal death

47. Key points
• Severe pre-eclampsia and eclampsia are
dangerous medical conditions, requiring referral
to the hospital level.
• Manage minor hypertensive problems during
pregnancy to prevent progression into eclampsia.
• In severe cases, control convulsion and BP,
maintain fluid balance, deliver the mother at
whatever gestation age, and keep records.

48. Evaluation
• What are the clinical features of imminent
eclampsia?
• How would you manage a patient with
eclampsia?

49. References
• Baker, P. & Monga, A. (2006). Obstetrics by Ten
Teachers (18th Ed.). London: Hodder Arnold.
• MOHSW. (2005). Advanced Life Saving Skills
Trainee Manual. Dar es Salaam, Tanzania:
Ministry of Health and Social Welfare.

50. References
• MOHSW. (2008). Emergency Obstetric Care:
Job Aid. Dar es Salaam, Tanzania: Ministry of
Health and Social Welfare.
• WHO. (2005). Managing Complications in
Pregnancy and Childbirth: A Guide for Midwives
and Doctors. Geneva: World Health
Organization.
• DC Dutta's Textbook of Obstetrics 7th Edition

51. THANKS!!!