Lecture for medical student

1. Update Management of
Preeclampsia,2022
Salah Roshdy Ahmed, M.D.,
Professor of Obstetrics & Gynecology
Sohag University . 2022

2. • Be able to define hypertension in relationship to
pregnancy
• Be able to classify hypertensive diseases in
pregnant women
• Be able to list criteria for the diagnosis of PET
• Be able to list criteria for the diagnosis of severe
preeclampsia/HELLP syndrome-Eclampsia
• Be able to discuss current management
considerations
• Understand and discuss the effects of
hypertension on the mother and fetus
OBJECTIVES

4. Introduction
• Preeclampsia is one of the ―great
obstetrical syndromes‖ in which multiple
and sometimes overlapping pathologic
processes activate a common pathway
consisting of endothelial cell activation,
intravascular inflammation, and
syncytiotrophoblast stress.
• PET complicates about 3–5% of all
pregnancies and is estimated to cause at least
70000 & 500000 maternal &neonatal deaths

6. 1-Maternal personal risk factors
• First pregnancy -New partner-
• Age younger than 18 years or older than 35
years
• History of preeclampsia
• Family history of preeclampsia in a first-
degree relative
• Black race -Obesity (BMI ≥30)
• Interpregnancy interval less than 2 years or
longer than 10 years

7. 2-Maternal medical risk factors
• Chronic hypertension, especially when secondary to
such disorders as hypercortisolism,
hyperaldosteronism, pheochromocytoma, or renal
artery stenosis
• Preexisting diabetes (type 1 or type 2), especially with
microvascular disease
• Renal disease-SLE -Obesity –Thrombophilia
• History of migraine
• Use of selective serotonin uptake inhibitor
antidepressants (SSRIs) beyond the first trimester

8. 3-Placental/fetal risk factors
• Multiple gestations
• Hydrops fetalis
• Gestational trophoblastic disease
• Triploidy

13. • Cardiovascular effects
• Hematologic effects
• Neurologic effects
• Pulmonary effects
• Renal effects
• Fetal effects
Pathophysiologic Changes

14. Cardiovascular effects
◦ Hypertension
◦ Increased cardiac output
◦ Increased systemic vascular
resistance
 Hematologic effects
 Neurologic effects
 Pulmonary effects
 Renal effects
 Fetal effects
Pathophysiologic Changes

15. • Cardiovascular effects
• Hematologic effects
• Volume contraction/Hypovolemia
• Elevated hematocrit
• Thrombocytopenia
• Microangiopathic hemolytic anemia
• Third spacing of fluid
• Low oncotic pressure
• Neurologic effects
• Pulmonary effects
• Renal effects
• Fetal effects
Pathophysiologic Changes

16.  Cardiovascular effects
 Hematologic effects
 Neurologic effects
◦ Hyper reflexes
◦ Headache
◦ Cerebral edema
◦ Seizures
 Pulmonary effects
 Renal effects
 Fetal effects
Pathophysiologic Changes

17.  Cardiovascular effects
 Hematologic effects
 Neurologic effects
Pulmonary effects
◦ Capillary leak
◦ Reduced colloid osmotic pressure
◦ Pulmonary edema
 Renal effects
 Fetal effects
Pathophysiologic Changes

18.  Cardiovascular effects
 Hematologic effects
 Neurologic effects
 Pulmonary effects
 Renal effects
◦ Decreased glomerular filtration rate
◦ Glomerular endotheliosis
◦ Proteinuria
◦ Oliguria
◦ Acute tubular necrosis
 Fetal effects
Pathophysiologic Changes

19. • Cardiovascular effects
• Hematologic effects
• Neurologic effects
• Pulmonary effects
• Renal effects
• Fetal effects
• Placental abruption
• Fetal growth restriction
• Oligohydramnios
• Fetal distress
• Increased perinatal morbidity and mortality
Pathophysiologic Changes

20. International Society for the Study of
Hypertension in Pregnancy (ISSHP)
• Chronic/pre-existing hypertension
• Gestational hypertension
• Pre-eclampsia – de novo or
superimposed on chronic
hypertension
• Eclampsia
• HELLP syndrome

22. Chronic/pre-existing hypertension
Hypertension is confirmed
before conception or before 20
weeks of gestation with or
without a known cause, as
measured on two or more
consecutive occasions at least
four hours apart.

23. Essential (Primary) Hypertension:
• Defined by a blood pressure
greater than or equal to 140
mmHg systolic and/or 90mmHg
diastolic confirmed before
pregnancy or before 20
completed weeks’ gestation
without a known cause.

24. Secondary Hypertension
• Hypertension occurring secondary to an
underlying medical cause.
• Chronic kidney disease e.g. GN, reflux
nephropathy, and adult polycystic kidney .
• Renal artery stenosis.
• Systemic disease with renal involvement e.g.
diabetes mellitus, SLE.
• Endocrine disorders e.g.
phaeochromocytoma, Cushing’s syndrome and
primary hyperaldosteronism
• Coarctation of the aorta.

25. White Coat Hypertension
• Elevated office/clinic (≥140/90 mm
Hg) BP,
• but normal BP measured at home
or work (<135/85 mm Hg);
• It is not an entirely benign
condition and conveys an
increased risk for preeclampsia

26. Masked hypertension
• is another form of hypertension, more
difficult to diagnose,
• characterized by BP that is normal at a
clinic or office visit but elevated at other
times,
• most typically diagnosed by 24-hour
ambulatory BP monitoring (ABPM) or
automated home BP monitoring.

27. Gestational hypertension
• Gestational hypertension is
characterised by the new onset of
hypertension after 20 weeks’
gestation without any maternal or
fetal features of pre-eclampsia,
followed by return of blood pressure
to normal within 3 months post-
partum.

30. Pre-eclampsia
Note it……………………..
• Preeclampsia can also occur
without proteinuria, with end
organ dysfunction
manifestations.
• Edema is no longer considered
a specific diagnostic criterion
for PET.

33. Early PET
• Rarely, pre-eclampsia presents before 20
weeks’ gestation; usually in the presence of a
predisposing factor such as
• Hydatidiform mole,
• Multiple pregnancy,
• Fetal triploidy,
• Severe renal disease or
• Antiphospholipid antibody syndrome.

34. Unstable pre-eclampsia
• Women with PET have
worsening PET blood results
and severe hypertension not
controlled by antihypertensive.
• Also known as fulminating
PET.

35. Atypical Preeclampsia
• Gestational proteinuria or FGR plus one or
more of the following symptoms of PE:
• hemolysis, thrombocytopenia,
elevated liver enzymes,
• early signs and symptoms of PE-
eclampsia earlier than 20 weeks,
and
• late postpartum PE-eclampsia (>48
hours postpartum).

36. Superimposed Preeclampsia On
Chronic Hypertension
New onset proteinuria or end organ
dysfunction in hypertensive
women but no proteinuria before 20 weeks'
gestation
A sudden increase in proteinuria or blood
pressure or platelet count < 100,000/L in
women with hypertension and proteinuria
before 20 weeks' gestation

37. HELLP Syndrome
• Rare, potentially life-threatening
obstetric condition that is a combination
of hemolysis, elevated liver enzyme , and
thrombocytopenia
• May represent a severe variant of
preeclampsia, but the exact relationship
between preeclampsia and HELLP is not
fully understood
• Up to 15% of patients do not have
hypertension or proteinuria

45. Eclampsia
• New-onset tonic-clonic, focal, or multifocal
seizures (in absence of alternative cause)
in association with hypertension in
pregnancy
• May be preceded by PET or occur abruptly
without prior signs and symptoms
• It is a severe manifestation of PET and
can occur before, during or after birth.
• It can be the presenting feature of PET in
some women.

47. Diagnosis of Hypertension
• Hypertension in pregnancy should be defined
as:
• A systolic blood pressure ≥ 140mmHg
• A diastolic blood pressure ≥ 90mmHg
• These measurements should be based on the average
of at least two measurements, taken using the same
arm, 4-6 hours apart.
• Elevations of both systolic and diastolic blood
pressures have been associated with adverse fetal
outcome and therefore both are important

48. Blood Pressure Assessment:
Patient preparation and posture
Standardized technique:
Patient
1. No caffeine in the preceding hour.
2. No smoking or nicotine in the preceding 15-30
minutes.
3. No use of substances containing adrenergic
stimulants such as phenylephrine or pseudoephedrine
(may be present in nasal decongestants or ophthalmic
drops).
4. Bladder and bowel comfortable.
5. Quiet environment. Comfortable room temperature.
6. No tight clothing on arm or forearm.
7. No acute anxiety, stress or pain.
8. Patient should stay silent prior and during the
procedure.

50. Blood Pressure Assessment:
Patient preparation and posture
Posture
• The patient should be calmly seated for at
least 5 minutes, with her back well
supported and arm supported at the level of
the heart. Her feet should touch the floor
and legs should not be crossed.
• The patient should be instructed not to talk
prior and during the procedure.

51. Recommended Technique
for Measuring Blood Pressure
• Standardized technique:
• Use a mercury
manometer or a
recently calibrated
aneroid or a validated
electronic device.
• Aneroid devices should
only be used if there is
an established
calibration check every
6-12 months.

53. Cuff size
Arm circumference (cm) Size of Cuff (cm)
From 18 to 26 9 x 18 (child)
From 26 to 33
12 x 23 (standard adult
model)
From 33 to 41 15 x 33 (large, obese)
More than 41 18 x 36 (extra large, obese)

54. Recommended Technique
for Measuring Blood Pressure (cont.)
• To exclude
possibility of
auscultatory gap,
increase cuff
pressure rapidly to
20-30 mmHg above
level of
disappearance of
radial pulse
• Place stethoscope
over the brachial
artery

55. Recommended Technique
for Measuring Blood Pressure (cont.)
• Drop pressure by 2 mmHg / sec
• Appearance of sound (phase I Korotkoff) =
systolic pressure
• Record measurement
• Drop pressure by 2 mmHg / beat
• Disappearance of sound (phase V
Korotkoff) = diastolic pressure
• Record measurement
• Take 2 blood pressure measurements,
1 minute apart

56. • Korotkoff phase V should be used to
measure the diastolic blood pressure
in pregnancy as it is far more
reproducible.
• Where Korotkoff 5 is absent,
Korotkoff 4 (muffling) can be
accepted but the method used
should be consistent and
documented.

57. Recommended Technique
for Measuring Blood Pressure
(cont.)
Systolic BP
Diastolic BP
Possible readings:
184 / 100
136 / 100
184 / 86 = correct
136 / 86
200
180
160
140
120
100
80
60
40
20
0
No sound
Clear sound
Muffled sound
Muffled sound
No sound
Phase 1
Phase 3
Phase 4
Phase 5
Muffling Phase 2
Auscultat
ory gap
No sound
mm Hg
Korotkoff sounds

59. How Should We Evaluate
Proteinuria During Pregnancy?
• The reference standard for measuring urinary
protein excretion is a 24-hour urine
collection.
• More convenient methods used in practice
involve urinary dipstick
• Or measurement of the UPCR in a spot urine
sample.
In many locations, the Spot UPCR is utilized
rather than 24- hour collections.

60. Urine dipsticks
• The use of a dipstick to screen the urine
for protein is an integral part of the
current antenatal care plan and usually
the first screening for proteinuria.
• This method is based on a change in pH
in the presence of anionic proteins, that
is, albumin and transferrin.

61. Urine dipsticks
• Routine urine dipstick screening for
low-risk women does not provide any
clinical benefit and proteinuria, with
dipstick analysis, cannot be
accurately detected or excluded at
the +1 threshold and is not
recommended for diagnosing
preeclampsia

62. Proteinuria Quantification
• Urinary reagent-strip testing is simple,
cheap and an appropriate screening test
for proteinuria especially when the
suspicion of pre-eclampsia is low.
Approximate equivalence is:
• 1+ = 0.3 g/l
• 2+ = 1 g/l
• 3+ = 3 g/l

63. Urine protein-to-creatinine ratio
UPCR
• In the spot urine tests, albumin concentration is
normalized for the urinary creatinine concentration
to approximate a 24-hour albumin or protein loss. It
is important to emphasize that creatinine production
and excretion are dependent on both kidney function
and muscle mass.
• A UPCR value of >0.3 would represent abnormal
proteinuria during pregnancy based on the current
cutoff
• A cutoff of UPCR of >0.3 had a sensitivity of 91% ,
specificity of 90%

64. UPCR
• A spot urine protein/creatinine cut-off level
of 30 mg/mmol equates to a 24-h urine
protein >300 mg per day and this
eliminates the inherent difficulties in
undertaking the 24-h urine collections and
speeds up the process of decision making.

65. 24-hour urine collection
• The gold standard test remains a 24- hour urine protein
measurement, but this method is not practical especially
for women requiring a rapid diagnosis. Moreover, the
24-hour urine collection may have other limitations as a
result of inadequate collection, inconvenience, spillage,
and other factors.
• Abnormal proteinuria in pregnancy is a 24-h urinary
protein >300 mg per day, However its accuracy is
affected by numerous factors such as adequacy and
accuracy of collection, and variations in protein
excretion.

70. Symptoms of pre-eclampsia
• Severe headache
• Problems with vision, such as
blurring or flashing before the eyes
• Severe pain just below the ribs
• Vomiting
• Sudden swelling of the face, hands or
feet.

71. Evaluation of the hypertensive
gravida
• Although most pregnant patients
who have a diagnosis of chronic
hypertension have primary or
essential hypertension,
• A secondary cause—including :
• Thyroid disease, SLE, and
underlying renal disease— might be
present and should be sought out.

72. Routine laboratory evaluation
• Serum creatinine, electrolytes,
• Liver enzymes.
• A 24-hour urine collection for protein
excretion and creatinine clearance or a
urine protein–creatinine ratio
• CBC
• Renal ultrasonography
• Thyroid function, SLE panel, and
vanillylmandelic acid/metanephrines.
• ECG or echocardiography,

73. Fetal monitoring
• At 28–30 and 32–34 weeks
perform:
1-Ultrasound for fetal growth and
amniotic fluid volume assessment
2-Umbilical artery Doppler
velocimetry
• Electronic fetal monitoring

74. Prediction of PET

75. FMF triple test 90%

77. Predicting the Development of Preeclampsia
• Uterine artery Doppler studies.
• Measurement of angiogenic factors (such as
soluble endoglin, PlGF (placental growth factor
), sFlt-1(soluble fms-like tyrosine kinase 1), and
sFLt-1/PlGF ratio).
• Numerous others, such as pregnancy-
associated plasma protein A,
• placental protein 13, homocysteine,
asymmetrical dimethylarginine,
• uric acid and leptin, urinary albumin, or
calcium

78. Prevention
Women with established
strong clinical risk factors
for pre-eclampsia be
treated, ideally before 16
weeks but definitely before
20 weeks, with 81–162
mg/day aspirin (ISSHP, 2018)

81. Antenatal management
• 1-PET without severe feature (BP
140/90– 149/99 mmHg)
• Treat hypertension .
• Measure BP ≥4 times a day.
• Test kidney function,
electrolytes, FBC, LFT twice a
week.

82. PET with Severe features
• Hospitalization.
• Treat with first-line oral labetalol to
keep BP <135/85 mmHg .
• Measure BP >4 times daily depending
on clinical circumstances.
• Test kidney function, electrolytes,
FBC, LFT 3 times a week.

83. The goal of antihypertensive
medication
• To reduce
- Maternal risk of stroke,
- Congestive heart failure, renal failure,
- Severe hypertension.
• No convincing evidence exists that
antihypertensive medications decrease the
incidence of superimposed preeclampsia,
preterm birth, placental abruption, or perinatal
death.

89. Obstetric Management
• Classically ―stabilize and deliver‖

90. Timing of Delivery
• Delivery should be effected depending on
gestational age and maternal and fetal
status, as follows
• Women with onset of preeclampsia at ≥37
weeks’ gestation should be delivered.
• Women with onset of preeclampsia
between 34 and 37 weeks’ gestation
should be managed with an expectant
conservative approach.

91. Timing of Delivery
• Women with onset of preeclampsia
at <34 weeks’ gestation should be
managed with a conservative
(expectant) approach .
• Women with preeclampsia with a
fetus at the limits of viability
(generally before 24 weeks gestation)
should be counseled that termination
of pregnancy may be required.

92. Delivery is necessary when ≥1
of the following indications
• Inability to control maternal BP
despite using ≥3 classes of
antihypertensives in appropriate
doses .
• Progressive deterioration in liver
function, creatinine, hemolysis, or
platelet count .

93. Delivery is necessary when ≥1
of the following indications
• Ongoing neurological features, such
as severe intractable headache,
repeated visual scotomata, or
eclampsia
• Placental abruption
• Reversed end-diastolic flow in the UA
Doppler velocimetry, a nonreassuring
cardiotocograph, or stillbirth

98. Intrapartum
• Oral antihypertensives should be
given at the start of labor.
• Treat hypertension urgently with oral
nifedipine or either intravenous
labetalol or hydralazine if BP rises
≥160/110 mm Hg.
• Total fluid intake should be limited to
60 to 80 mL/h

99. Postpartum care
• Monitor BP at least 4 to 6 hourly
during the day for at least 3 days
postpartum.
• Preeclampsia may develop de
novo intra- or early postpartum.
• Monitor general well-being and
neurological status as per
predelivery; eclampsia may occur
postpartum.

100. • Repeat Hb, platelets, creatinine, liver
transaminases the day after delivery and
then second daily until stable if any of
these were abnormal before delivery.
• Antihypertensives should be restarted
after delivery and tapered slowly only after
days 3 to 6 postpartum unless BP
becomes low (<110/70 mm Hg) or the
woman becomes symptomatic in the
meantime.
Postpartum care

104. Take home message
• Hypertension is the most common medical
complication during pregnancy.
• • PE is a leading cause of maternal mortality
and morbidity worldwide.
• • The pathophysiologic abnormalities of PE are
numerous, but the etiology is unknown.
• • At present, there is no proven method to
prevent PE. However, LDA may have a role in
certain women.
• • The HELLP syndrome may develop in the
absence of maternal hypertension and
proteinuria.

105. Take home message
• Start antihypertensive drugs when there is
sustained elevation of BP above
140/90(target BP less than 135/85.
• Women with severe preeclampsia at pre-
viable gestational ages should be
delivered.
• Expectant management improves
perinatal outcome in a select group of
women with severe PE before 32 weeks’
gestation as long as the maternal and fetal
status is stable .
• Women with severe preeclampsia above

106. Take home message
Labetalol is the drug of choice for the treatment of
hypertension during pregnancy; ACE inhibitors
should not be used.
• Women with mild preeclampsia or gestational
hypertension, induction of labor at term is
recommended.
• Magnesium sulfate is the preferred agent to
prevent or treat eclamptic convulsions.
• • Rare cases of eclampsia can develop before
20 weeks’ gestation and beyond 48 hours
postpartum ,
• Antihypertensives should be continued in the
postpartum period until blood pressure