Preeclampsia is a pregnancy complication characterized by high blood pressure and protein in the urine. It affects over 5-8% of pregnancies worldwide and is a leading cause of maternal and infant illness and death. The condition is caused by poor development of the placenta, which fails to properly remodel the mother's uterine arteries. This results in reduced blood flow to the placenta and release of factors that cause damage to other organs. Risk factors include first pregnancy, obesity, diabetes, and family history. Symptoms range from mild to severe, including headaches, visual issues, pain, and seizures in severe cases. Management involves monitoring and delivery of the baby if the condition worsens. Ongoing research is

1. Preeclampsia
(Toxemia of pregnancy)
 Mohammed Abbas Hasan

2. ‫بسم‬‫ا‬ ‫الرحيم‬ ‫الرحمن‬
‫ا‬‫تغيض‬ ‫ما‬ ‫و‬ ‫أنثى‬ ‫كل‬ ‫تحمل‬ ‫ما‬ ‫يعلم‬
‫عنده‬ ‫شيء‬ ‫ككل‬ ‫و‬ ‫تزداد‬ ‫مكا‬ ‫و‬ ‫الحرحام‬
‫بمقداحر‬
‫صدق‬‫ا‬‫العظيم‬ ‫العلي‬

3. Pre-eclampsia
Pre-eclampsia is an idiopathic disorder of
pregnancy characterized by proteinuric
hypertension . Recent estimates indicate that
over 63000 women die worldwide each year
because of pre-eclampsia and its complications ,
with 98% of these occurring in developing
countries. In the UK , pre-eclampsia is the
second largest cause of both direct maternal
death and perinatal loss , responsible for the
death of six to nine women annually and

4. More than 10% of women will develop pre-
eclampsia in their first pregnancy and although the
overwhelming majority of these will have successful
pregnancy outcomes, the condition can give rise to
severe multisystem complications including cerebral
haemorrhage, hepatic and renal dysfunction and
respiratory compromise . The development of
strategies to prevent and treat the disorder has been
challenging due to an incomplete understanding of
the underlying pathogenesis.

5. Hypertension in pregnancy
 Hypertension in pregnancy is defined as one of the
following :
1. One measurement of diastolic BP of 110 mmHg or
more ; or
2. Two consecutive measurements of diastolic BP of ≥
90 mmHg 4 hours or more apart.
 BP should be measured in the sitting position with a
cuff that is large enough for the subject’s arm.

6. Proteinuria
Proteinuria : is defined as one of the following:
1. Twenty four hours urine sample collection with a
total protein excretion of 300 mg or more ; or
2. Random clean-catch urine specimen with a 2+ or
more on reagent strip.

7. Classification of hypertensive disorders
during pregnancy
Gestational hypertension
Preeclampsia
Chronic hypertension
Pre-eclampsia superimposed on chronic
hypertension

8. Gestational hypertension
Hypertension arising for the first time after the
twentieth week of gestation, in the absence of
proteinuria ( < 300 mg in a 24-hour urine
collection ) , this usually have no significant
maternal or fetal consequences. Blood pressure
returns to normal by 6 weeks postpartum .

9. Preeclampsia
Preeclampsia is defined as hypertension
associated with proteinuria arising de novo after
the 20th week of gestation in a previously
normotensive woman & resolving completely by
the 6th postpartum week .

10. Chronic hypertension
Hypertension which is apparent prior to, in the
first half of, or persisting more than 6 weeks after
pregnancy.

11. Pre-eclampsia superimposed on
chronic hypertension
Chronic hypertension in pregnancy may be
complicated by preeclampsia . This kind of
hypertension is determined when there is a new
outset of proteinuria , or sudden deterioration of
either hypertension or proteinuria , or evolution
of other signs and symptoms of preeclampsia
after twentieth week of gestation .

12. Pre-eclampsia as a hypertensive
disorder of pregnancy

13.  Eclampsia: is a serious life-threatening complication
of pre-eclampsia when tonic-clonic convulsion occur
in a woman with established pre-eclampsia, in the
absence of any other neurological or metabolic cause.
 Severe pre-eclampsia : pre-eclampsia with severe
hypertension and/or with symptoms, and/or
biochemical and/or haematological impairment. It is
identified by a blood pressure of 160/110 mmHg or
more .

14.  Symptoms of preeclampsia :
1. May be asymptomatic
2. Headache
3. Visual disturbances
4. Epigastric and right upper abdominal pain
 Signs of preeclampsia :
1. Elevation of blood pressure
2. Fluid retention (non-dependent oedema)
3. Brisk reflexes
4. Ankle clonus (more than three beats)
5. Uterus and fetus may feel small for gestational age

15.  Symptoms of severe preeclampsia :
1. Frontal headache
2. Visual disturbances
3. Epigastric pain
4. General malaise and nausea
5. Restlessness
 Signs of severe preeclampsia :
1. Agitation
2. Hyper-reflexia
3. Facial and peripheral oedema
4. Right upper quadrant tenderness
5. Poor urine output

16. Risk Factors for pre-eclampsia
 Antiphospholipid syndrome
 Previous history of pre-eclampsia
 Pre-existing diabetes
 Multiple pregnancy
 Nulliparity Family history
 Raised body mass index (BMI)
 Age over 40 years
 Raised diastolic blood pressure (>80mmHg)

17. Management and Laboratory evaluation
of PE can include the following tests
Women who have a diastolic blood pressure ≥ 90
mmHg need further assessment. The following
investigations should be done:
 Urinalysis by dipstick
 24-hour urine collection ( total protein &
creatinine clearance)
 Full blood count ( platelet & Hematocrit) .
 Blood chemistry ( renal function, protein
concentration)

18.  Plasma urate concentration
 Liver function
 Coagulation profile
 Ultrasound assessment:
 Fetal size
 amniotic fluid volume
 maternal & fetal Doppler
 These investigations will be repeated at intervals
depending on the overall picture .

21. Etiology and Pathophysiology
 In normal placental development , extravillous
cytotrophoblasts of fetal origin invade the uterine spiral
arteries of the decidua and myometrium . These invasive
cytotrophoblasts replace the endothelial layer of the
maternal spiral arteries, transforming them from small,
high-resistance vessels to high-caliber capacitance
vessels capable of providing adequate placental
perfusion to sustain the growing fetus as in figure
below :

22. Normal placenta

23.  In preeclampsia , this transformation is
incomplete. Cytotrophoblast invasion of the
spiral arteries is limited to the superficial
decidua, and the myometrial segments remain
narrow as in figure below :

24. Preeclamptic placenta

25. Angiogenic factors in preeclampsia
 Although the pathophysiology of preeclampsia
remains undefined , placental ischemia/hypoxia is
widely regarded as a key factor. The poorly perfused
and hypoxic placenta is thought to synthesize and
release increased amounts of vasoactive factors
including soluble fms-like tyrosine kinase-1 (sFlt-1) ,
cytokines (interleukin-6 (IL-6) , tumour necrosis
factor (TNF)-α), angiotensin II (ANG II) type 1
receptor autoantibodies (AT1-AA) , and thromboxane
TX.

26.  Elevations in these factors are proposed to
result in endothelial dysfunction by decreases
in bioavailable nitric oxide (NO) and increased
reactive oxygen species (ROS) and endothelin-
1 (ET-1), which in turn results in altered renal
function, increased total peripheral resistance
(TPR), and ultimately hypertension. PlGF, is a
placental growth factor and VEGF is a vascular
endothelial growth factor . These are decreased.

28. Some biochemical
changes in
preeclampsia

29. The Association of Serum Androgen
Levels with Preeclampsia
In a previous study , researchers found levels of total
testosterone and dehydroepiandrosterone sulfate
(DHEA-S) were significantly higher in women with
severe preeclampsia than in normotensive women.
The levels of these androgens were higher in women
severe pre-eclampsia when compared to women with
mild preeclampsia . This difference may indicate a
role for androgens in the pathogenesis of preeclampsia
and stimulates research in the potential role of anti-
androgens in the management of preeclampsia.

30. The Relationship between Testosterone Hormone and Lipid
Profile, Proteins and Some Trace Elements in the Sera of Patients
with Preeclampsia
 This study tried to elucidate the relationship between
testosterone and some biochemical constituents which
vary during pregnancy (lipid profile, total protein,
albumin and minerals (Ca & Mg)). The results were :
1. Increase in serum testosterone levels in PE .
2. Increase in serum level of total cholesterol , TG , LDL ,
VLDL .
3. Decrease in serum HDL level .
4. Decrease in the levels of total protein , albumin ,Ca and
Mg .

31. The Relationship Between Serum Testosterone Level
And Antioxidants Status In Pre-Eclampsia
This study shows :
1. A significant increment in the concentration of
testosterone  , malondialdehyde  , and
globulin  in sera of preeclamptics compared to
normotensive .
2. A significant reduction in the serum level of
reduced glutathione  , catalase  , total protein
 , and albumin  in sera of preeclamptics
compared to normotensive pregnants .

32. The Relationship between Insulin Resistance
and Oxidative Stress in Pre-eclamptic Women
in Babylon Governorate
 Insulin resistance is an important part of metabolic
syndrome and may be a contributor factor in pre-
eclampsia.
 It has been suggested the presence of insulin resistance
in preeclamptics and normotensive pregnant but the
insulin resistance higher in PE than normal pregnant
women.
 The diminution in antioxidants in sera of PE added to
imbalance between prooxidants and antioxidants would
result in oxidative stress ,which in turn may cause
oxidative stress in pre-eclampsia.

33. Oxidative stress in preeclamptic
pregnant women

34. Calcium and Phosphate Excretion in
Preeclampsia, as Markers of Severe
Disease
Urine calcium and phosphorus level are ≥
significant determinant of severity of
preeclampsia and may be considered as useful
marker for predicting the level of renal
impairment and time of delivery.

35. The Relationship between Leptin and
Some Steroid Hormones in the Sera of
Pre-eclamptic Iraqi Women
 In this study , serum levels of leptin were
significantly higher in mild and severe group
compared with control group in the third
trimester.
 Also free testosterone and estradiol were
significantly higher in mild and severe groups
compared to their control group.
 Estradiol plays a major part in the induction of
leptin synthesis in preeclampsia .

36. Trace elements in preeclampsia
 Trace elements such as zinc (Zn), selenium (Se) and
copper (Cu) display antioxidant activity, while
others such as calcium (Ca) and magnesium (Mg)
are essential micronutrients. The disturbance in the
metabolism of these elements may be a contributing
factor in the development of certain diseases such as
pre-eclampsia observed in pregnant women .
 Reduced serum calcium and zinc levels are found
associated with elevated blood pressure in
preeclampsia.

37.  Previous trials have suggested that calcium
supplementation during pregnancy may reduce
the risk of preeclampsia.
 Because the trace element selenium behaves as an
antioxidant and peroxynitrite scavenger when
incorporated into selenoproteins, the reduction in
selenium status in a number of European countries
in recent years, this case raises the question of
whether a small increase in selenium intake might
help prevent preeclampsia in susceptible women.

38. Thank you for
your attention