Pre- eclampsia and eclampsia accounts for approximately 63000 maternal deaths worldwide .The maternal mortality rate is as high as 14% in developing countries

1. PREGNANCY INDUCED
HYPERTENSION
BY
AMIT JHA
KIST MEDICAL COLLEGE

2. CASE PRESENTATION

3. PATIENT PARTICULARS :
Name: Sani Maya Tamang
Age: 26 years
Sex: Female
Address: Sindhuli
Religion: Hindu
Occupation : Housewife/Husband: Farmer
Education : Uneducated
Marital Status: Married
Date of Admission: 15thAsoj2072 at 3PM from OPD
Date of History Taking: 15th Asoj 2072
BED NO.199

4. CHIEF COMPLAINTS
• Cessation of menstruation for 8 months
• Swelling of both lower limbs for 15 days
• Headache for 4 days
• Epigastric pain for 3 days
• Decreased fetal movement for 3 days

5. HISTORY OF PRESENT ILLNESS
• She presented with cessation of menstruation
for 8 months
• LMP : 4th Magh 2071
• EDD: 11th Kartik 2072
• Gestational age : 36 weeks & 3 days
• She confirmed her pregnancy by Urine
Pregnancy Test after 2months of cessation of
menstruation at a medical store

6. • She has done 2 ANC visits till date
• 1st ANC visit during 2nd trimester
• 2nd ANC visit in the 3rd trimester
• 1st trimester
Few episodes of vomiting in the morning
which subsided on its own.
Increased frequency of micturition
No fever or flu like symptoms, rashes, per
vaginal bleeding, pain abdomen.

7. 2nd trimester –
• Perceived fetal movements at 4months
• No fever, urinary symptoms, per vaginal
bleeding or leaking
• Taken 1 dose of TT
• Deworming was done
• Iron tablets for 1 month

8. 3rd trimester
• No per vaginal bleeding or leaking
• No dyspnea , palpitation or blurring of vision

9. • History of swelling of both lower limbs for last
15 days
• Gradual in onset
• Started 1st around the ankle
• Gradually progressing upto shin of tibia

10. • Headache for 4 days
• Gradual in onset
• Intermittently occurring
• Localized to frontal region
• Aggravated on doing her daily activities
• Relived on taking rest
• No blurring of vision,
• Has not taken any medicines for it

11. • Abdominal pain for 3 days
• Localized to epigastric region
• Burning in nature
• Intermittent type
• Non radiating
• No aggravating or relieving factors
• Subsides on its own
• Not associated with fever, nausea or vomiting or
altered bowel habit
• No per vaginal bleeding or leaking

12. • Decreased fetal movement since last 3days
• Previously perceived fetal movements
throughout the day but for last few days only
2-3 times a day

13. • No urinary symptoms such as decreased
output , burning micturition or passage of
frothy urine
• No palpitation, dyspnea or blurring of vision
• No history of abnormal body movements and
loss of consciousness
• No altered bowel habits

14. Obstetric History
• Married for 1 year
• Primigravida

15. Menstrual History
• Menarche at 13 years
• LMP: 4th Magh, 2071
• Duration of flow: 4 days
• Length of cycle: 28 ± 5 days
• Regular
• 2-3 partially soaked pads, no clots, no post-
coital bleeding, no intermenstrual bleeding,
no dyspareunia

16. Contraceptive History
• No use of any contraceptives.

17. Past History
• No history of diabetes mellitus, hypertension,
epilepsy, tuberculosis, thyroid disorders, blood
transfusion
• No history of surgeries done

18. Family History
• No history of diabetes mellitus, hypertension,
tuberculosis, female genital tract malignancy,
congenital anomalies.
• History of twin pregnancy in family

19. Personal History
• Non-smoker
• Doesn’t consume alcohol
• Non vegetarian
• No known allergies

20. Treatment History
• Not under any medications

21. General Examination
• General condition:
– Fair, conscious, co-operative, lying on bed, well
oriented to time, place and person
– Average built
– Well hydrated
• Weight: 60 kgs

22. • Cardinals:
– Bilateral pedal pitting edema present
– No pallor, icterus, cyanosis, clubbing, no palpable
lymph nodes

23. • Vitals:
– BP: 160/120 mm of Hg in Right arm supine
180/110 mm of Hg in Left arm supine
– Pulse: 86 beats per min, regular, normal volume
and character
– Temperature: 98℉
– Respiratory rate: 20/min

24. • Thyroid Examination
– Non tender
– Not enlarged
• Breast Examination
– Not done

25. Systemic Examination
• Respiratory examination
– Bilateral normal vesicular breath sounds
– No added sounds
• Cardiovascular examination
– First and second heart sounds
– No murmur

26. • Abdominal Examination
– Inspection:
• Abdomen distended till the level of umbilicus
• Umbilicus centrally placed and inverted
• No scars or pigmentation
• No linea nigra
• No stria gravidarum or albicans
• No visible pulsations or venous prominences
• Hernial orifices intact

27. – Palpation
• Abdominal wall edema present
• Temperature not raised
• No tenderness

28. Obstetric examination
– Fundal height: 24 weeks size
– Abdominal girth: 32 inches
– Fundal grip: Broad, firm, irregular, mass felt, most
probably buttock
– Left Lateral grip: Smooth, curved, resistant feel,
most probably back
– Right lateral grip : Multiple knob like structure ,
most probably limbs

29. – Pelvic grip:
• 1st: smooth, hard, globular mass, most probably
head
• 2nd: smooth, hard, globular mass felt, most
probably head, mobile from side to side, head
is not engaged.
– Fetal heart sound:
• 136 beats per minute at left spinoumbilical line,
regular.

30. • Pelvic examination
– Not done

31. Diagnosis
• Primigravida at 36 weeks and 3 days of
gestation with pre-eclampsia with intra-
uterine growth retardation

32. Management
• At the time of admission (2072/6/15)
– Investigations
• ANC investigations
– Hb: 12.8 gm/dl
– Blood group: A +ve
– Platelets: 2,59,000/cumm
– VDRL/HIV I,II/HbsAg: Non-reactive
– RBS: 96 mg/dl
– Urine R/E: Colour: light yellow, Reaction: Acidic,
Albumin: ++ , WBC: 22-25/HPF, RBC: 2-4/HPF,
Epithelial cells: 12-15

33. • USG abdomen and pelvis:
–singleton pregnancy of 30 weeks and 1 day
of gestation
–Oligohydramnios , AFI: 6.4 cm
–Findings suggestive of IUGR

34. – Other investigations
• LDH: 1023 IU/L (<480)
• Serum urea: 22 mg/dl (10-40)
• Serum creatinine: 0.8 mg/dl (0.5-1.4)
• Sodium : 141 mEq/L (135-146)
• Potassium : 3.9 mEq/L (3.5-5.2)
• Serum uric acid: 6.9 mg/dl (2.4-5.7)
• SGPT: 33 IU/L (0-40)
• SGOT: 56 IU/L (0-40)
• ALP: 534 IU/L (80-306)

35. • BT: 3 min (2-6)
• CT: 7 min (5-12)
• PT: 14 sec
• INR: 0.96

36. • On admission:
– BP monitoring was done half hourly with range
from 130-180/90-110 mm of Hg
– Urine protein 12 hourly
– 24 hour urine protein
– Foley’s catheter inserted
– Keep NPO from 10 PM next day
– Daily weight measurement
– Counsel the patient and the patient party
regarding the condition and EmLSCS if to be done

37. • Treatment(copied from chart)
– Tab Nifedipine 10 mg PO stat and TDS
– Tab Iron 1 tab PO OD
– Tab Calcium 1 tab PO OD
– L-arginine 1 sachet in 1 glass of water
– Inj. Dexamethasone 6 mg IM 12 hrly (4 doses)
– Tab Methyldopa 250 mg PO TDS

38. • 1st DOA (2072/6/16)
– Continuous monitoring of BP
– Monitoring of fetal well being
– Weight: 60 kgs
– Urine RE
• Colour: Light yellow
• Reaction: Acidic
• Albumin: Trace
• Sugar: Nil
• WBC: 1-2/HPF
• RBC: Nil

39. • 2nd DOA (2072/6/17)
– BP monitoring (1 AM to 8:45 AM) every hour:
• 130-150/90-100 mm of Hg episodes
– Weight: 60 kgs

40. – Investigations:
• USG doppler:
– Singleton pregnancy of 30 weeks and 2 days of gestation
– Absent end diastolic flow of umbilical artery
– S : D ratio = 8.9 ( < 3 Normal )
– Features of oligohydramnios (AFI: 4.3 cm)
– Features of fetoplacental insufficiency
– Moderate ascites
– Fetal Wt: 1236 gm
• 24 hr urine protein: 3.76 gm
• Serum uric acid: 5.9 mg/dl

41. • Following USG doppler EmLSCS was planned
• Pre-op assessment done
• EmLSCS at 1:30 PM

42. • Outcome:
– Single, alive, preterm, female baby delivered on
2072/6/17 at 1:37 PM with a birth weight of 1100
gms and APGAR score 8/10, 9/10
– Shifted to NICU for VLBW baby.

43. • OT findings:
– Abdominal wall edema
– Peritoneal fluid: 1500 ml, clear
– Lower uterine segment: not well formed
– Liquor: moderate meconium stained and
adequate
– Presentation: cephalic, Left-occipito anterior
– Placenta: Fundo-posterior
– Bilateral tubes and ovaries: normal looking

44. • Total blood loss: 400 ml
• Urine: 50 ml, clear
• Post-op BP: 130/80 mm Hg

45. Hypertensive Disorders in
Pregnancy

46. Incidence
• 3.7 % of pregnancies
• 16% of pregnancy-related deaths
• Eclampsia 1 in 2000 deliveries

47. Classification
by the working group of the NHBPEP
(2000)
• Gestational hypertension
• Preeclampsia
• Eclampsia
• Preeclampsia superimposed on chronic
hypertension
(superimposed preeclampsia)
• Chronic hypertension

48. Gestational hypertension
• BP >= 140/90 mmHg for first time during
pregnancy
• No proteinuria
• BP returns to normal < 12 wk postpartum
• Final diagnosis made only postpartum
• May have other features preeclampsia like
epigastric discomfort or thrombocytopenia

49. Preeclampsia
• Minimum criteria
• BP >= 140/90 mmHg after 20 wk gestation
• Proteinuria >= 300 mg/24hr or >=1+ dipstick
• Mild preeclampsia
• Severe preeclampsia

50. Severe preeclampsia
• BP >= 160/110 mmHg
• Proteinuria 5 g/24hr or >= 2+ dipstick (persistent)
• Cr > 1.2 mg/dl
• Platelets < 100,000 /mm3
• Microangiopathic hemolysis
• Elevated ALT or AST
• Persistent headache , visual disturbance , epigastric
pain
• HELLP syndrome

51. Eclampsia
• Seizures that cannot be attributed to other
causes in a woman with preeclampsia
• Seizures are generalized
• May appear before , during or after labor
• 10% develop after 48 hr postpartum

52. Superimposed preeclampsia
• New onset proteinuria >= 300mg/24 hr in
hypertensive women but no proteinuria
before 20 wk
• A sudden increase in proteinuria or BP or
platelet count < 100,000 in women with
hypertension and proteinuria before 20 wk

53. Chronic hypertension
• BP >= 140/90 mmHg before pregnancy or
diagnosed before 20 wk , not attributable to
GTD or
• Hypertension first diagnosed after 20 wk and
persistent after 12 wk postpartum

54. Risk Factors for PIH :
• Primigravidae
• Family history of HTN , pre- eclampsia &
eclampsia
• Placental abnormalities :
1) Poor Placentation : Decreased trophoblastic invasion
2) Hyperplacentosis : Multiple pregnancy , Rh incompatibility
, DM etc .
3) Placental Ischaemia :
4) Molar pregnancy

55. Risk Factors for PIH
• Polyhydraminos
• Genetic ( Multifactorial Inheritance )
• Immunological Phenomenon
• New Paternity
• Pre existing vascular or renal disease
• Thrombophilias ( Anti – Phospholipid &
Protein C , S deficiency )

56. Pre – Eclampsia
• Definition : Pre – eclampsia is a multi system
disorder of unknown aetiology characterized
by development of hypertension to the extent
of 140 / 90 mm Hg or more with proteninuria
after the 20th week of pregnancy in a
previously normotensive or non – proteinuric
patient .

57. Diagnostic criteria for Pre – eclampsia
• Hypertension
• Oedema
• Proteinuria

58. Hypertension
• BP : 140 / 90 mm Hg
• atleast on two occasions
• at least 6 hours apart

59. Oedema :
• Bilateral pitting oedema
• over ankles over 20 hours of bed rest
• or rapid gain in weight of more than 1 / 2 kg a
week

60. Proteinuria
• Presence of total protein more than 0.3 g, in
24 hours urine
• or >= ++ ( > 1 gm / L ) on atleast two random
clean – catch urine samples
• tested >= 4 hours apart in absence of UTI

61. Clinical features of Pre-eclampsia :
• Symptoms :
A ) Mild symptoms :
- Slight swelling over ankles
- Gradually the swelling extends to face , abdominal wall ,
vulva or even whole body
B ) Alarming Symptoms :
- Headache (frontal or occipital )
- Disturbed sleep
- Diminished urine output ( < 400 ml / 24 hours )
- Eye symptoms ( Blurring or dimness of vision )
- Epigastric pain

62. Signs of Pre – eclampsia
• Abnormal weight gain : > 2.2 kg in 1 month or > 450
gm in 1 week
• Persistent rise of BP more than 140 / 90 mm of Hg
• Visible oedema over ankles from rise of bed at
morning
• Sings of Pulmonary edema
• Abdominal examination reveal scanty Liquor or IUGR
( chronic placental insufficiency )

63. Etiology: UNCLEAR
• Immune mechanism (rejection phenomenon, insufficient
blocking Ab)
• Injury of vascular endothelium----disruption of the
equilibrium between vasoconstriction and vasodilatation,
imbalance between PGI and TXA
• Compromised placenta profusion
• Genetic factor
• Dietary factors: nutrition deficiency
• Insulin resistance
• Increase CNS irritability

64. Pathophysiology :

65. Pathophysiology

66. Abnormal trophoblastic invasion

67. Central nervous system
• Raised BP disrupt autoregulation
• Increased permeability due to vasospasm---thrombosis of
arterioles, microinfarcts, and petechial hemorrhage
• Cerebral edema: increased intracranial pressure

68. Eyes
• Serous retinal detachment
• Cortical blindness

69. Pulmonary system
• Pulmonary edema
• Cardiogenic or noncardiogenic
• Excessive fluid retention, decreased hepatic synthesis of
albumin, decreased plasma colloid oncotic pressure
• Often occurs postpartum

70. Kidneys
• Characteristic lesion of preeclampsia:
glomeruloendotheliosis
• Swelling of the glomerular capillary endothelium
• Decreased GFR
• Fibrin split products deposit on basement
membrane
• Proteinuria
• Increase of plasma uric acid and creatinine

71. Liver
• Hepatic infarction, subcapsular hematoma
• HELLP syndrome: hemolysis, elevated liver
enzymes and low platelets

72. Cardiovascular system
• Generalized vasoconstriction, low-output, high-
resistance state
• Capillary leak
• Cardiac ischemia, hemorrhage, infarction, heart
failure
• Increased sensitivity to vasoconstrictor effects of
angiotensin

73. Blood
• Volume: reduced plasma volume
• Generalized vasoconstriction and capillary
leak

74. Blood : coagulation
• Isolated thrombocytopenia: <150,000/ml
• Microangiopathic hemolytic anemia
• DIC (5%)
• HELLP syndrome: in severe preeclampsia
1. schistocytes on the peripheral blood smear
2. lactic dehydrogenase > 600 u/L
3. total bilirubin > 1.2 mg/dl
4. aspartate aminotransferase >70 U/L
5. platelet count <100,000/mm3
• Misdiagnosis: hepatitis, gallbladder disease, ITP

75. Endocrine system
• Vascular sensitivity to catecholamines
and other endogenous vasopressors
such as antidiuretic hormone and
angiotensin II is increased in
preeclampsia

76. Placenta perfusion
• Acute atherosis of spiral arteries: fibrinoid
necrosis of the arterial wall, the presence of lipid
and lipophages and a mononuclear cell infiltrate
around the damaged vessel----vessel
obliteration---- placental infarction
• Fetus is subjected to poor intervillous blood flow
• IUGR or stillbirth

77. Laboratory findings
Blood test: elevated Hb or Hct, in severe cases, anemia secondary
to hemolysis, thrombocytopenia, FDP increase, decreased
coagulation factors
Urine analysis: proteinuria and hyaline cast, specific gravity > 1.020
Liver function: ALT and AST increase, alkaline phosphatase increase,
LDH increase, serum albumin
Renal function: uric acid: 6 mg/dl, serum creatinine may be
elevated
Other tests: ECG, placenta function, fetal maturity, cerebral
angiography

78. Differential diagnosis
• Pregnancy complicated with chronic
nephritis
• Eclampsia should be distinguished from
epilepsy, encephalitis, brain tumor,
anomalies and rupture of cerebral vessel,
hypoglycemia shock, diabetic
hyperosmatic coma

79. Complications
1) Immediate complications :
A ) Maternal complications :
a ) During pregnancy :
1 ) Eclampsia ( 2 % )
2 ) Antepartum hemmorrhage
3 ) Acute Renal failure
4 ) Cardiac Failure
5 ) HEELP syndrome
6 ) vision problem
7 ) Premature labor

80. • B ) During Labor :
- Eclampsia
- PPH
- Shock
c ) Puerperium :
- Eclampsia
- Puerperal sepsis
- Shock

81. B ) Fetal complications
a ) Intrauterine death
b ) Intrautherine Growth Retardation
c ) Birth Asphyxia
d ) Prematurity
2 ) Remote complications :
a ) Residual Hypertension
b ) Recurrent pre – eclampsia

82. Prevention
• Calcium supplementation: not effective in low
risk women bur show effect in high risk group
• Aspirin (antithrombotic): uncertain
• Good prenatal care and regular visits
• Baseline test for high-risk women
• Eclampsia cannot always be prevented, it may
occur suddenly and without warning.

83. Treatment
A. Mild preeclampsia: bed rest & delivery
• Hospitalization or home regimen
• Bed rest and daily weighing
• Daily urine dipstick measurements of proteinuria
• Blood pressure monitoring
• Fetal heart rate testing
• Periodic 24-h urine collection
• Ultrasound
• Liver function, renal function, coagulation profile

84. A. Mild preeclampsia: bed rest & delivery
• Observe for danger signals: severe headache,
epigastric pain, visual disturbances
• Sedatives: debatable

85. B. Severe preeclampsia:
• Prevention of convulsion: magnesium sulfate or
diazepam and phenytoin
• Control of maternal blood pressure: antihypertensive
therapy
If BP > 140 / 90 mm of Hg in more than one occasion or >
160 / 100 mm Hg on one occasion , start Cap. Nifedipine
10 mg orally 6 – 8 hourly
• Initiation of delivery: the definitive mode of therapy if
severe preeclampsia develops at or > 36 wk or if there is
evidence of fetal lung maturity or fetal jeopardy.

86. Antihypertensive therapy: reduce the Diastolic
pressure to 90-110 mmHg
Indication
• Bp> 160/110 mmHg
• Diastolic Bp > 110 mmHg
• MAP > 140 mmHg
• Chronic hypertension with previous
antihypertensive drugs usage

87. Medication
Mechanism
of action
Effects
hydralazine
Direct peripheral
vasodilation
CO, RBF maternal flushing,
headache, tachycardia
labetalol
a, b- adrenergic
blocker
CO, RBF maternal flushing,
headache, neonatal depressed
respirations
nifedipine
Calcium channel
blocker
CO, RBF maternal orthostatic
hypotension
Headache, no neonatal effects
methyldopa
Direct peripheral
arteriolar vasodilation
CO, RBF maternal flushing,
headache, tachycardia
sodium nitroprusside Direct peripheral
vasodilation
Metabolite (cyanide)
toxic to fetus

88. Delivery
• Indication of termination of pregnancy
1. Preeclampsia close to term
2. <34 wk with decreased placental function
3. 2 hs after control of seizure

89. Eclampsia
• Eclampsia is the occurrence of convulsions in a patient with
preeclampsia with no coincident neurological disease .
• Eclampsia is more common in primigravida ( 75 % )
• Five times more common in twins than in singleton
pregnancies
• More than 50 % cases . It is occurred in between 36 weeks &
term
• Eclampsia occurs rarely in early month pregnancy ( e.g. In
Hydatiform Mole )
• Fits occur beyond 7 days of delivery , reasonably rules out
eclampsia

90. Stages of Eclampsia
• Premonitary stage(30 secs)
• Tonic stage(30secs)
• Clonic stage(1-4 mins)
• Coma stage

91. Clinical classification of Eclampsia
• Antepartum Eclampsia(50%): Fits occur before
onset of labor
• Intrapartum Eclampsia(30%):Fits occur first
time during labor
• Postpartum Eclampsia(20%): Usually within 48
hours of delivery

92. Management of Eclampsia
• Investigations
1) Platelets
2) Coagulation profile: BT, CT
3) Uric acid
4) Renal function test
5) Liver function test
6) Urine R/E
7) 24 hours urine albumin is case of severe pre-eclampsia

93. General measures
1) ABCD resuscitation
2) Oxygen inhalation
3) A mouth Gag
4) Left lateral position to prevent Aspiration pneumonia
5) Wide bore IV channel
6) Intravenous fluid
Total fluid: Last 24 hours urine output + 1000 ml fluid
(should not exceed 2 litres).
7)Catheterization
8) Vitals monitoring
9) Antibiotics: I/V Ampicillin (500 mg) 6 hourly to prevent
infection.

94. Magnesium sulfate
1. Decreases the amount of acetylcholine
released at the neuromuscular
junction
2. Blocks calcium entry into neurons
3. Vasodilates the smaller-diameter
intracranial vessels

95. Specific Management :
Magnesium sulfate ( Mgso4 )
Loading dose :
4 gm iv over 3-4 min ( 20 % solution ) , followed by 10 gm ( 50 % )
IM , 5 gm in each buttock
Maintenance dose :
5 gm ( 50 % solution ) deep IM in alternate buttocks every 4 hourly (
Continue same treatment for 24 hours after delivery or the last
convulsion , whichever is last
IV dose : 4g IV over 30 minutes , followed by 1 gm / hr maintaince
dose for atleast 24 hour postpartum

96. Toxicity:
• Diminished or loss of patellar reflex
• Diminished respiration
• Muscle paralysis
• Blurred speech
• Cardiac arrest

97. How to prevent toxicity?
• Frequent evaluation of patellar reflex and
respirations
• Maintenance of urine output at >25 ml/hr or 600
ml/d
• Reversal of toxicity:
1. Slow i.v . 10% calcium gloconate
2. Oxygen supplementation
3. Cardiorespiratory support

98. • Anti-hypertensive drugs
• Nifedipine :
10 mg orally 6-8 hourly
• Other drugs:
methyl dopa, labetolol, Hydralazine, frusemide
* Treatment of Complications

99. Termination of pregnancy in Eclampsia
• Immediate termination of the pregnancy is
treatment of choice and plan of obstetric
management
• There is no role of continuation of pregnancy. The
use of partograph is mandatory
• In majority of cases with antepartum eclampsia
labor started soon after convulsions

100. Indications of CS in Eclampsia
• Controlled Fits or convulsion inspite of
medical treatment
• Unconscious patient
• Poor prospect of vaginal delivery
• Obstetric Indication

101. Complications of Eclampsia
• Maternal complications :
1) Pulmonary Oedema
2) Pneumonia
3) Acute respiratory distress syndrome
4) Cerebral haemorrhage
5) Acute Renal failure
6) Retinal detachment
7) Hyper-pyrexia
8) PPH
9) Sepsis
10) Hepatic failure

102. • Fetal Complications:
1) Intrauterine death
2) IUGR
3) Birth asphyxia
4) Prematurity

103. Bad prognostic Factor in Eclampsia
1)Antepartum Eclampsia
2) No of Fits is > 10
3) Coma in between Fits
4) Temperature > 102 F
5) Pulse > 120 beats/min
6)Systolic BP > 200 mm Hg
7) Oliguria < 400 ml/ 24 hours with proteinuria . 5 gm/ 24 hours
8) No response to medical therapy
9) Jaundice

104. Causes of Maternal mortality in
Eclampsia
• Cardiac failure
• Pulmonary edema
• Aspiration pneumonia
• Cerebral hemorrhage
• Acute renal faiure
• Cardiopulmonary arrest
• Acute respiratory distress syndrome
• Pulmonary embolism
• Postpartum shock
• peuperal sepsis

105. HELLP syndrome :
• It is rare complication of pregnanccy induced hypertension
and acronym for :-
* Haemolysis
* Elevated liver enzymes
* Low platelets count
Clinical features
• Raised BP
• Proteinuria
• Nausea and Vomiting
• Epigastric or right upper quadrant pain

106. Treatment of HELLP Syndrome
• Same as Pre-eclampsia
• Prophylactic use of Mgso4
• Termination of pregnancy by CS
• Administration of corticosteriods
• Platelets or fresh blood transfusion ( platelets
count < 50,000 mm^3
• Patient should be managed in ICU untill there
is improvement of platelets count urine
output , BP and liver enzymes

107. • In KISTMCTH , there were total of 22 cases of
PIH out of 480 total delivery upto 19th ASOJ
in the year 2072 BS

108. PIH in Nepal
• In Nepal, PE/E is the second leading direct cause of maternal mortality at the
community level after PPH.
• It is the number one direct cause of maternal death in health facilities which
accounts for 30% of maternal deaths
• The Nepal Maternal Mortality and Morbidity Study 2008/2009 revealed that
21% maternal death was due to eclampsia, which was increased from 14% in
1998.
• The same study found that the rate for eclampsia in EOC* facilities in the eight
districts was 6 per 1000 births.
• The incidence ranged from none in Baglung district, 0.8 in Kailali to 27 in
Rasuwa district .
Family Health Division, Options UK, New Era and CREHPA. 2009. Nepal Maternal
Mortality and Morbidity Study 2008/2009. Nepal
*EOC = emergency operations center

109. • Study conducted in Paropakar Maternity and Women’s
Hospital (PMWH) and Patan Hospital found the incidence of
eclampsia 0.29%and 0.24% respectively in 2009
• Incidence of eclampsia in BPKIHS was 0.66 / 1000 births in
2008
• One study conducted at Koshi Zonal Hospital in 2007 revealed
the incidence of eclampsia at 1.3%.
• The findings of Nepal Health Directory (2011) revealed that
urine sample was taken for only 31.6% of pregnant women **
** Population Division Ministry of Health and Population
Government of Nepal, New ERA Nepal and Macro International Inc.
USA. 2011. Nepal Demographic and Health Survey 2012. Nepal

111. Some Vital statistics worldwide :
• Pre- eclampsia and eclampsia accounts for
approximately 63000 maternal deaths worldwide
• In developed countries maternal death reported is 0-
1.8%
• The maternal mortality rate is as high as 14% in
developing countries
• The perinatal mortality rate ranges from 5.6-11.8% in
US and Great Britain

112. • Study from US Centres for Disease Control and
Prevention (CDC) found an overall pre-
eclampsia / eclampsia case fatality rate of 6.4
per 10000 delivery.
• The study also found a particularly high risk of
maternal death at 20-28 weeks of gestation

113. • A majority of women who suffer eclampsia
associated death have concurrent HEELP
syndrome
• Fatal mortality rate varies from (13- 30)% due
to premature delivery and its complications
• Pre-eclampsia occurs upto 5% of all
pregnancies, in 10% of first pregnancies and in
(20-25)% with history of chronic hypertension

114. References :
• Cunningam , Leveno , Williams obstetrics , 24TH edition , Mc Graw
Hill
• Jones, Derek, Fundamentals of Obstetrics and Gynecology, 7th ed.,
Mosby, 1999.
• Konar Hiralal , DC Dutta’s Textbook of Obstetrics , 7th ed. , Jaypee ,
2013
• Daftary S , Chakravarti S , Holland and Brews Manual of obstetrics ,
3rd edition , Elsevier
• Eiland, Elosha; Nzerue, Chike; Faulkner, Marquetta (2012).
"Preeclampsia 2012". Journal of Pregnancy 2012: 1–7.
• Drife, James O.; Magowan, Brian. (2004). Clinical obstetrics and
gynecology. Edinburgh ; New York: Saunders. pp. 367–370
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