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РОССИЙСКИЙ УНИВЕРСИТЕТ ДРУЖБЫ НАРОДОВ

Кафедра акушерства и гинекологии с курсом перинатологии

ИНТЕРАКТИВНОЕ СЕМИНАРСКОЕ ЗАНЯТИЕ

Preeclampsia

10 семестр 5 курс (весна)

 Preeclampsia

Preeclampsia (PE, from Greek eclampsia, lightning) is a multisystem

abnormality manifested in the second half of pregnancy (after 20
weeks); it is characterized by arterial hypertension in combination with
proteinuria (over 0.3 g/l in daily urine), often by edema and
manifestations of multiple organ failure.
 CLASSIFICATION

The following forms of PE are distinguished abroad:

• gestational arterial hypertension;
• PE;
• severe PE;
• eclampsia;
• PE and eclampsia superimposed on chronic
arterial hypertension;
• arterial hypertension;
• hypertonic disease;
• secondary arterial hypertension.
 Gestational hypertension

• Gestational hypertension (at systolic BP ≥140 and/or diastolic BP

≥90 mm Hg) is a sign developing during pregnancy or in the first 24
hours after delivery in women with previously normal BP.
• It emerges secondary to vascular spasm and hyperdynamic systolic
function of the heart.
 ETIOLOGY of Preeclampsia

• Social and demographic: early and advanced reproductive

age, low-socio economic standing, some ethnic groups (like
negroid race, for instance).
• Genetic predisposition to PE development
• Specific features of pregnancy: multiple pregnancy, first
pregnancy, PE in previous pregnancies.
• Diseases of the mother: obesity, chronic renal disease,
chronic arterial hypertension, diabetes mellitus, thrombophilia.
Pathogenesis of preeclampsia
 pathogenesis of preeclampsia

The following disturbing factors in patients with PE have been

identified:
• generalized vascular spasm following endothelial dysfunction
and accompanied by hypovolemia,
• disorder of rheological and coagulation properties of the
blood, which results in (sometimes critical) reduction in
perfusion of vital organs and the placenta.
 Pathophysiology of hypertension
in preeclampsia

ü It is thought to be related to a mechanism of reduced

placental perfusion inducing systemic vascular endothelial
dysfunction.
ü This arises due to a less effective cytotrophoblastic invasion
of the uterine spiral arteries.
ü The resultant placental hypoxia induces a cascade of
inflammatory events, disrupting the balance of angiogenic
factors, and inducing platelet aggregation, all of which result
in endothelial dysfunction manifested clinically as the
preeclampsia syndrome.
 CLINICAL FEATURES

• Stable edema
• Proteinuria
The Zangemeister
• Arterial Classical Triad (1913)
hypertension
 CLINICAL FEATURES

Edema is an early PE sign. It is classified in the following way:

• invisible edema (abnormal weight gain by 500 g and more within a
week, positive ring symptom, nocturia, decrease in diuresis below 900–
1000 ml while fluid intake is 1400–1500 ml);
• visible edema divided into stages:
– stage I: edema of upper and lower extremities;
– stage II: edema of upper and lower extremities, abdominal wall;
– stage III: edema of upper and lower extremities, abdominal wall and
face;
– stage IV: anasarca.
 CLINICAL FEATURES

• Arterial hypertension (at systolic BP ≥140 and/or

diastolic BP ≥90 mm Hg) is a sign developing during
pregnancy or in the first 24 hours after delivery in
women with previously normal BP.

• Proteinuria is not considered abnormal until it

reaches or exceeds 0.3 g/day or 0.3 g/l in three
samples obtained at an interval of 4 hours.
 Criteria for diagnosing severe PE

– systolic BP >160 mm Hg, diastolic BP >110 mm Hg after two measurements

– made within 6 hours;
– proteinuria >5g/day;
– oliguria <500 ml/day (or less than 30 ml/h);
– neurological and/or vision disorders (persistent headache, hyperreflexia, nausea
– and vomiting);
– pulmonary edema / cyanosis;
– epigastric / right subcostal pain;
– extensive edema (especially of sudden origin);
– hepatic dysfunction of unknown origin: increased alanine aminotransferase
– (ALT) and aspartate aminotransferase (AST) over 70 IU/l;
– thrombopenia <100×109/l;
– pronounced hypoproteinemia <50 g/l;
– serum creatinine >90 mcmol/l;
– fetal distress: fetal growth restriction stage II and more, reverse outflow in
– umbilical artery; areactive non-stress test, pronounced oligohydramnios.
 Diagnosis

Laboratory and instrumental investigations of patients with PE

Obligatory investigations:
• register the changes in body weight;
• BP and pulse on both arms;
• measuring the fluid balance (intake, ml; diuresis, ml);
• complete blood count;
• urinalysis;
• daily loss of protein with urine;
• bloodbiochemistry(total protein, albumin, urea, glucose, electrolytes,
creatinine, residual nitrogen, uric acid, cholesterol, conjugated and
unconjugated bilirubin,
• ALT, AST, alkaline phosphatase, triglycerides).
 Diagnosis

• Additional investigations:
– daily BP monitoring;
– hemostasiogram (thromboelastography, APTT, platelet count and
aggregation,
– fibrinogen and its degradation products, endogenous heparin
concentration,
– antithrombin III);
– ultrasound of mother’s vital organs;
– ultrasound fetometry;
– CTG;
– dopplerometry of maternal and fetal hemodynamics;
– ocular fundus examination;
– lupus anticoagulant;
– ECG.
 THERAPY OF PREECLAMPSIA

• The only radical treatment of preeclampsia is delivery; thus

all other methods are aimed at curbing the progress of PE
and preventing eclampsia.
• Patients with severe PE and eclampsia should be
hospitalized at specialized obstetric departments within the
framewok of a multifield hospital with facilities for
resuscitation and special neonatal care, or at perinatal
centres.
 Drug therapy

• According to meaningful empirical data, only two variants of

symptomatic treatment can be recommended at present:
anticonvulsant and antihypertensive therapy.
• Magnesium sulfate is recommended as the only first line drug in the
treatment of eclampsia, prevention of eclampsia in women with
severe PE, and in women with moderate PE.
• The following regimens of administering magnesium sulfate are
effective: loading dose of magnesium sulfate 4 g over 5–10 min
administered with an infusion pump; after that the dose is 1 g/h for 24
hours. Patients with severe PE and preterm pregnancy should
continue the therapy until delivery, during delivery and 24 hours
postpartum.
• Recurring attacks require bolus infusion of 2 g magnesium sulfate or
increase in the rate of infusion to 1.5–2.0 g/h; alternative medications
like diazepam, sodium thiopental can be administered additionally.
Method of administration of magnesium sulfate

Infusomat
 Antihypertensive therapy:

• According to recommendations by European Society of

Hypertension/European School of Hematology (ESH/ESH) (2013), it is
expedient co consider the issue of pharmaceutical therapy for all pregnant
women with BP >150/95 mm Hg.
• First line. Methyldopa (Dopegit), a central α-adrenomimetic (methyl
tyrosinederivative). Initial dose 250 mg/day, every 2 days the dose is
increased by 250 mg/ day. Maximum daily dose is 2.5 g.
• Second line. Dihydropyridine calcium antagonists, preferably of prolonged
• action: nifedipine (Cordipine retard, Corinfar retard, Cordaflex) 30–40
mg/day.
• Third line. Β-adrenergic blockers: metoprolol (Betaloc, Metocard, Egiloc,
Corvitol) 25–100 mg/day.
 Antihypertensive drugs for rapid BP decrease

– Dihydropyridine calcium antagonists: nifedipine (Cordipine, Corinfar).

Initial dose 10 mg (never place under the tongue or chew!); it is
repeated in 15 min thrice to bring down diastolic BP to the range 90–
100 mm Hg (maximum dose is 60 mg). If this is ineffective, the
antihypertensive drug is replaced or supplemented by another one.
Maximum daily dose is 120 mg.
– Β- adrenergic blockers: metoprolol (Metoprolol-Akri, Betaloc,
Metocard, Egiloc) 50–100 mg/day (avoid their administration in
bronchial asthma).
– Clonidine (Clofelin, Hemiton), central α-adrenomimetic (imidazoline
derivative) 0.15 mg thrice a day or IV slow infusion 100 mcg
dissolved in 10 ml of 0.9% sodium chloride solution for 1 min, thrice
a day.
 Antihypertensive drugs for rapid BP decrease

– Dihydropyridine calcium antagonists: nifedipine (Cordipine, Corinfar).

Initial dose 10 mg (never place under the tongue or chew!); it is
repeated in 15 min thrice to bring down diastolic BP to the range 90–
100 mm Hg (maximum dose is 60 mg). If this is ineffective, the
antihypertensive drug is replaced or supplemented by another one.
Maximum daily dose is 120 mg.
– Β- adrenergic blockers: metoprolol (Metoprolol-Akri, Betaloc,
Metocard, Egiloc) 50–100 mg/day (avoid their administration in
bronchial asthma).
– Clonidine (Clofelin, Hemiton), central α-adrenomimetic (imidazoline
derivative) 0.15 mg thrice a day or IV slow infusion 100 mcg
dissolved in 10 ml of 0.9% sodium chloride solution for 1 min, thrice
a day.
 Eclampsia

is emergence of one or two cramps that are not

associated with other manifestations of cerebral
disorder (epilepsy or insult) in patients with PE.

Four stages are distinguished in the clinical course

of eclampsia:
• fibrillary tremor of muscles;
• tonic convulsions;
• clonic convulsions;
• resolution of the attack.
 Algorithm of management
of developing eclampsia attack

Immediately after a convulsive attack the following is

done:
• clear the mouth and larynx with an aspirator, if needed;
start magnesium sulfate therapy at once:
– initial dose 4–6 g of dry substance (20 ml of 25% solution)
IV slow stream infusion for 5–10 min;
– if seizure reoccurs, IV infusion of 2 g of magnesium
sulfate for 5 min;
– maintaining dose 1–2 g/h through an infusion pump;
if the above fails, IV administration of 0.5% diazepam
(seduxen) solution 2.0 ml or barbiturates (sodium thiopental
in a dose of 0.2–0.3 g);
 Algorithm of management
of developing eclampsia attack

• register vital parameters (heart rate, BP, oxygen saturation)

continuously with a
• monitor or every 5 min:
– CTG continues only after the seizure is over;
– drain the bladder with Foley catheter; it is left in the bladder
until diuresis returns to normal.

!!! Eclampsia is an indication for emergency

delivery. However, one must first of all stabilize the
woman’s condition over one to three hours.
 ALGORITHM OF LABOR MANAGEMENT IN
PREGNANT WOMEN WITH PREECLAMPSIA

• At gestational age under 34 weeks, when there is an option

to postpone the delivery, one should administer
glucocorticoids for prevention of fetal respiratory distress,
and assess the effect of conservative treatment in 24 hours.
• At preterm age conservative treatment may improve the
perinatal outcome; however, this should be weighted
against the risk for the mother.
• The mode of delivery depends on fetal presentation, its
condition and maturity of the birth canal.
• The decision about delivery is made when the patient is in a
stable condition, in the presence of senior obstetric
personnel.
 ALGORITHM OF LABOR MANAGEMENT IN
PREGNANT WOMEN WITH PREECLAMPSIA

Upon admitting the patient to the delivery department, one performs the
following procedures:
• summon the responsible obstetrician-gynecologist on duty, intensive care
specialist, neonatologist;
• fill out the intensive surveillance chart;
• provide the intravenous access: peripheral vein catheterization (18G);
• BP monitoring: at moderate arterial hypertension once an hour at least, at
severe hypertension — continuous monitoring;
• continue antihypertensive and anticonvulsant therapy (if it was initiated
earlier) at previous doses, and adjust them according to indications;
• provide adequate analgesia of labor (pharmaceutical analgesia as
indicated). The gold standard of analgesia is epidural nerve block;
• perform early amniotomy;
• do not routinely limit the duration of the second stage of labor if the
mother’s and fetus’s condition is stable.
 POSTPARTUM PERIOD MANAGEMENT

• A puerpera with moderate and severe PR should be

closely followed up by experienced personnel in intensive
care unit (at least for 24 hours) or until her general
condition and BP stabilizes.
• Oxytocin infusion is continued into the early postpartum
period as there is a high risk for hemorrhage.
• Depending on the BP level, antihypertensive therapy and
magnesium sulfate therapy are continued after delivery
until stable water balance and BP readings are achieved.
 PREVENTION OF PREECLAMPSIA

• According to ESH/ESH recommendations (2013), aspirin

(acetylsalicylic acid) intake at a dose of 75 mg/day
starting at 12 weeks gestation and until delivery can be
recommended to women with a high PE risk (arterial
hypertension in previous pregnancies, chronic renal
disease, diabetes mellitus, chronic arterial hypertension).
• Calcium in the form of food supplements is
recommended at a dose of up to 1 g daily (if the woman
does not get enough calcium in her meals).
 ЗАНЯТИЕ ЗАВЕРШЕНО
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