Best Practices in Management of

Severe Pre-Eclampsia/Eclampsia

Best Practices in Maternal and Newborn Care

Session Objectives

• Review incidence of pre-eclampsia/eclampsia

and relation to maternal and perinatal mortality
• Discuss best practices for diagnosing and
managing pre-eclampsia and eclampsia
• Describe strategies for preventing and treating
convulsions in eclampsia
• Describe strategies for controlling hypertension

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Magnitude of the problem

• Between 7-15% of pregnant women develop

preeclampsia
• Approximately 1-2% develop eclampsia
• Contribute between 8-25% of maternal mortality
• Increased risk of perinatal mortality:
– PE : RR 1.7-3.7
– E : RR 2.9-13.7

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 Penyebab Kematian Ibu dan BBL

others congenital anomaly unknown

post maturity 1% 4%
11% 3%
heamtologic
unknown disorder/icteric
5% 6%
hemorrhage
28% hypothermia
complications of 6%
puerperium
8% respiratory distress
36%
sepsis
obstetric emboli
3% 12%

prolonged labour
5%

abortion
eclampsia
5% infection 24%
11% premature
32%
http://www.who.int/publications/en/
Pre-Eclampsia

• Woman over 20 weeks gestation with:

– Diastolic blood pressure > 90 mm Hg AND
– Proteinuria
• Predisposes woman to develop eclampsia

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Mild Pre-Eclampsia

• Two readings of diastolic blood pressure 90-

110 mm Hg 4 hours apart after 20 weeks
gestation
• Proteinuria up to 2+
• No other signs/symptoms of severe pre-
eclampsia

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Severe Pre-Eclampsia

• Diastolic blood pressure > 110 mm Hg

• Proteinuria > 3+
Other signs and symptoms sometimes present:
• Epigastric tenderness
• Headache
• Visual changes
• Hyperreflexia
• Pulmonary edema
• Oliguria
Eclampsia: Typical Signs

• Convulsions occurring after 20 weeks

gestation in a woman without a previously
known seizure disorder. (Can also occur in
first few days postpartum.)
• Proteinuria 2+ or more
• Blood pressure 90 mm Hg or more:
– A small proportion of women with eclampsia
have normal blood pressure

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Strategies for Preventing Eclampsia

• Antenatal care and recognition of

hypertension
• Identification of patients with risk factors
• Identification and treatment of pre-
eclampsia by a skilled birth attendant
• Appropriate referral to proper level facility
3.4% of women with severe pre-eclampsia will have a seizure

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High Risk Populations

• Previous pre-eclampsia
• Chronic hypertension
• Renal disease
• Diabetes
• Autoimmune disease
WHO Recommendation 2011: Calcium

• In areas where dietary calcium intake is

low, calcium supplementation during
pregnancy (at doses of 1.5-2.0 g
elemental calcium/day) is recommended
to prevent pre-eclampsia in all women but
especially those at high risk of developing
pre-eclampsia
WHO Recommendation 2011: Aspirin

• Low dose aspirin (75 mgs) is

recommended to prevent pre-eclampsia
in women at high risk of developing the
condition
• Start before 20 weeks of pregnancy
General Management Principles

• All cases of severe pre-eclampsia at term

should be managed actively with urgent
delivery by either induction or cesarian.
• Symptoms and signs of “impending
eclampsia” are unreliable and expectant
management is not recommended.
• Magnesium sulfate administered
intravenously is recommended to prevent and
treat seizures
General Management Principles

• Maintain a strict fluid balance chart and

monitor the amount of fluids administered
and urine output to ensure that there is no
fluid overload.
• Catheterize the bladder to monitor urine
output and proteinuria.
Management during a convulsion

• Give anti convulsant drugs

• Gather equipment (airway, suction, mask and
bag, oxygen) and give oxygen at 4-6 L per
minute
• Protect the woman from injury but do not
actively restrain her.
Never leave the woman alone

• A convulsion followed by aspiration of vomit

may cause death of the woman and the fetus.
• Observe vital signs, reflexes and fetal heart
rate hourly.
• Auscultate the lung bases hourly for rales
indicating pulmonary edema.
Magnesium Sulfate Regimen

• Loading dose: Mag SO4 20% solution, 4 g IV

over 5 minutes.
• Follow promptly with 10 g of Mag SO4 50%
solution, 5 g in each buttock as deep IM
injection with 1 mL of 2% lignocaine in the
same syringe.
• If seizures recur, 2g MagSO4 solution IV over
5 minutes
Magnesium Sulfate Regimen

• Maintenance dose:
• 5 g MagSO4 50% solution plus 1 mL lignocaine
2% IM every 4 hours into alternate buttocks.
• Continue treatment with MagSO4 for 24 hours
after delivery or the last convulsion, whichever
occurs last.
Withhold or Delay Drug if

• Respiratory rate falls below 15 per minute.

• Patellar reflexes are absent
• Urinary output falls below 30 mL per hour
over preceding 4 hours
Keep antidote ready

• In case of respiratory arrest:

Assist ventilation.
Give calcium gluconate 1 g (10 ml of 10%
solution) IV slowly
Diazepam

• Not as effective as magnesium sulfate

• Greater risk of maternal and neonatal
respiratory depression
• Unless magnesium sulfate, no antidote
Evidence for Magnesium

• Magnesium sulfate for Eclampsia

prevention
• Placebo comparison: 6 trials (11,444
women), including the large Magpie trial
(10,141 women)
• RR 0.41, 95% CL 0.29-0.58
• No statistically significant differences in
respiratory arrest, need for calcium
gluconate
Magnesium Sulfate vs. Placebo in Women
with Pre-Eclampsia: Results

In women with severe pre-eclampsia,

eclampsia occurred 11 times less often in
women receiving magnesium sulfate than in
women receiving placebo

Source: Coetzee, Domisse and Anthony 1998.

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Magnesium vs. Diazepam (Valium)

• Magnesium sulfate for eclampsia

treatment
• 7 RCTS (1396 women); comparison:
diazepam
• Death: RR 0.59, 95% CL 0.38-0.92
• Recurrence of convulsions: RR 0.43, 95% CL
0.33-0.55
WHO Recommendation 2011

Magnesium sulfate is first line therapy for:

• prevention of eclampsia in women with
severe pre-eclampsia
• Treatment of women with eclampsia
WHO Recommendation 2011

• Full intravenous or intramuscular

magnesium sulfate regimens are
recommended
• For settings where it is not possible to
administer the full magnesium sulfate
regimen, the use of magnesium sulfate
loading dose followed by immediate
transfer to a higher level facility is
recommended
Use of Antihypertensive drugs

• If the diastolic pressure is 110 mm Hg or more,

give antihypertensive drugs.
• Goal: keep diastolic pressure between 90 and
100 mm Hg to prevent cerebral hemorrhage.
Hydralazine

• Hydralazine 5 mgs IV slowly every 5 minutes

until BP is lowered. Repeat hourly as needed.
Nifedipine

• 5 mgs under the tongue.

• If response inadequate, after 10 minutes,
give an additional 5 mgs under the tongue.
Labetolol

• Labetolol 10 mgs IV: if diastolic BP remains

above 110 after 10 minutes, give labetolol 20
mgs IV
• May increase dose to 40 mgs and then 80 mgs
if satisfactory response is not obtained after
10 minutes of each dose.
WHO Recommendation 2011 Hypertension

• Treat all women with severe hypertension

with antihypertensive drugs
• Choice of drug and route of
administration should be based primarily
on prescribing clinician’s experience, its
cost and local availability: usually
hydralazine, nifedipine
WHO recommends against:

• Bedrest at home for primary prevention of

pre-eclampsia
• Strict bedrest for improving outcomes of
PE/E
• Restricted dietary salt intake
• Vitamin C, D, E supplementation
• Diuretics
EMAS Messages

• Magnesium sulfate is drug of choice for

severe pre-eclampsia/eclampsia
• All puskesmas and hospitals should stock
magnesium sulfate
• Valium should NEVER be used for pre-
eclampsia/eclampsia unless it is the only
drug available
• All midwives should be trained and
competent to administer magnesium sulfate
Relative risk

Used to compare the risk of developing a disease, in

people not receiving the new medical treatment (or
receiving a placebo) versus people who are receiving
an established (standard of care) treatment. In a
simple comparison between an experimental group
and a control group:
• A relative risk of 1 means there is no difference in risk between
the two groups.
• An RR of < 1 means the event is less likely to occur in the
experimental group than in the control group.
• An RR of > 1 means the event is more likely to occur in the
experimental group than in the control group.