Pre- Eclampsic Toxmaemia

HEO teaching Session

Obstetric and Gynaecology

Dr. Michael Kuri

Advanced Emergency Medicine Trainee finalist
O&G attachment 2022
Outline
 Hypertensive disorders in pregnancy
 PET definitions
 Incidence of PET in PNG and Madang
 Risk Factors
 Causes
 Pathophysiology
 Clinical features
 Complications
 Relevant investigation (bedside, laboratory, radiology)
 Management- resuscitative management, definitive management
Hypertensive disorders in Pregnancy
1. Pregnancy induced hypertension

2. Pre-eclampsia (PET)

3. Eclampsia

4. Pre-eclampsia superimposed on Chronic Hypertension

5. Chronic Hypertension
Definitions –Preeclampsia

1) BP: >140/90 on 2 occasions 4-6hrs apart

or >160/110 on one occasion
or incr from baseline >20-30 SBP / >10-15 DBP
**after 20 weeks of gestation

2) Proteinuria: >300mg/24hrs, 1+ on dipstick

3) Evidence of end organ damage

Evidence of end organ damage
 Renal Involvement: Cr ≥ 0.09 mmol, oligouria (≤120ml in 4hrs)
 Haematologic Involvement: Thrombocytopenia or Haemolysis
 Liver involvement: Elevated liver enzymes, severe epigastric pain
 Neurologic Involvement: Eclampsia,headaches,visual
disturbances,CVA
 Pulmonary edema
 IUGR
 Placental Abruption

**N.B. Proteinuria is not mandatory to conclude a clinical diagnosis

(Guidelines for Obstetric care, Labour Ward, PMGH, 2017)
Definitions
Pre-eclampsia (PET)
Eclampsia – PET + Convulsion

Pregnancy Induced hypertension

-like PET but NO Proteinuria, no end organ damage; BP normal
12 weeks post partum
Chronic Hypertension
- hypertension before 20 weeks/ persisted after12wks delivery
Pre-eclampsia superimposed on Chronic Hypertension
- new onset proteinuria 20 weeks gestation
- sudden inc proteinuria, inc BP, or PLT <100,000/mm3 before
20 weeks, for women who already had inc BP and proteinuria
 Risk factors
 Age  Pre-existing conditions
 >40 years of age  Chronic Hypertension

 Obstetric hx  Chronic Renal Disease

 Diabetes
 Previous Hx of PET
 CHD- Congenital Heart Diasase
 Previous hx of PIH
 Obesity BMI>35
 Primiparity
 Multiple pregnancy  Family Hx
Etiology –proposed mechanisms
1. Abnormal trophoblastic invasion of uterine vessels

2. Immunological intolerance between mother and feto-

placental tissue

3. Maternal maladaptation to cardiovascular or inflammatory

changes of pregnancy

4. Dietary deficiencies

5. Genetic influences
Normal placental flood flow
Pathophysiology-complications
1. Generalized vasospasm of due to hypoxia

2. Widespread increase in vascular permeability

3. Coagulopathy
Complications

 HAEMATOLOGICAL  CNS
 DIC  Eclampsia, Hypertensive crisis-
 HELLP syndrome SAH/ICH

 RESPIRATORY  CVS
 Acute pul.oedema  Hypertensive crisis
 LIVER
 FETAL CRISIS  Failure
 IUGR  RENAL
 FDIU
 Acute kidney failure
 Placental abruption  Oligouria
Principles of management
Antepartum monitoring
 All patients should be tested for proteinuria during their initial booking visit.

 Women with hypertension in pregnancy (BP≥140/90), should have an

immediate test for proteinuria.

 Elevated BP (BP≥140/90) + significant proteinuria (≥ +) with symptoms

require admission.

 Women with severe hypertension (SBP≥160, DBP≥110) with or without

symptoms require admission
Management
Established hypertensive disorder in pregnancy
Admit to ward
Resuscitative management
A, B, C
 Supportive management
Oxygen
IVC
IVF
Maternal and fetal monitoring
Investigations-Bedside, Laboratory, Imaging
Definitive management
MgSO4
Antihypertensive
Delivery
 Management
1. Confirm hypertensive disorder in pregnancy & gestational age
2. Admit to ward
3. Secure IVC: FBE, UECs, LFT, FBSL
4. Advice for strict Bed rest
5. Stabilize BP (SBP 130-150mmHg and DBP 80-100)
a) Hydralazine 5mg IVI PRN (if SBP ≥ 160mmHg or DBP ≥110mmHg)
• Administer bolus of 5mg IVI every 5min with 15min observations until BP is reduced
(SBP 140-150, DBP 80-90)
b) Commence Oral anti-hypertensive
• Aldomet 500mg PO TDS
• Nifedipine 20mg PO BD (optional/only as indicated)

6. If gestation ≤ 37/40, give dexamethasone 12mg IMI x 2 doses

7. QID Maternal and fetal observations
8. Induction of Labour at term (≥37/40 weeks)
9. Patients with severe hypertension and are symptomatic without
improvement on oral anti-hypertensives require MgSO4.
 Gestation ≤ 36/40 Gestation ≳ 37/40

Asymptomatic 1. Dexamethasone 12mg IMI x 1. Anti-hypertensives

2 doses 2. Induction of labour
2. Anti-hypertensives 3. MgSO4
3. D/C when BP stabilizes
4. Review at ANC

Symptomatic 1. Dexamethasone 12mg IMI x 1. Anti-hypertensives

2 doses 2. MgSO4
2. Anti-hypertensives 3. Induction of labour
3. MgSO4
4. Induction of labour if
symptoms persist
MgSO4
Mechanism of Action Prevents or controls seizures by blocking
neuromuscular transmission

Indications: • Eclampsia

• Antenatal MgSO4 administration at gestations

prior to 30/40 weeks may be used for fetal
neuroprotection.

Dosage: • Loading Dose: 14g (4g IVI Stat + 10g IMI Stat)
• Maintenance Dose (6hrs after LD): 5g IMI QID x
4 doses
 Preparation and administration of magnesium
sulphate
Using 10ml Syringe Using 20ml Syringe
 IVI dose: • IVI dose:
 2 x preparations • 1 x preparation
 MgSO4 4ml (2g) + Sterile water • MgSO4 8ml (4g) + Sterile water
6ml 12ml

 IMI dose: • IMI dose:

 2 x preparations • 2 x preparations
 MgSO4 10ml (5g) + Lignocaine • MgSO4 10ml (5g) + Lignocaine
(1%) 1ml (1%) 1ml
Administration
1. Secure cannula

2. Administer MgSO4 Loading Dose 14g

a. 4g IVI – slow infusion over 15-20min

b. 10 IMI stat – 5g IMI on right thigh + 5g IMI on left thigh

3. Insert IDC

4. Continue with Maintenance Dose MgSO4 5g IMI 6hrs after the loading
dose
 Definitions
 Risk factors
 Causes
 Pathophysiology
 Clinical features
 Complications
 Management (use of MgSO4 and delivery)
 References

 Edmonds K. (2007). Dewhurst’s Textbook of Obstetrics and

Gynecology (7th ed.). California: Blackwell Publishing.

 Gary Cunningham, et al (2007). Williams Obstetrics. The

McGraw-Hill Companies.

 Hayes J. (2014, June). Preeclampsia. James Hayes Guidelines.

 Richard Drake et al (2004). Gray's Anatomy for Students.

Elsevier Inc.