Definitions

 Hypertension in pregnancy:

 Bl/P of 140/90 or more is abnormal.

 If there is a rise of 30 mmHg or more in the systolic blood

pressure or 15 mmHg or more in the diastolic blood
pressure In 2 occasions 6 hours apart.

 Mean arterial BP> 105 mmHg .

Systolic + 2 Diastolic
Mean arterial BP = -----------------------------
3
Classifications
 National High Blood Pressure Education
Program Classification ( NHEP) 2000

 Gestational hypertension.
 Preeclampsia (mild, severe).
 Eclampsia.
 Superimposed preeclampsia upon
chronic hypertension.
 Chronic hypertension with
pregnancy.
 Definitions
 Gestational hypertension:
 Hypertension for first time after 20 w, without
Proteinuria. BP returns to normal before 12 weeks
postpartum.

 Chronic hypertension with pregnancy:

 Hypertension antedates pregnancy and detected
before 20 w, & lasts more than 12 weeks postpartum.
Definitions
 Preeclampsia:
 The development of hypertension and Proteinuria
after 20 w
 May occur earlier in vesicular mole or twins.

 Eclampsia (in Greek= Flash of light):

 The occurrence of convulsions (without any
neurological disease) in a woman with pre-eclampsia.
 Definitions

 Superimposed pre-eclampsia:
¤ It is the new development of Proteinuria
after 20 weeks gestation in a patient with
chronic hypertension
 Definitions
 Proteinuria:
 ≥ 300mg/24 hours urine.

 Heavy Proteinuria :
 = ≥ 2gm/24 hours
Preeclampsia
Epidemiology

Risk factors:
 Chronic hypertension.
 Chronic nephritis.
 Past history .
 Family history.
 Obesity.
 Multiple pregnancy.
 Epidemiology ( risks)
 Diabetes mellitus.
 Nulliparity.
 Teenage Pregnancy.
 Smoking.
 Stress
Multisystem Features Of
Preeclampsia
Hypertension Proteinuria

Systemic blood vessels Kidneys

Multi-organ disease
Cerebral vessels Liver

Eclampsia HELLP syndrome

Fetus

Intra-uterine growth restriction

A): Signs : :

it is a disease of signs :
2 cardinal signs + or - Edema:
 Hypertension:
 usually precedes Proteinuria,
 Proteinuria: detected by
 Boiling test.
 Quantitative assay.
+ or - Edema
 The lower extremities.
 Abdominal wall, vulva or may be generalized
anasarca.

 usually after hypertension.

Peripheral edema is not a
useful diagnostic criterion

1) it is common in normal pregnancy.

2) PE can occur without edema (dry type).

so its presence does not ensure a poor prognosis

and its absence not ensure a favorable outcome.
 B) Symptoms (non specific):

 Headache.
 Blurring of vision.
 Nausea and vomiting.
 Epigastric pain (distension of the liver capsule)
 Oliguria or anuria
 Severity Of Pre-eclampsia

 The severity of pre-eclampsia is assessed by:

 The frequency and intensity of the
signs and symptoms.

 The more the severity of PET, the

more likely is the need to
terminate pregnancy.
 Classifications of Eclampsia

 Ante partum (65%) with the best

prognosis.
 Intrapartum (20%).
 Postpartum (15%) with the worst
prognosis as it indicates extensive
pathology and multisystem damage..
 Classifications of Eclampsia
1)Mild
2) Severe (Eden's criteria):
 Coma > 6 hours.
 Temperature > 39 (pneumonia or pontine hge)
 Systolic Bp > 200 (risk of cerebral hge)
 Pulse > 120/min ( acute heart failure).
 Anuria or Oliguria( renal failure).
 Respiratory rate > 40/min( pneumonia)
 More than 10 fits (status eclampticus).
 Investigations

 A. Laboratory:
 Urine: 24 hour urine, Proteinuria.
 Kidney functions: serum creatinine, urea, creatinine
clearance and uric acid.
 Liver functions: bilirubin, Enzymes
 Blood: CBC, HCt , Hemolysis and Platelet count
(Thrombocytopenia).
 Coagulation Profile: Bleeding and clotting time
 Investigations

B. Instrumental
 Fundus Examination .
C. Imaging techniques :
 CT scan for the brain.
 Ultrasonograghy .
E. Doppler .
 Treatment
 PREVENTION.
 Antepartum ttt.
 Proper antenatal care
 Expectant treatment.
 Control hypertension.
 Treatment of eclampsia .
 Prevention and control of convulsions.
 Termination of pregnancy .
 Intrapartum care.
 Postpartum care.
Prevention
Prevention

 Low dose aspirin: 75 mg/day.

 Decrease TxA2 (from Platelets).
 Not affect endothelial prostacyclin
(PGI2 )
 Calcium supplementation:
 Ca++ supplementation may increase
the production of prostacyclin (PGI2 )
from endothelial cells.
TTT of preeclampsia

 Expectant Treatment .
 Control of Hypertension.
 Prevention of convulsions .
 Termination of pregnancy .
1) Expectant Treatment
 Rest: Complete Physical and mental rest.
 Diet: Increase protein and carbohydrate with
low Na diet !!!!!.
 Sedation AND TRANQULIZER:
Phenobarbitone & DIAZEPAAM.
 Observation ( MATERNAL & FETAL).
1) Expectant Treatment
(Observation)
 Maternal:
 Blood pressure.
 Pulse and Respiratory rate.
 Urine output.
 Proteinuria.
 Any new symptoms.
 Investigations (creatinine, creatinine clearance,
blood picture, coagulation profile,….)

 Fetal:
fetal well-being
 Treatment of Eclampsia
 1) General and first aid measures( A &B &C &D
…………cont )
 Ensure patent airway with tracheal and
bronchial suction.
 Put the patients in Trendlenburg position (to
avoid aspiration of secretions) .
 Insert a catheter.
 Nasogastric tube may be inserted .
 Nothing by mouth and fluid chart.
 Full laboratory investigation.
 Treatment of Eclampsia
 2) Observation:
 Pulse, temperature, BP
and RR.
 Level of consciousness.
 Duration of coma.
 Fetal heart sounds.
 Urine output and albuminuria .

 Number of convulsions
 4) Control of
Convulsions:
 A) Magnesium Sulfate (MgSO4):
 It is the drug of choice.
 Mechanism:
 CNS depression.
 Mild VD.
 Mild diuresis.
 Inhibits platelet aggregation.
 Increase PGI2 synthesis.
 Magnesium Sulfate (MgSO4):

 It can be given IV (20%) or IM (50%) or SC (15%):

 The therapeutic level is 4-7mEq/L.
 The total dose of MgSO4 should not exceed 24 gms in 24
hours .
 The dose of MgSO4 is monitored by:
 Preserved patellar reflex.
 Respiratory rate >16/min.
 Urine output >100ml/4hours.
 Serum Mg++ level.
 Is stopped 24 hours after delivery.
N.B Antidote is ca gluconate
 Magnesium Sulfate (MgSO4):
 IV regimen:
 initially 4-6 gm (20%) in 100ml solution .
 Given over 15-20 minutes.
 Then, 2 gm/hour by IV drip.
 IM regimen:
 10 gms of 50% solution are given deeply IM (5 gms
in each buttock).
 Maintain with 5 gm/6 hours of 50% solution.
Side effects of MgSO4 (small safety
margin)
 At a level of 8-10mEq/L patellar reflex is lost and starts
myometrial inhibition.
 10-15mEq/L respiratory depression.
 >15mEq/L cardiac depression.
 Curare like action.
 Synergistic effect with Ca++ channel blockers.
 Uterine inertia.
 Neonatal hypermagnesemia.
 Decreased beat to beat variability in FHS.
Antidote : 10ml of 10 percent calcium gluconate
4) Control of Convulsions:

 C) Diazepam (Valium):
 This regimen is mainly for eclamptic patients.
 Initially 20-40mg IV slowly over 5 minutes.
 then 10-20mg/6hours.
 then the dose is adjusted at 10mg/hour to
maintain drowsiness.
 Treatment of Eclampsia
8) Management during labor:
 With the onset of labor give IV hypotensives and
sedation.
 The patient must be at rest with oxygen source
and other equipments for treating fits.
 Maternal observation.
 Continuous electronic fetal monitoring.
 Treatment of Eclampsia
9) Postpartum management
 Improvement is monitored by:
 Increased urine output.
 Decreased edema.
 Disappearance of Proteinuria within 1 week
 Decreased hemotocrite value to normal level.
 BP normalize within 2 weeks
 No ergometrine postpartum.
 MgSO4 stopped 24 hours postpartum.
 Prognosis:
 BP usually normalize after placental delivery .
 Hypertension may persist.
 Postpartum eclampsia carries the worst
prognosis.
 Maternal mortality is about 2% in severe
preeclampsia and 10% in eclampsia.
 Perinatal mortality rate is about 5% in mild
cases, 25% in severe cases and 30% in eclampsia.