Pre-eclampsia

2. PRE- ECLAMPSIA & ECLAMPSIA

3. GOALS
1. Understand the definition and classification
of hypertensive disease in pregnancy
2. To identify and diagnose severe
preeclampsia/eclampsia
3. Management of severe
preeclampsia/eclampsia patient

4. DEFINITION
BP ≥ 140/90 mmHg on at least 2 occasions,
taken at least 15 minutes apart
Severity
Severity BP range
Mild 140 – 149/90 – 99 mmHg
Moderate 150 -159/100 – 109 mmHg
Severe Systolic BP of  160 mmHg; Diastolic BP of  110 mmHg (2 readings
at 15 minutes interval);
Hypertensive emergency when systolic BP  180 mmHg

5. CLASSIFICATION
International Society of Study of Hypertension in
Pregnancy (ISSHP) 2018
Classification Characteristics
1) Gestational hypertension HPT ≥ 20weeks; without significant proteinuria or other
characteristics that define proteinuria
2) Preeclampsia Hypertension ≥ 20weeks; with significant proteinuria or other
other characteristics that define preeclampsia
Pre-eclampsia can be de novo or superimposed on chronic
hypertension
3) Chronic hypertension HPT < 20 weeks @ before pregnancy
4) Unclassified hypertension HPT >20 weeks with no BP recorded before 20 weeks
5) White-coat hypertension Office/clinic BP is elevated but home BP monitoring is
normal
6) Masked hypertension Normal BP in clinic but HBPM/ABP monitoring is abnormal
7) Transient hypertension Elevated BP due to environmental stimuli and pain

6. PREECLAMPSIA
A multisystem disorder
Develops after 20 weeks of gestation
With
Hypertension ≥ 140/ 90 (2x readings 4 - 6 hours apart with rest in
between)
With or without
Proteinuria Urine dipstick for protein : ≥ 2+
24 hour urine albumin ≥ 300 mg

7. PROTEINURIA IS NO LONGER REQUIRED TO DIAGNOSE
PRE-ECLAMPSIA
OTHERS:
PULMONARY OEDEMA
PLACENTA ABRUPTION
OLIGURIA
EPIGASTRIC /RHC PAIN

8. Complications of PE/Severe features
Maternal
Complications
Hypertension
Risk of Cerebrovascular accident e.g. stroke
Pulmonary oedema
Renal failure
Liver failure as part of HELLP syndrome
DIVC
Placenta abruptio
Eclampsia (Risk of aspiration pneumonia)
Maternal death
Fetal
Complications
Prematurity
IUGR
IUD
Acute fetal distress

9. Assessment of PE with severe features
History
◦ Headache
◦ Blurring of vision
◦ Epigastric pain
◦ Potential complications from severe PE
◦ Shortness of breath
◦ PV bleeding and abdominal pain to suggest abruption
◦ Fetal movement
Examination including
◦ BP & PR; General examination – CVS, Lungs, Abdomen
◦ Reflexes (Brisk)

10. Investigations
Blood Urine
1) FBC (esp. platelet)
2) BUSE
3) Se Creatinine & Uric
acid
4) LFT
5) PT/APTT
6) Group & Save (GSH)
1) Urine albumin/protein (dipstick or UFEME)
*24h urine collection – usually done if urine
albumin + or 2+ (not needed if clear cut PE)
Assessment of PE with severe features

11. Principle of management
◦ Control BP (anti-hypertensives)
◦ Prevent/control seizures (MgSO4)
◦ Maternal and fetal monitoring
◦ Fluid management
◦ Decide on mode & timing of delivery

12. 1. Control BP
Severe hypertension
◦ Systolic BP ≥ 160 mmHg; medical emergency if SBP ≥ 180 mmHg
◦ Diastolic BP ≥ 110 mmHg
Persistent hypertension
◦ BP ≥ 140/90 mm Hg
Severe hypertension Persistent HPT
IV labetalol
IV hydralazine
IV GTN
T. Nifedipine
T. Labetalol
T. Methyldopa
T. Nifedipine

13. General principles of BP control
Oral Nifedipine and IV labetalol are the agents of choice when BP ≥
160/110 mmHg
• When SBP ≥ 180 mmHg, IV labetalol is preferred
• IV hydralazine is used when IV labetalol fails to control BP or contraindicated
for labetalol
• IV GTN in cases of resistant hypertension
Lower BP to non-severe level; NOT normalization of BP
• Target BP 140 – 159/90 – 109 mmHg
• Avoid maternal hypotension
Close fetal monitoring during BP control
• Continuous CTG/FHR monitoring every 5 minutes

14. 2. Prevent/control seizure
Seizures usually occurring in women with PIH/PE not due to
other causes (e.g. epilepsy, brain tumour)
Any seizures occurring in pregnancy is usually treated as
eclampsia until proven otherwise
◦ Antenatally 38%
◦ Intrapartum 18%
◦ Postpartum 44% (especially the first 24 hours)

15. Seizures are usually self limiting
MGSO4 is the anticonvulsant of choice
◦ Both in controlling as well as in preventing seizure
◦ IV diazepam is NOT the drug of choice unless MgSO4 is
not available.
Avoid poly-pharmacy to treat seizures, as this
increases the risk of respiratory arrest

16. Management for Eclampsia
Do not leave patient alone
Call for HELP
DR ABC—left lateral position, if supine, turn the patient’s head to
the side
◦ Airway (e.g. oropharyngeal airway, prevent tongue biting)
◦ Breathing
◦ Circulation
Obtain IV access (2x, large bore (14-16G))
Control seizure – MgSO4
Control HPT
Deliver once stable

17. Management of recurrent seizures
Seizure continues or recurs
◦ Give a 2nd bolus dose of MgSO4 at the dose of 2 – 4g
◦ Over 10 to 15 minutes
◦ Check deep tendon reflex & RR before repeating dose
◦ Serum Mg can be checked before the repeat dose if
condition allows

18. Management of recurrent seizures
What if seizures continues despite further bolus dose of
MgSO4?
• Options include: DIAZEPAM (10mg) or IV THIOPENTONE
50mg
• Intubation then becomes necessary in such women to protect
the airway and ensure adequate oxygenation.
• FURTHER SEIZURES SHOULD BE MANAGED BY INTERMITTENT
POSITIVE PRESSURE VENTILATION AND MUSCLE RELAXATION
(anaesthetist)
• CT Scan Brain to assess for intracerebral bleeding

19. 3. Maternal monitoring
Parameters Interval of monitoring Target
Blood Pressure 15 minutes 140 – 150/90 – 109 mmHg
Pulse rate 15 minutes  60 bpm
Respiratory rate Hourly  16 breaths per minute
Urine output Hourly  30 ml/H or  100 ml/4 hours
Deep tendon reflex
of knee
Hourly Presence of reflexes
*Monitoring of magnesium level is NOT routine in women receiving MgSO4.
However, if there is suspicion of magnesium toxicity, the Mg level should be checked

20. Management of MgSO4 toxicity
Urine output <100ml/4hr @ <30mls/hr
◦ Assessment for hydration status and lungs examination; check
reflexes and respiratory rate
◦ Send renal profile and magnesium level (if available)
◦ May challenge with 250cc of Hartman solution
◦ If no clinical signs of magnesium toxicity, reduce rate to
0.5gm/hrs
Absent patellar reflexes
◦ Stop MgSO4 infusion
◦ May resume if patellar reflexes return

21. Respiratory depression
◦ Stop MgSO4 infusion
◦ Maintain airway, nurse patient in recovery position and monitor
closely
Respiratory arrest / Cardiac arrest
◦ Resuscitate---CPR, intubate and ventilate immediately
◦ Stop MgSO4 infusion
◦ ANTIDOTE : IV Calcium gluconate
10% Calcium Gluconate 10ml IV over 10 minutes
Management of MgSO4 toxicity

22. Other parameters of monitoring
 Designate one to one midwifery care
 Transfer to Labour Ward when stable
MATERNAL FETAL
- SYMPTOM
- BP, PR
- REFLEXES + CLONUS
- URINE PROTEIN
- URINE OUTPUT
-CTG
-ULTRASOUND
-DOPPLER (IF INDICATED)

23. 4.Management of fluid balance
BEWARE: Iatrogenic fluid overload in PE/ eclampsia
◦ Due to damage endothelial linings of the capillary - 3rd space
fluid loss
◦ Can cause pulmonary edema
Strict I/O chart
Maintain crystallloid fluid (N/S & Hartman)
◦ Total fluid/day : 83 mls/H (1ml/kg/H)
◦ Includes all fluid given (e.g IVD, IV drugs)
Diuretics--only if confirmed pulmonary oedema

24. 5. Delivery
Delivery is the ultimate treatment for PET
Delivery is decided based on:
◦ Patient’s condition (Clinical/Biochemical)
◦ Gestational age
In severe pre-eclampsia or eclampsia, the definitive
treatment is delivery
◦ However, it is inappropriate to delivery an unstable
mother even if there is fetal distress.

25. If delivery to be delayed and gestation less than 34
weeks
◦ IM Dexamethasone 6mg 12 hours apart for 48 hours or
12 mg bd for 1 day
◦ Close monitoring
Either IOL @ Caesarean section depending on
situation
Avoid ergometrine in 3rd stage

26. Post delivery care
High dependency care for the first 24 to 48 hours
after delivery
One-to-one care
Anti-hypertensive reduce in a step-wise fashion
Close attention to fluid balance
Contraception and spacing
Future pregnancy plan- early booking & aspirin

27. Maintain vigilance as majority of eclamptic seizures
occur after delivery
Reduce anti-hypertensive medications as indicated
Repeat Investigations (FBC, clotting screen, liver
function test, urea and electrolytes) 6-12 hrly if
indicated

28. CARE DURING TRANSFER
EARLY REFERRAL
STABILIZE PATIENT
◦ To control and stop the fit with IV/IM MgSO4
◦ To secure airways
◦ To control BP
EQUIPMENT AND DRUGS
◦ Resuscitation equipment, MgSO4, Labetalol, Hydralazine, Diazepam,
anaesthetic drugs
MONITORING OF PATIENT AND BABY
◦ MgSO4 charting, Fluid balance, intermittent auscultations of fetal heart rate
PROPER DOCUMENTATIONS AND PASSOVER