obstetrics & gynecology,

1. Zahid ullah
Roll no 08-216
BATCH “L”

2. Introduction
1. Hypertensive disorders of
pregnancy are leading causes of
maternal mortality.
2. Worldwide: 50,000 women die each
year.

3. 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

4. Classifications

5. National High Blood Pressure Education
Program Classification ( NHEP) 2000
 Gestational hypertension.
 Preeclampsia (mild, severe).
 Eclampsia.
 Superimposed preeclampsia upon
chronic hypertension.
 Chronic hypertension with
pregnancy.

6. 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.

7. 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.

8. Definitions
 Superimposed pre-eclampsia:
¤ It is the new development of Proteinuria
after 20 weeks gestation in a patient with
chronic hypertension

9. Definitions
 Proteinuria:
 ≥ 300mg/24 hours urine.
 Heavy Proteinuria :
 = ≥ 2gm/24 hours

10. Preeclampsia

11. Epidemiology
Risk factors:
 Chronic hypertension.
 Chronic nephritis.
 Past history .
 Family history.
 Obesity.
 Multiple pregnancy.

12. Epidemiology ( risks)
 Diabetes mellitus.
 Nulliparity.
 Teenage Pregnancy.
 Smoking.
 Stress

13. Multisystem Features Of
Preeclampsia
Hypertension Proteinuria
Eclampsia HELLP syndrome
Intra-uterine growth restriction
Multi-organ disease
Cerebral vessels
Fetus
Liver
Systemic blood vessels Kidneys

14. A): Signs: :
it is a disease of signs :
2 cardinal signs + or - Edema:
 Hypertension:
 usually precedes Proteinuria,
 Proteinuria: detected by
 Boiling test.
 Quantitative assay.

15. + or - Edema
 The lower extremities.
 Abdominal wall, vulva or may be generalized
anasarca.
 usually after hypertension.

16. 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.

17. B) Symptoms (non specific):
 Headache.
 Blurring of vision.
 Nausea and vomiting.
 Epigastric pain (distension of the liver capsule)
 Oliguria or anuria

18. 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.

19. 4) Diagnosis Of Eclampsia:
 Eclamptic fit stages ( 4 stages):
 Premonitory stage (1/2 minute):
 Eye rolled up.
 Twitches of the face and hands.
 Tonic stage (1/2 minute):
 Generalized tonic spasm with episthotonus.
 Cyanosis.
 Tongue may be bitten between the clenched
teeth.

20. 4) Diagnosis Of Eclampsia:
 Clonic stage (1-2 minutes):
 Convulsions .
 Tongue may be bitten.
 face is congested and cyanosed.
 conjunctival congestion.
 blood stained froth from the mouth,
 Stertorous breathing,
 temperature may rise.
 involuntary passage of urine or stool.
 Gradually convulsions stop.

21. 4) Diagnosis Of Eclampsia:
 Coma:
 Variable duration due to respiratory and metabolic
acidosis.
 Deep coma may occurs (cerebral hemorrhage).
 Labor usually starts shortly after the fit.

22. 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..

23. 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).

24. 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

25. Investigations
B. Instrumental
Fundus Examination .
C. Imaging techniques :
CT scan for the brain.
 Ultrasonograghy .
E. Doppler .

26. VI. Differential Diagnosis:
 A. Hypertension With Pregnancy.
 B. Proteinuria With Pregnancy.
 C. Edema With Pregnancy:

27. VI. Differential Diagnosis:
D. Convulsions With Pregnancy:
 Eclampsia.
 Epilepsy.
 Hysteria.
 Meningitis and Encephalitis.
 Tetanus.
 Tetany.
 Strychnine poisoning.
 Brain tumors.
 Uremic convulsions

28. VI. Differential Diagnosis:
E. Coma With Pregnancy:
 Hypoglycemic .
 Hyperglycemic coma
 Uremic coma.
 Hepatic coma.
 Alcoholic coma.
 Cerebral coma.

29. VI. Differential Diagnosis:
F. HELLP Syndrome:
 Acute fatty liver in pregnancy.
 Hepatitis.
 Thrombocytopenia purpura.
 Hemolytic Uremic syndrome.

30. 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.

31. PreventionPrevention
 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.

32. TTT of preeclampsia
 Expectant Treatment .
 Control of Hypertension.
 Prevention of convulsions .
 Termination of pregnancy .

33. 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).

34. 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

35. 2) Control of
Hypertension:
 A)Parentral drugs:
 1) Hydralazine:
 It is a peripheral VD.
 The best Antihypertensive drug used during Pre-
eclampsia and Eclampsia.
 Dose: 5-10mg IV or IM as initial dose.
 Repeated every 20-30 minutes until blood
pressure is controlled.

36. 2)Control of
Hypertension: 2) Labetalol (Trandate):
 α and non selective β- adrenergic blocker resulting in
VD.
 Dose: 10-20mg IV .
 The dose can be doubled every 10 minutes if proper
response is not achieved.
 3) Diaz oxide (Hyperstat):
 Used in severe dangerous resistant hypertension as a
last resort.
 Dose: 50-150mg IV bolus dose.
 Repeated every 1-2 minutes until BP decreases.

37. 2)Control of
Hypertension: A )Oral drugs:
1) α-methyl DOPA (aldomet):
 It is the most commonly used.
 It is α-adrenergic agonist causing depletion of
catecholamine stores.
 Dose: 500mg 3-4 times/day orally.

38. 2)Control of
Hypertension: 3) β- adrenergic blockers:
 Atenolol (tenormin) 50-100mg 4 times daily.
 Labetalol (Trandate) 10-20mg 3 times daily.
 4) Prazocin (minipres):
 It is postsynaptic α-adrenergic receptor blocker
resulting in VD and reflex tachycardia.
 It is a weak Antihypertensive drug so used in
combination with other drugs.
 5) Calcium Channel Blocker:
 Nifedipine (adalat or Epilat) .

39. TTT of Preeclampsia
3)Prevention of convulsions .
4)Termination of pregnancy

40. 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.

41. 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

42. 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.

43. 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

44. 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.

45. 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

46. 4) Control of Convulsions:
 B ) Phyntoin (Epanutin):
 In severe pre-eclampsia
 In imminent eclampsia .
 The dose is 15mg/kg.

47. 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.

48. Treatment of Eclampsia
 7)Termination of Pregnancy
 Indications:
 Eclampsia.
 Retinal hemorrhage:
 Deteriorated cardiac, renal or liver functions.
 Severe PET not controlled after 24 hours.
 Mild PET reaching 38 weeks and not controlled.
 Expectant treatment reaching maturity.
 Deterioration of the fetal conditions.
 Other obstetric indications as CPD, malpresentations, APH,
…

49. 7)Termination of Pregnancy
 Methods:
 As a rule vaginal delivery is safer and better than CS.
 Artificial rupture of membranes .
 CS.

50. 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.

51. 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.

52. 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.