A discussion on preeclampsia its management and treatment.

3. The National High Blood Pressure Education Program (NHBPEP) Working
Group defines HYPERTENSION in PREGNANT WOMAN:
systolic blood pressure (BP) of 140 mmHg or higher
diastolic BP of 90 mmHg or higher
on more than 1 occasion

4. Multifactorial
3% of all pregnancies

5. Primiparity Immunologic factors Previous pregnancy complicated by
Preeclampsia/Eclampsia/HELLP
Family history of Preeclampsia BMI Pregnancy related conditions

6. Primipaternity Sexual co-habituation Maternal infection
Gestational age at delivery of 1st
Pregnancy Socioeconomic status Smoking

7. Stage 0
3-8 weeks
Stage 1
8-18 weeks
Stage 2
20 weeks to
birth
Poor Immunoregulation
Inadequate tolerance to feto-paternal antigens
during conception and implantation
Poor Placentation
Deficient trophoblast invasion and spiral artery
remodelling
Clinical manifestation
Over activation of maternal endothelium and
systemic inflammatory network
Oxidative Stress
Endoplasmic reticulum Stress
Inflammatory Stress

8. invasive cytotrophoblasts
of fetal origin invade the
maternal spiral arteries
transforms them from
small-caliber resistance
vessels to high-caliber
capacitance vessels
capable of providing
placental perfusion
adequate to sustain the
growing fetus
Normal Pregnancy

9. cytotrophoblasts fail to adopt an invasive
endothelial phenotype
invasion of the spiral arteries is shallow and they
remain small caliber, resistance vessels
placental ischemia
Preeclampsia

10. Soluble Flt-1 (sFlt-1) causes endothelial
dysfunction by antagonizing vascular
endothelial growth factor (VEGF) and
placental growth factor (PlGF)
In normal pregnancy, the placenta
produces modest concentrations ofVEGF,
PlGF, and soluble Flt-1
In preeclampsia, excess placental soluble
Flt-1 binds circulatingVEGF and PlGF and
prevents their interaction with endothelial
cell-surface receptors
decreased prostacyclin
nitric oxide production
release of procoagulant
proteins
ENDOTHELIAL
DYSFUNCTION

11. Faulty placentation
Excessive trophoblastsMaternal vascular disease
Reduced Uteroplacental Perfusion
Genetic/Immunologic/Inflammatory factors
Activation of CoagulationCapillary Leak
Endothelial Activation
Vasospasm
Vasoactive Agents:
 Prostaglandin
 Nitric oxide
 Endothelins
Noxious Agents:
 Cytokines
 Lipid Peroxidases
 Multiple gestation
 Hydrops fetalis

12. Activation of CoagulationCapillary LeakVasospasm
Abruption
Seizures
Hypertension
Liver Ischemia
Oliguria
Proteinuria
Edema
Hemoconcentration
Endothelial Activation
Thrombocytopenia

13. Gestational HPN
• Previously normal BP
• Elevated BP without proteinuria
• Develops after 20 weeks of gestation and BP normalizes 12 weeks postpartum
Preeclampsia
• Previously normal BP
• Elevated BP with proteinuria
• Develops after 20 weeks of gestation and BP normalizes 12 weeks postpartum
Eclampsia
• Hypertension in pregnancy with proteinuria along with convulsions
• Preeclampsia with occurrence of grand mal seizures

14. Chronic HPN
• Previously elevated BP
• Use of antihypertensive medications before pregnancy
• Develops before 20 weeks of gestation and
• BP elevation persists longer than 12 weeks postpartum
Chronic HPN with
Superimposed
Preeclampsia
• Previously elevated BP or persists postpartum with associated signs and symptoms of
preeclampsia
• Develops before 20 weeks of gestation with new-onset proteinuria
• Development of HELLP syndrome

15. Ideal: mercury manometer
• Alternative: aneroid, digital, or other automated devices
• Cuff should cover: 2/3 of arm or at least 80% of pt’s arm circ
Position: seated, supine, or left lateral recumbent position
• Should be rested at least 5-10 minutes
• Not smoked or ingested caffeine 30 min. before measurement
Bladder is inflated 30 mmHg above point of radial pulse
extinction
• Deflation: 2 mmHg per beat

16. Systolic BP: 1st clear tapping sound (Korotkoff phase I)
• Diastolic BP: disappearance of tapping sounds (Korotkoff phaseV) OR
• Present near 0: softening of sounds (Korotkoff phase IV)
If BP taken for the 1st time: take BP of both arm, subsequent
determination is done on the arm with higher BP
• Arm with the higher values will be used for all BP measurements
For white coat HPN: ambulatory BP monitoring
• Instruct proper BP monitoring if BP monitoring is done at home

17. Screening maneuvers
• Mean Arterial Pressure
• Roll over test
• MAP-2 with Roll over test
• 48 hour BP monitoring
• 24 hours ambulatory BP
with heart rate
• Hyperbaric Index
Laboratory Test
• Doppler Velocimetry
• Fibronectin
• Hematocrit
• Proteinuria
• Serum uric acid
LaboratoryTest
• Hemoglobinuria
• Masternal Serum AFP
• Hypocalciuria
• Glucose intolerance
• Inhibin A
Others:
biochemical markers

19. Calcium Supplementation
Dose: 1.5 to 2 g per day before 32 weeks AOG until delivery
Antiplatelet agents
ASA or dipyridamole: reduce risk of preeclampsia by 17%
Insufficient evidence on others
Antioxidants, nitric oxide, rest, exercise, diuretics, ↓ed salt intake, marine oil, prostaglandin

20. PREECLAMPSIA
MILD No manifestations of any of severe preeclampsia
SEVERE
BP SBP ≥ 160 or
DBP ≥ 110
Laboratories
Elevated serum creatinine
Thrombocytopenia
Hepatocellular dysfunction (↑ed AST and ALT)Pulmonary edema
Microangiopathic hemolysis
Urine
≥5 g/24h or ≥ 3 in 2 random urine sample (q4h)
Oliguria <500ml/24h
IUGR or Oligohydramnios
Symptoms of End-organ involvement
Headache
Visual disturbances
Epigastric pain or RUQ pain

21. Criteria for home health care
Ability to comply with recommendation
Diastolic BP <100 mm Hg
Systolic BP <140 mm Hg
Proteinuria < 1,000 mg/24 hr OR < 2+ on dipstick
Platelet count > 120,000/mm
Normal fetal growth and testing
No indications for delivery

22. TimingofDelivery Gestational Age
≥ 40 weeks
• Bishop score > 5
• Fetal weight < 10th percentile
• Non-reactive non-stress test (NST)
Gestational Age
≥ 37 weeks with:
• Labor
• Rupture of membranes
• Vaginal bleeding
• Abnormal biophysical profile
• Criteria for severe preeclampsia
Gestational Age
≥ 34 weeks with:
DELIVER
Expectant management: remote from term with mild preeclampsia

23. Maternal and fetal well-being at least once weekly
• BP each visit
• Platelet count and liver enzymes at regular intervals
• NST at regular interval
• Fetal growth every 2 to 3 weeks
MEDICATIONS
Anti-HPN meds will be given only if there is an increase in
BP reading.
Not recommended:
• Magnesium sulfate and other anti-convulsants
• Low-dose aspirin and high dose calcium for prevention
of progression to severe preeclampsia

24. 5-6% of all pregnancies worldwide
5-10% - severe
Local incidence: 2-5%
2nd most common cause of maternal death
High perinatal mortality and morbidity rate: Iatrogenic prematurity
Definitive treatment: Delivery of fetus and placenta

25. CNSDysfunction
• Blurred
vision
• Scotomata
• Altered
mental
status
• Severe
headache
Livercapsuledistentionor
rupture
• Persistence
right
quadrant
pain
• Epigastric
pain
Bloodpressurecriteria
• Sitting
SBP ≥160
mm Hg
• DBP ≥110
mm Hg
• * On 2 separate
occasions at rest or
at least 6 hours
apart
Eclampsia
• Generalized
seizure
• Unexplained
coma in
setting of
preeclampsia
in absence of
neurologic
d/o

26. Pulmonaryedemaorcyanosis
• Excessive
fluid
accumu-
lation in
the lungs
Cerebrovascularaccident(CVA)
• Acute loss
of brain
function
• Altered
mental
status
• coma
CorticalBlindness
• Partial or
total loss of
vision in
normal
appearing
eye
IUGR
• EFW < 5
percentile for
gestational
age
• EFW <10
percentile for
gestational
age with
evidence of
fetal
compromise
CoagulopathyandThrombocytopenia
• Prolonged
prothrombin
time: >1.4s
• Low
fibrinogen:
<300 mg/dl
• Low
platelet:
<100,000
mm3
Due to disturbance
of vasculature that
supplies the brain
Damage to the
visual region of
occipital cortex

27. Proteinuria
• >5 g per 24h
or ≥3+ on 2
random
urine
samples
collected at
least 4 hours
apart
Oliguriaand/orRenalFailure
• Urine output
<500 ml per
24h
• Serum
creatinine:
>1.2 mg/dl
HELLPSyndrome
• Hemolysis:
• Abnormal
peripheral smear
• total bilirubin >1.2
mg/dl
• LDH >600 U/L
• Elevated liver
enzyme:
• ALT > 70 U/L
• LDH > 600 U/L
• Low platelet:
• Platelet <100,000
mm3
Hepatocellularinjury
• Serum
transaminase
≥ 2x the
normal

28. Activation of CoagulationCapillary LeakVasospasm
Hypertension
Seizures
Proteinuria
Edema
Hemoconcentration
Endothelial Activation
Thrombocytopenia
Multiple factors
Oliguria↓ed kidney perfusion
Liver Ischemia
↓ed liver
perfusion
Severe headache
Cortical blindness
Altered mental status
Scotomata
Blurred vision
Occipital cortex
damage
CNS Dysfunction
Hepatocellular damage
↓ed brain perfusion
RUQ pain/abd’l pain
↑ed AST Pulmonary edema
HELLP SYNDROME
ARF
Uteroplacental
insuffieciency
IUGR
Eclampsia
ComplicationsSigns and symptomsProcess
Abruption
Oligohydramnios

29. Objectivesofmanagement Reduce severity or prevent progression of disease process
Prevent convulsions
Control severe hypertension
Deliver the fetus at the optimum time and with the least trauma
Detect and appropriately treat end-organ damage
Completely restore the health of the mother

30. •Safety of mother
and fetus
Main objective
• Stabilization of mother’s
condition
• Confirmation of gestational age
• Assessment of fetal well-being
Initial

31. Maternal
DELIVER
Fetal

34. Drug of choice for prevention of seizures
Drug is considered when women is at risk for eclampsia: moderate to severe
preeclampsia (at least BP 150-160/100-110 mm Hg)
Can be given in 2 ways:
(2) intermittent intramuscular injections
(1) continuous intravenous infusions
When given, regularly assess:
Maternal reflexes
Urine output
Oxygen saturation
Respiratory rate

35. Continuous intravenous infusion
• Loading dose: 4-6 g dose of MgSO4 diluted in 100 ml of IVF administered over 15-20 min
• Begin 2 g/h in 50 ml of IV maintenance infusion
• Measure serum Mg level at 4-6 h and adjust infusion to maintain levels between 4 and 7 mEq/L
• MgSO4 is discontinued 24 h after delivery
Intermittent intramuscular injections
• Give 4 g MgSO4 as 20% solution of intravenous at a rate not to exceed 1 g/min
• Follow with 10 g of 50% MgSO4 solution:
• 5 g (one-half) injected deep in the upper outer quadrant of both buttocks through a 3-inch-long, 20 gauge
needle.
• If convulsion persists after 15 min, give up to 2 g more IV as 20% solution at a rate not to exceed 1 g/min. (if the
woman is large up to 4 g may be given slowly)
• Every 4 h thereafter: 5 g of 50% solution of MgSO4 deep IM upper outer quadrant of alternate buttocks, assuring
that:
• Patellar reflex is present
• Respirations are not depressed
• Urine output during the previous 4 h exceeded 100 ml
• MgSO4 is discontinued 24 h after delivery

37. SBP: 140-155 mm Hg
DBP: 90-105 mm Hg
 Labetolol
 Hydralazine
 Nifedipine
 IV Nicardipine
 Methyldopa
 Second line agent:
• Labetolol
• Nifedipine
• Hydralazine
• Beta-receptor blocker
• Hydrochlothiazide
 ACE-I
 ARB
 Diuretics
Given if BP >150/100
mm Hg PP:
 Drugs used during
antepartum
 Diuretics
 Avoid NSAIDs PP

38. Labetalol (C)
> 10 to 20 mg IV, then 20 to 80 mg every
20 to 30 minutes
> maximum of 300 mg;
> for infusion: 1 to 2 mg/min
> Lower incidence of maternal hypotension and
other adverse effects, displaces hydralazine;
> Avoid in women with asthma or congestive
failure.
> Not available locally
Hydralazine (C)
> 5 mg IV or IM, then 5 to 10 mg every 20
to 40 minutes; once BP controlled repeat
every 3 hours;
> for infusion: 0.5 to 10.0 mg/hr; if no
success with 20 mg IV or 30 mg IM,
consider another drug
A drug of choice according to
NHBEP; long experience of
safety and efficacy
Nifedipine (C) >Tablets recommended only: 10 to 30 mg
PO, repeat in 45 minutes if needed Should be used with caution if
concomitantly used with MgSO4
IV Nicardipine
> D5W 90 mL + Nicardipine 10 mg in
soluset
Concentration = 0.1 mg/mL
> Start drip at 10 ugtts/min (equivalent to
1 mg/hr).
> Maximum dose 10mg/hr
*Note:The IV infusion site must be
changed every 12 horus
Should be used with caution if
concomitantly used MgSO4
DRUG Dose and Route Precautions andAdverse Effects

39. Methyldopa (B)
Secondlineagents
Preferred agent:
0.5 to 3.0 g in 2 divided dosage
Labetolol (C)
Nefidipine (C)
Hydralazine (C)
Beta Blockers (C)
Drug Dose Concerns
Drug of choice (NHBEP)
Safety after 1st trimester
200 to 1200 mg/d in 2-3 divided dose
30 to 120 mg/d slow release prep
May be assoc. with fetal growth restriction
May inhibit labor and synergistic
action with MgSO4 in lowering BP
Useful in combination with
sympatholytic agents
May cause neonatal thrombocytopenia
May ↓ uteroplacental blood flow
May impair fetal response to hypoxia
Risk of IUGR when start 1st or 2nd Tri (Atenolol)
Associcated with neonatal hypoglycemia
50 to 300 mg/d in 2-4 divided doses
Depends on specific agent

40. Hydrochlothiazide (C)
Contraindicated
Second line agents:
12.5 to 25.0 mg/d
ACE-I
ARB
Drug Dose Concerns
 Can cause volume contraction and
electrolyte d/o
 Useful in combination with Methyldopa and
vasodilator to mitigate fluid retention
Leads to fetal loss in animals
Human use is associated with:
1. Cardiac defects
2. oligohydramnios
3. Fetopathy
4. Growth restriction
5. Renal agenesis
6. Neonatal anuric renal failure

41. Controlof
seizures
MgSO4 For prevention and reduction of recurrence
Diazepam Loading dose: 10
mg IV over 2 min
Followed by: IV infusion
40 mg in 500 ml Normal
saline for 24 h
After 24 h: 20 mg
in 500 ml NS,
slowly reduced
Phenytoin
Only for seizure
prevention
Dose: initial - 1 g slow IV d by 100 mg every 6 hours for the next 24 hours
Anti-HPN
Therapy
Hydralazine Drug of choice
IV boluses of 5 to 10 mg at 20-30 min interval until
desired BP attained
Clonidine Next recommended drug IM: 75-150 mcg
Nifedipine 5-10 mg orally NOT sublingual
Labetalol Initial dose: 20 mg IV bolus
If desired BP not attained w/in 10 min, give 40
mg then 80 mg every 10 minutes

42. > 34 weeks
Deliver
Mode: vaginal
delivery
< 34 weeks
Defer delivery
Give corticosteroids
(24-34 weeks)
<32 weeks: CS
Eclampsia
Deliver after seizure
is controlled
CS is done if:
Anticonvulsant therapy
continued atleast 24 hours after
deliver
Betamethasone: 12 mg IM every 24 h for 2 doses
Dexamethasone: 6 mg IM every 12 h for 4 dosesGiven between 23-34 weeks for
fetal lung maturity
Corticosteroids
 Vaginal delivery is
not easy and
imminent
 Failure of
progress after
induction
 Fetal compromise

43. DEFINITION: Amniotic fluid index < 5cm
Fetal Growth restriction
ChromosomalAbnormalities
Demise
Congenital anomalies
Postterm pregnancy
Ruptured membranes
Placental
Abruption
Twin-twin transfusion
Maternal Preeclampsia
Uteroplacental insufficiency
Diabetes
Hypertension
Drugs
Prostaglandin synthase inhibitors
ACE Inhibitors
Idiopathic

45. Most widely used for assessment of fetal well
being
Hypothesis: HR of non-acidotic fetus temporarily
increase in response to movement
Normal or reactive:
≥2 accelerations of ≥15 bpm lasting for ≥15 sec
within 20 min
Nonreactive:
Does not contain at least 2 accelerations
Uteroplacental insufficiency:
Absent acceleration during 80-min period with variability or late
deceleration following spontaneous uterine contractions

46. 5 biophysical
variables
Highest
score: 10

47. NST
2
≥2 accelerations of ≥15 bpm
lasting for ≥15 sec within 20
min
0 0 or 1 acceleration in 20-
40 min
Fetal
Breathing
2 ≥1 ep rhythmic breathing
lasting ≥30 sec w/in 30 min
0 <30 sec of breathing in 30
min
Fetal
mov’t
2 ≥3 discrete or body limb
movement w/in 30 min
0 <3 discrete
movements
Fetal
tone
2
≥1 ep of ext and flex of
extremity OR
opening/closing of hand
w/in 30 min
0 No movement or no
extension/felxion
AF
volume
2 Single vertical
pocket >2cm
0 Largest single vertical
pocket <2cm

48. Modified BPP
NSTUTZ assessment of AF
Requires less time
Excellent method of fetal surveillance

49. Biophysical
Score
Interpretation Recommended management
10 Normal, nonasphyxiated
No fetal indication for intervention
Repeat test weekly
Repeat 2x weekly for postterm and diabetic
8
Normal fluid
Normal, nonasphyxiated
fetus
No fetal indication for intervention
Repeat test per protocol
8
oligohydramnios
Chronic fetal asphyxia
suspected
Deliver if ≥37 weeks, otherwise repeat test
6 Possible fetal asphyxia
IF:
AF is abnormal: deliver
Norma AF >36 weeks w/ favourable cervix: deliver
Repeat test <6: deliver
Repeat test >6: observe and repeat per protocol
4 Probable fetal asphyxia Repeat test on same day: if ≤6 - deliver
0-2
Almost certain fetal
asphyxia
Deliver

50. Non-invasive way to assess blood flow characterizing downstream impedance
Umbilical artery systolic/diastolic ratio is commonly used Doppler index
Ratio compares max systolic flow with end-diastolic flow: evaluate downstream impedance to
flow
Consider abnormal if elevated above 95th percentile OR if diastolic flow is absent or reversed
Doppler of the uterine and uteroplacental arteries at 24 weeks is an effective test to predict
Preeclampsia

52. ABSENCE OF END-DIASTOLIC
FLOW
NORMAL DIASTOLIC FLOW
REVERSED END-DIASTOLIC
FLOW

53. ABNORMALITY BPS FREQUENCY DECISION TO DELIVER (FETAL)
Elevated Indices
Only
Weekly
Abnormal BPS orTerm or >36
weeks with no fetal growth
AEDV Twice weekly
Abnormal BPS or >34 weeks
proven maturity or conversion to
REDV
REDV Daily
Any BPS < 10/10 or >32 weeks
dexamethasone given
REDV-UVP Three times daily
Any BPS < 10/10 or >28 weeks
dexamethasone given