1. Ri 簡睦旼
2012/5/3

2. Classification
 Pregnancy-induced hypertension (Gestational
hypertension)5-10%
 Preeclampsia3.9%
 Eclampsia
 Preeclampsia superimposed on chronic hypertension
 Chronic hypertension
William’s Obstertrics, 23ed

3. Gestationa Pre- Eclampsia
l HTN Eclampsia
Superimposed
Preeclampsia
SBP≥140
Proteinuria Generalized
or
seizures
DBP ≥ 90
Severe
Preeclampsia
≥ 0.3 g/ 24hr
> GA 20th wk before , during
>30 mg/dL
< PP 12th wk or after labor
(1+ on dipstick)
HELLP
syndrome

4. Preeclampsia
 2~7% of healthy nulliparous; 0.8~5% of
multiparous women
 The third leading cause of maternal mortality
(17%)
 A major cause of neonatal morbidity and
mortality (intrauterine growth restriction,
abruptio placentae and the need for preterm
delivery) Preeclampsia
Deadly
Triad
Hemorrhage Infection

5. Severe preeclampsia
 BP 160/110 mm Hg
 Proteinuria 2.0 g/24 hours or 2+ dipstick
 Increase severity /certainty
 Serum creatinine >1.2 mg/dL unless known to be previously elevated
 Platelets < 100,000/L
 Microangiopathic hemolysis—increased LDH
 Elevated serum transaminase levels—ALT or AST
 Persistent headache or other cerebral or visual disturbance
 Persistent epigastric pain

6. Superimposed
Chronic
Preeclampsia
HTN
SBP≥140
or Proteinuria
DBP ≥ 90
< GA 20th wk > 20th GA wk
> PP 12th wk
HTN + PTuria b4 20wk
↑proteinuria or
↑BP or
PLT < 100,000/L

7. Risk factors
 Nulliparity
 Age >35 years (superimposed) or teenager
 Obesity
 Multifetal gestation
 Medical illness: Chronic hypertension, lupus
erythematosus, IDDM, APS, PT C/S deficiency, renal
disease
 Genetic: Hx / FH of previous preeclampsia or eclampsia
 Hydatidiform moles
 Smoking, placenta previa

8. ↓NO, PGE2, PGI2,
PlGF, VEGF
↑TXA2, Endothelin
Stage 1
Poor
Placentation Vasoconstriction
Endothelial
Stage 2 Cytokines
integrity ↓
Placental
oxidative Antiangiogenic
stress Endothelial
peptides
damage
sFlt-1,sEng

9. Endothelial
integrity ↓
Vasoconstriction Endothelial
damage
MAHA
HELLP

10. Principle of management
 Difinitive treatment is delivery
 BP control
 Seizure prophylaxis

11. Evaluation of a new-onset HTN
 Clinical findings:
 headache, visual disturbance, epigastric pain, rapid
weight gain…
 Measure BW QD
 Analysis for proteinuria on admission and QOD
 BP measurement Q4H
 CRE, AST/ALT, CBC (for PLT). UA? LDH?
Coagulation profile?
 Sonography: fetal size, amnionic fluid
William’s Obstertrics, 23ed

12. Management of HTN disorder
 Dietary
 Lifestyle
 Place of care
 Antihypertensive therapy
 Corticosteroids
 Mode of delivery

13. Management of HTN disorder
 Dietary
 Salt restriction is not recommended
 Insufficient evidence to make recommendation
 Lifestyle
 Avoid vigorous exercise
 Bed rest?
 Place of care
 Severe hypertension or preeclampsia
(BP>160/110)should be hospitalized
Laura Magee et al, 2008, JOGC

14. Management of HTN disorder
 Antihypertensive therapy
 For severe hypertension (BP>160/110)
 BP goal: <160/110
 Initial antihypertensive: labetalol, nifedipine
hydralazine.
 MgSO 4 is not recommended as antihypertensive
(only transient decrease in 30 mins)
 Continuous FHR monitoring is advised until BP is
stable.
Laura Magee et al, 2008, JOGC

15. Management of HTN disorder
 Antihypertensive therapy
 Non-severe hypertension (BP:140-159/90-109
mmHg)
 BP goal: w/o cormorbid - 130-155/80-105
w/ cormorbid – 130-139/80-89
 Drug of choice: methyldopa, labetalol, other beta-
blockers, CCB (nifedipine). (I-A)
 ACEi and ARBs should not beused. (II-2E)
 Atenolol and prazosin are not recommended.
Laura Magee et al, 2008, JOGC

16. Management of HTN disorder
 Mode of delivery
 Induction of labour
 Vaginal delivery, unless C/S is indicated
 Oxytocin at 3rd stage of labor, esp.
thrombocytopenia or coagulopathy
 Ergometrine should not be given
Laura Magee et al, 2008, JOGC

17. Management of HTN disorder
 Corticosteroids
 To accelerate fetal pulmonary maturity
 Pre-eclampsia & GA < 34 wks
 Gestational HTN & GA < 34 wks, about to deliver
within next 7 days
Laura Magee et al, 2008, JOGC

18. Management of Pre-eclampsia
 Delivery is the only cure
 Timing of delivery
 MgSO4
 Plasma volume expansion
Laura Magee et al, 2008, JOGC

19. Management of Pre-eclampsia
 Timing of delivery
 GA < 34 wks: expectant management
 GA: 34-36 wks, non-severe pre-eclampsia:
debated
 GA > 37 wks: immediate delivery
Laura Magee et al, 2008, JOGC

20. William’s Obstertrics, 23ed

21. Management of Pre-eclampsia
 MgSO4
 First-line Tx for eclampsia
 Prophylaxis against eclampsia in severe-
preeclampsia
 Phenytoin and BZD should not be used for
eclampsia prophylaxis, unless MgSO4 is
contraindicated or ineffective
 Plasma volume expansion
 Not recommended
Laura Magee et al, 2008, JOGC

22. Management for HELLP
syndrome
 PLT count > 50x109 /L
 Prophylactic transfusion of platelets is not
recommended
 Consider ordering blood when PLT drop rapidly
 PLT count < 20 x 109 /L.
 Platelet transfusion prior to vaginal delivery or C/S)
 Corticosteriods may be considered for PLT count
< 50x109 /L
 Plasma exchange or plasmapheresis?
Laura Magee et al, 2008, JOGC

23. Postpartum treatment
 BP follow-up
 Peak postpartum, D3, D6
 Antihypertensive therapy may be restart, BP
goal <160/110 mmHg
 Acceptable in breastfeeding: Nifedipine, labetalol,
methyldopa, captopril, enalapril
 NSAID should be avoid if hypertension is
difficult to control, or oliguria, CRE ↑, PLT↓
 Thromboporphylaxis may be considered
Laura Magee et al, 2008, JOGC