Dr.P.

Rekha
MD OG Final year
RMMCH

Elevation of a pregnant woman's blood pressure

Most common complication in pregnancy

Contributes significantly to maternal and perinatal
morbidity and mortality
5-15% - preeclampsia, 10% in primi & 5% in
multigravidae
10% of whom develop eclampsia

1)Gestational Hypertension
2)Pre-eclampsia
3)Eclampsia
4)Chronic Hypertension
- Essential Hypertension
- Chronic renal disease
- Co-arctation of aorta
- Pheochromocytoma
- Thyrotoxicosis & SLE
5)Pre-eclampsia or eclampsia superimposed on chronic
Hypertension

Systolic > 140 mmHg

Diastolic > 90 mmHg
Occurs after 20 weeks of gestation
Returns to baseline - postpartum

A clinical diagnosis defined by a classic triad after

20 weeks of pregnancy as
Hypertension (BP 140/90)
Proteinuria (2+ dipstick or 300 mg/24 hr)
[Edema (especially non-dependent)]
No longer considered a required component

Primigravide(young&elderly)
Family history(hypertension, pre-eclampsia & eclampsia)
Placental abnormalities
*poor placentation - trophoblast invasion
*hyperplacentosis multiple pregnancy,
Rhesus incompatibility, Diabetes
*placental ischemia
*molar pregnancy
Genetic
Immunological phenomenon
Pre-existing vascular or renal disease
Thrombophilias (antiphospholipid antibody syndrome, protein C or
S deficiency, Factor v Leiden mutation)

Incompletely understood
Strong genetic component
Thought to stem from inadequate invasion of
cytotrophoblast into the myometrium
This lack of invasion allows the myometrial
portion of the spiral arterioles to maintain their
muscular walls, preventing development of the
normal low-resistance uteroplacental circulation,
leading to vasoconstriction & blood flow.

Increased vascular reactivity

Altered prostanoid balance favoring production
of TXA2 and PGF2 (vasoconstrictors, platelet
aggregators) over PGI2 and PGE2
Abnormal lipid metabolism-oxidative stress
Results in high resistance low-flow
uteroplacental circulation (ischemia)
Platelet dysfunction (aggregation)

Alterations are seen in nearly every system:

Hematologic
Thrombocytopenia, hemolysis, increased
platelet activation
Cardiovascular
Vasospasm, hemoconcentration
Renal
_ Proteinuria, oliguria, ATN, acute renal failure

Hepatic
- Elevated transaminases, hyperbilirubinemia,
hepatic hemorrhage
Neurological
Headache, scotomata, blurred vision,
hyperreflexia, temporary blindness, seizures
Fetoplacental
IUGR, oligohydramnios, abruption, impaired
gas exchange, nonreassuring fetal status

MILD PREECLAMPSIA
BP: 140/90 mmHg
Proteinuria ( 2+)
Wt. gain
Edema

SEVERE
PREECLAMPSIA
BP: 160/110 mmHg
Proteinuria (+3,
+4)or>5gm/24hrs
Extreme edema
Severe epigastric pain
Nausea and vomiting
Cerebral or visual
disturbances
Oliguria < 400ml/24hrs
Platelet
count<1,00,000/mm3
HELPP syndrome
Retinal hemorrhages
IUGR
Pulmonary edema

Serial blood pressure measurements

Serum Uric acid Biochemical marker
Serum Urea
Serum creatinine
Urine protein excretion
Fetal monitoring
Tests to rule out HELLP: Hematocrit, platelets, uric
acid, alanine aminotransferase (ALT), aspartate
aminotransferase (AST), lactic dehydrogenase (LDH)
Opthalmoscopic examination

Immediate
1) Maternal
2) Fetal
Remote

Immediate maternal
*During pregnancy
- Eclampsia(2%)
- Dimness of vision
- preterm labour
- HELPP syndrome
*During labour
- Eclampsia
- post partum hemorrhage
*During puerperium
- Eclampsia
- shock
- sepsis

Immediate fetal
*intra uterine death
*IUGR
*Asphyxia
*Prematurity
Remote
*Residual hypertension
*recurrent pre-eclampsia
*chronic renal disease

Occurs in up to 20% of women with severe

preeclampsia, more commonly in white women
and multigravid women
H-Hemolysis
EL-Elevated liver function tests
AST> 72 IU; LDH > 600 IU
LP-Low platelets

Complications:
DIC
Placental abruption
Pleural effusion
Acute renal failure
Wound infection
If it develops postpartum there is a higher
incidence of pulmonary edema and renal failure
Treatment immediate termination
Platelet transfusion <50,000/mm3

Presence of diastolic notch at 24 week - Doppler

velocimetry in uterine artery
Absence of end diastolic frequencies or reverse
diastolic flow patterns in umbilical artery.
MAP > 90 mm Hg in second trimester
Roll over test 28 32 weeks - 20mmHg DBP
from lateral to supine position

Regular antenatal checkup.

Aspirin prophylaxis:
- low dose 60 mg/day
Calcium supplementation
Antioxidants Vitamin E, C
Nutritional supplementation

Bed rest
Diet- Protein rich with salt and fluid restriction
Sedative Phenobarbitone 5mg at bed time
Diuretics
cardiac failure
pulmonary edema
massive edema
Blood pressure control
Seizure prophylaxis
Delivery

BP persistently over 160-170/110 warrants

treatment
Goal - 10-15% decrease (140-150/95-100)
Overtreatment leads to uterine underperfusion and
risk of fetal bradycardia

Labetalol - alpha-1/beta blocker

Hydralazine - direct arteriolar relaxation
Nifedipine - calcium channel blockade
Sodium nitroprusside - severe hypertension
AVOID:
ACE-inhibitors - fetal renal failure with chronic
use
Diuretics - decrease uterine perfusion

Delivery is a short-term goal

Induction of labor is appropriate after maternalfetal observation/stabilization
Cesarean reserved for standard obstetric
indications
Cesarean may be recommended in cases of
severe preeclampsia where delivery is remote

Mild preeclampsia - expectant management with

close maternal-fetal surveillance
severe preeclampsia at preterm gestational age:
Hospitalization
Magnesium sulfate for seizure prophylaxis, at least
during initial observation period
Blood pressure control to range of 140-155/90-105
(labetalol or nifedipine)
Daily assessment of maternal-fetal condition
24-34 weeks corticosteroids for fetal lung
maturation

Eclampsia (Greek, like a flash of lightening"), an

acute and life-threatening complication of
pregnancy
Characterized by the appearance of tonic-clonic
seizures, usually in a patient who had developed
pre-eclampsia but are not due to pre-existing or
organic brain disorders
Commonly seen in primi(75%), twin pregnancies(5
times)
Histopathologiacal and biochemical changes are
similar but intensified than preeclampsia

Causes
*Anoxia spasm of cerebral vessels
*cerebral oedema
*cerebral dysrhythmia
Onset
*common in 3rd trimester
*Antepartum(50%) before onset of labour
*Intrapartum(30%)
*postpartum(20%)
- usually within 48hrs of delivery
- beyond 7 days rules out eclampsia
*Intercurrent conscious after recovery from convulsions
&pregnancy continues beyond 48 hrs.

Four stages of an eclamptic event:

Premonitory stage, lasts for 30 sec
*facial twitching around the mouth & eye balls roll
& become fixed
Tonic stage , lasts for 30 sec
*tonic contractions, opisthotonus trunk, flexed
limbs & clenched hands
*Respiration cease& tongue protrudes
Clonic stage, lasts for 1 - 4 min
*voluntary muscles undergo alternate contraction
& relaxation
Stage of coma

Early detection & effective institutional treatment

with judicious termination of pregnancy during preeclampsia
In postpartum period, adequate sedation,
antihypertensive therapy &/or prophylactic
anticonvulsant therapy
Meticulous observation 24-48 hrs after delivery

Resuscitation maintain airway

Oxygen administration
Arrest convulsions
Ventilatory support if needed
Hemodynamic stabilisation
Organise investigations
Deliver by 6 8 hrs
Intensive post partum care

Anticonvulsant and sedative regime to control

fits & prevent recurrence
magnesium is the primary agent in the treatment
of eclampsia
motor endplate sensitivity to Ach &
neuromuscular irritability
Blocks neuronal calcium influx
Raises the seizure threshold
Has a direct vascular relaxant effect, but is NOT
an antihypertensive agent
No detrimental effects on neonate

Pritchard regimen 4gm iv over 3-5 min, followed by

10gm deep im(5gm in each buttock) & maintenance
by 5gm im 4th hourly in alternate buttock
serum Mg2+ therapeutic range 4.0-7.0 mEq/L. 7.0
10.0 mEq/L - loss of patellar reflex
10.013.0 mEq/L - respiratory depression
15.025.0 mEq/L - altered atrioventricular
conduction and (further) complete heart block
>25.0 mEq/L cardiac arrest
Antidote - Calcium gluconate

Repeat injections only if

*knee jerks are present
*urine output exceeds 30ml/hr
*respiratory rate > 12/min
Continued until about 24 hours after the last
seizure

Termination of pregnancy to be done

During labour, low rupture of membranes done to
accelerate labour
Curtail second stage by foreceps/ventouse
No contraindication for im ergometrine
Avoid iv Ergometrine following delivery of anterior
shoulder
Indications for caesarean section
*uncontrolled fits despite therapy
*unconscious patients
*obstetric indications

Mild SBP140mmHg, DBP90mmHg

Severe SBP180, DBP110
Using antihypertensives before pregnancy
Onset before 20 weeks GA
Persistence beyond postpartum period (12
weeks)