PREECLAMPSIA & ECLAMPSIA

Hypertension
 Sustained BP elevation of 140/90 or greater
PIH Gestasional

Preeclampsia Severe

Chronic HELLP
Mild Synd

Effect

Impending
eclampsia

Eclampsia
 20 Proteinuria (-)

Proteinuria (+)

Preeklampsia Hipertensi Gestasional

Hipertensi kronik Proteinuria (+) Super imposed

Hypertensive Disease Associated with
Pregnancy
 Chronic Hypertension

 Gestational Hypertension

 Preeclampsia

 Eclampsia

 HELLP Syndrome
Hypertensive Disease Associated with
Pregnancy
 Chronic Hypertension
 Diagnosed before the 20th week or present before the
pregnancy
 Mild hypertension
 > 140-180 mmHg systolic
 > 90-100 mmHg diastolic

 Gestational Hypertension

 Preeclampsia

 Eclampsia

 HELLP Syndrome
Hypertensive Disease Associated with
Pregnancy
 Chronic Hypertension

 Gestational Hypertension
 Criteria
 Develops after 20 weeks of gestation
 Proteinuria is absent
 Blood pressures return to normal postpartum
 Morbidity is directly related to the degree of hypertension

 Preeclampsia

 Eclampsia

 HELLP Syndrome
 Overlap/Disease Progression
Patient with Hypertension

Elevated BP above Gestational hypertension Preeclampsia

first trimester No proteinuria Hypertension
levels 5-10% of singletons
25% Proteinuria
55-75% 30% of multiples 5-8% of prognancies
Hypertensive Disease Associated with
Pregnancy
 Chronic Hypertension

 Gestational Hypertension

 Preeclampsia
 Criteria
 Develops after 20 weeks
 Blood pressure elevated on two occasions at least 6 hours
apart
 Associated with proteinuria and edema
 May occur less than 20 weeks with gestational
trophoblastic neoplasia

 Eclampsia

 HELLP Syndrome
Preeclampsia vs. Severe Preeclampsia
Criteria for Preeclampsia
 Previously normotensive
woman

 > 140 mmHg systolic

 > 90 mmHg diastolic

 Proteinuria > 300 mg in

24 hour collection

 Nondependent edema
 Criteria for Severe Preclampsia
 BP > 160 systolic or >110 diastolic

 > 5 gr of protein in 24 hour urine or > 3+ on 2 dipstick urines greater than 4

hours apart

 Oliguria < 500 mL in 24 hours

 Cerebral or visual distrubances (headache, scotomata)

 Pulmonary edema or cyanosis

 Epigastric or RUQ pain

 Evidence of hepatic dysfunction

 Thrombocytopenia

 Intrauterine growth restriciton (IUGR)

Risk Factors for Preeclampsia

 Nulliparity  Vascular and connective

tissue disorders
 Multifetal gestations  Nephropathy
 Antiphospholipid
 Maternal age over 35 syndrome
 Obesity
 Preeclampsia in a
 African-American race
previous pregnancy

 Chronic hypertension

 Pregestational diabetes
Hypertensive Disease Associated with
Pregnancy
 Chronic Hypertension

 Gestational Hypertension

 Preeclampsia

 Eclampsia
 Diagnosis of preeclampsia
 Presence of convulsions not explained by a neurologic
disorder
 Grand mal seizure activity
 Occurs in 0.5 to 4% or patients with preeclampsia
 HELLP Syndrome
Hypertensive Disease Associated with
Pregnancy
 Chronic Hypertension

 Gestational Hypertension

 Preeclampsia

 Eclampsia

 HELLP Syndrome
◦ A distinct clinical entity with:
 Hemolysis, Elevated Liver enzymes, Low Platelets
◦ Occurs in 4 to 12 % of patients with severe preeclampsia
 Microangiopathic hemolysis
 Thrombocytopenia
 Hepatocellular dysfunction
Morbidity and Mortality from
Hypertensive Disease
 Hypertension affects 12 to 22% of pregnant patients

 Hypertensive disease is directly responsible for

approximately 20% of maternal mortality in the
United State
Mississippi Classification:
Class 1 : Platelet count : <= 50.000 / ml
LDH >= 600 IU / l
AST and/or ALT >= 40 IU / l
Class 2 : Platelet count : >50.000 <= 100.000 / ml
LDH >= 600 IU / l
AST and/or ALT >= 40 IU / l
Class 3 : Platelet count : >100.000 <= 150.000 / ml
LDH >= 600 IU / l
AST and/or ALT >= 40 IU / l
Pathophysiology
 Vasospasm

 Uterine vessels

 Hemostasis

 Prostanoid balance

 Endothelium-derived factors

 Lipid peroxide, free radicals and antioxidants

Pathophysiology
 Vasospasm
◦ Predominant finding in gestational hypertension and
preeclampsia

 Uterine vessels

 Hemostasis

 Prostanoid balance

 Endothelium-derived factors

 Lipid peroxide, free radicals and antioxidants

Pathophysiology
 Vasospasm

 Uterine vessels
◦ Inadequate maternal vascular response to trophoblastic
mediated vascular changes
◦ Endothelial damage

 Hemostasis

 Prostanoid balance

 Endothelium-derived factors

 Lipid peroxide, free radicals and antioxidants

Pathophysiology
 Vasospasm

 Uterine vessels

 Hemostasis
 Increase platelet activation resulting in consumption
 Increased endothelial fibronectin levels
 Decreased antithrombin III and α2-antiplasmin levels
 Allows for microthrombi development with resultant
increase in endothelial damage
 Prostanoid balance

 Endothelium-derived factors

 Lipid peroxide, free radicals and antioxidants

Pathophysiology
 Vasospasm

 Uterine vessels

 Hemostasis

 Prostanoid balance
◦ Prostacyclin (PGI2):Thromboxane (TXA2) balance shifted to
favor TXA2
◦ TXA2 promotes:
 Vasoconstriction
 Platelet aggregation

 Endothelium-derived factors

 Lipid peroxide, free radicals and antioxidants

Pathophysiology
 Vasospasm

 Uterine vessels

 Hemostasis

 Prostanoid balance

 Endothelium-derived factors
◦ Nitric oxide is decreased in patients with preeclampsia
 As this is a vasodilator, this may result in vasoconstriction

 Lipid peroxide, free radicals and antioxidants

Pathophysiology
 Vasospasm

 Uterine vessels

 Hemostasis

 Prostanoid balance

 Endothelium-derived factors

 Lipid peroxide, free radicals and antioxidants

◦ Increased in preeclampsia
◦ Have been implicated in vascular injury
Pathophysiologic Changes
 Cardiovascular effects

 Hematologic effects

 Neurologic effects

 Pulmonary effects

 Renal effects

 Fetal effects
Pathophysiologic Changes
 Cardiovascular effects
◦ Hypertension
◦ Increased cardiac output
◦ Increased systemic vascular resistance

 Hematologic effects

 Neurologic effects

 Pulmonary effects

 Renal effects

 Fetal effects
Pathophysiologic Changes
 Cardiovascular effects

 Hematologic effects
◦ Volume contraction/Hypovolemia
◦ Elevated hematocrit
◦ Thrombocytopeniz
◦ Microangiopathic hemolytic anemia
◦ Third spacing of fluid
◦ Low oncotic pressure

 Neurologic effects

 Pulmonary effects

 Renal effects

 Fetal effects
Pathophysiologic Changes
 Cardiovascular effects

 Hematologic effects

 Neurologic effects
◦ Hyperreflexia
◦ Headache
◦ Cerebral edema
◦ Seizures
 Pulmonary effects

 Renal effects

 Fetal effects
Pathophysiologic Changes
 Cardiovascular effects

 Hematologic effects

 Neurologic effects

 Pulmonary effects
◦ Capillary leak
◦ Reduced colloid osmotic pressure
◦ Pulmonary edema

 Renal effects

 Fetal effects
Pathophysiologic Changes
 Cardiovascular effects

 Hematologic effects

 Neurologic effects

 Pulmonary effects

 Renal effects
◦ Decreased glomerular filtration rate
◦ Glomerular endotheliosis
◦ Proteinuria
◦ Oliguria
◦ Acute tubular necrosis
 Fetal effects
Renal Effects
 Decreased glomerular filtration rate

 Glomerular endotheliosis

 Proteinuria

 Oliguria

 Acute tubular necrosis

Pathophysiologic Changes
 Cardiovascular effects

 Hematologic effects

 Neurologic effects

 Pulmonary effects

 Renal effects

 Fetal effects
◦ Placental abruption
◦ Fetal growth restriction
◦ Oligohydramnios
◦ Fetal distress
◦ Increased perinatal morbidity and mortality
Management
 The ultimate cure is delivery

 Assess gestational age

 Assess cervix

 Fetal well-being

 Laboratory assessment

 Rule out severe disease!!

Gestational HTN at Term
 Delivery is always a reasonable option if term

 If cervix is unfavorable and maternal disease is

mild, expectant management with close observation
is possible
Mild Gestational HTN not at Term
 Rule out severe disease

 Conservative management

 Serial labs

 Twice weekly visits

 Antenatal fetal surveillance

 Outpatient versus inpatient

Indications for Delivery
 Worsening BP

 Nonreassuring fetal condition

 Development of severe PIH

 Fetal lung maturity

 Favorable cervix
Unfavorable Cervix
 No contraindication to prostaglandin agents

 If < 32 weeks, consider cesarean

 When favorable, oxytocin

Hypertensive Emergencies
 Fetal monitoring

 IV access

 IV hydration

 The reason to treat is maternal, not fetal

 May require ICU

Criteria for Treatment
 Diastolic BP > 105-110

 Systolic BP > 200

 Avoid rapid reduction in BP

 Do not attempt to normalize BP

 Goal is DBP < 105 not < 90

 May precipitate fetal distress

Characteristics of Severe HTN
 Crises are associated with hypovolemia

 Clinical assessment of hydration is inaccurate

 Unprotected vascular beds are at risk, eg, uterine

Key Steps Using Vasodilators
 250-500 cc of fluid, IV

 Avoid multiple doses in rapid succession

 Allow time for drug to work

 Maintain LLD position

 Avoid over treatment

Acute Medical Therapy
 Hydralazine

 Labetalol

 Nifedipine

 Nitroprusside

 Diazoxide

 Clonidine
Hydralazine
 Dose: 5-10 mg every 20 minutes

 Onset: 10-20 minutes

 Duration: 3-8 hours

 Side effects: headache, flushing, tachycardia, lupus

like symptoms

 Mechanism: peripheral vasodilator

Labetalol
 Dose: 20mg, then 40, then 80 every 20 minutes, for
a total of 220mg

 Onset: 1-2 minutes

 Duration: 6-16 hours

 Side effects: hypotension

 Mechanism: Alpha and Beta block

Nifedipine
 Dose: 10 mg po, not sublingual

 Onset: 5-10 minutes

 Duration: 4-8 hours

 Side effects: chest pain, headache, tachycardia

 Mechanism: CA channel block

Clonidine
 Dose: 1 mg po

 Onset: 10-20 minutes

 Duration: 4-6 hours

 Side effects: unpredictable, avoid rapid withdrawal

 Mechanism: Alpha agonist, works centrally

Nitroprusside
 Dose: 0.2 – 0.8 mg/min IV

 Onset: 1-2 minutes

 Duration: 3-5 minutes

 Side effects: cyanide accumulation, hypotension

 Mechanism: direct vasodilator

Seizure Prophylaxis
 Magnesium sulfate

 4-6 g bolus

 1-2 g/hour

 Monitor urine output and DTR’s

 With renal dysfunction, may require a lower dose

Magnesium Sulfate
 Is not a hypotensive agent

 Works as a centrally acting anticonvulsant

 Also blocks neuromuscular conduction

 Serum levels: 6-8 mg/dL

Toxicity
 Respiratory rate < 12

 DTR’s not detectable

 Altered sensorium

 Urine output < 25-30 cc/hour

 Antidote: 10 ml of 10% solution of calcium

gluconate 1 v over 3 minutes
Treatment of Eclampsia
 Few people die of seizures

 Protect patient

 Avoid insertion of airways and padded tongue

blades

 IV access

 MGSO4 4-6 bolus, if not effective, give another 2 g

 THE FIRST THING TO DO AT A
SEIZURE IS TO TAKE YOUR OWN
PULSE!
Alternate Anticonvulsants
 Have not been shown to be as efficacious as
magnesium sulfate and may result in sedation that
makes evaluation of the patient more difficult
 Diazepam 5-10 mg IV
 Sodium Amytal 100 mg IV
 Pentobarbital 125 mg IV
 Dilantin 500-1000 mg IV infusion
After the Seizure
 Assess maternal labs

 Fetal well-being

 Effect delivery

 Transport when indicated

 No need for immediate cesarean delivery

Other Complications
 Pulmonary edema

 Oliguria

 Persistent hypertension

 DIC
Pulmonary Edema
 Fluid overload

 Reduced colloid osmotic pressure

 Occurs more commonly following delivery as colloid

oncotic pressure drops further and fluid is
mobilized
Treatment of Pulmonary Edema
 Avoid over-hydration

 Restrict fluids

 Lasix 10-20 mg IV

 Usually no need for albumin or Hetastarch (Hespan)

Oliguria
 25-30 cc per hour is acceptable

 If less, small fluid boluses of 250-500 cc as needed

 Lasix is not necessary

 Postpartum diuresis is common

 Persistent oliguria almost never requires a PA cath

Persistent Hypertension
 BP may remain elevated for several days

 Diastolic BP less than 100 do not require treatment

 By definition, preeclampsia resolves by 6 weeks

Disseminated Intravascular
Coagulopathy
 Rarely occurs without abruption

 Low platelets is not DIC

 Requires replacement blood products and delivery

Anesthesia Issues
 Continuous lumbar epidural is preferred if platelets
normal

 Need adequate pre-hydration of 1000 cc

 Level should always be advanced slowly to avoid

low BP

 Avoid spinal with severe disease

HELLP Syndrome
 He-hemolysis

 EL-elevated liver enzymes

 LP-low platelets
HELLP Syndrome
 Is a variant of severe preeclampsia

 Platelets < 100,000

 LFT’s - 2 x normal

 May occur against a background of what appears to

be mild disease
Conservative Management
 Controversial

 Steroids

 Requires tertiary care

 Must have stable labs and reassuring fetal status

 May use antihypertensives

Prevention
 Low dose ASA ineffective in patients at
low risk
 Recent study done with antioxidant
(1,000mg VitC and 400mg VitE).
 Small study that needs to be confirmed.