Clinical features Abnormal vasculogenesis and angiogenesis and releasing of anti-angiogenic factors results in Vasospasm Endothelial dysfunction Etiology of various clinical signs and symptoms

So, Preeclampsia usually develops in third trimester Abnormal placentation Endothelial dysfunction

Clinical diagnosis of Preeclampsia ACOG Task Force on Hypertension in Pregnancy 2013

Classification of Preeclampsia Preeclampsia-eclampsia Chronic hypertension Chronic hypertension with superimposed preeclampsia Gestational hypertension

Preeclampsia-eclampsia 2013 PROTEINURIA Not always necessary HYPERTENSION OR SEVERE FEATURES **edema, IUGR, oligohydramnios, 24 hour proteinuria > 5 gms/day NOT include in diagnostic criteria

Systolic BP 140 Diastolic BP 90 (4 hours apart) HYPERTENSION

24 hours ≥ 300 mg Urine dipstick ≥ 1+ PROTEINURIA

SEVERE FEATURES Severe hypertension (≥ 160/110 mmHg) Low platelet count (< 100,000/cu.mm.) Abnormal liver function (Increase AST/ALT 2 folds or RUQ pain) Abnormal renal function (Cr > 1.1 mg/dl or 2 folds of baseline level) Pulmonary edema Symptoms of nervous system and vision CBC with platelet, AST, ALT, LDH, Creatinine, Bilirubin, Uric acid

Mild preeclampsia Severe preeclampsia Preeclampsia without severe features Severe preeclampsia Preeclampsia with severe features

ECLAMPSIA

fit during pregnancy 38-55%

fit 18-36% during labor

fit 11-44% postpartum Mostly within 48 hours

Can Preeclampsia-eclampsia be prevented?

ASPIRIN Low dose aspirin (60-80 mg) for high risk group beginning in the late first trimester

ASPIRIN High risk group Previous preeclampsia, diabetes, hypertension, renal disease, autoimmune disease, multiple pregnancy

Preeclampsia-eclampsia Principle of management

Preeclampsia-eclampsia Controlling or prevention of eclampsia Lowering blood pressure Adequate hydration Termination of pregnancy

MgSO4 1 Preeclampsia with severe features Eclampsia

MgSO4 1 Dosage : Therapeutic level : 4.8-8.4 mg/dL Monitor : 20% MgSO4 2-6 gram IV loading dose in 10-15 min, then 50% MgSO4 40 gram + 5%DW 920 mL IV drip 2 gram (50 mL)/hr Therapeutic level : 4.8-8.4 mg/dL Monitor : urine output, reflex, respiratory rate, blood pressure Antidote : 10% Calcium gluconate 10 mL (1gram) IV

Antihypertensive 2 BP ≥ 160/110 mmHg Labetalol Hydralazine Nifedipine

Antihypertensive 2 Labetalol 20 mg IV over 2 minutes 10 minutes BP ≥ 160/110 mmHg and viable fetus Labetalol 20 mg IV over 2 minutes Hydralazine 10 mg IV over 2 minutes Labetalol 40 mg IV over 2 minutes 10 minutes Labetalol 80 mg IV over 2 minutes Consult or Surveillance ACOG Committee opinion; FEB 2015

Antihypertensive 2 20 minutes Hydralazine 10 mg IV over 2 minutes BP ≥ 160/110 mmHg and viable fetus Hydralazine 5-10 mg IV over 2 minutes Labetelol 40 mg IV over 2 minutes Hydralazine 10 mg IV over 2 minutes 20 minutes Labetelol 20 mg IV over 2 minutes 10 minutes Consult or Surveillance ACOG Committee opinion; FEB 2015

Labetelol 40 mg IV over 2 minutes Antihypertensive 2 BP ≥ 160/110 mmHg and viable fetus Nifedipine 10 mg PO Labetelol 40 mg IV over 2 minutes Nifedipine 20 mg PO 20 minutes Consult or Surveillance ACOG Committee opinion; FEB 2015

2 Special precaution Do not prescribe diazepam (valium®) in case of preeclampsia-eclampsia Unless status epilepticus was observed

3 Limited IV access

4 Termination as soon as possible 37 weeks gestation Preeclampsia without severe features 37 weeks gestation Preeclampsia with severe features at least 34 weeks gestation

4 Termination as soon as possible Expectant management should be considered If GA >24 to < 34 weeks gestation and available NICU Corticosteroids are recommended if GA < 34 weeks gestation

4 Termination as soon as possible Delivery after completion of 4 doses of corticosteroids PPROM Labour Platelet < 100,000 Abnormal LFT Renal dysfunction Fetal growth restriction Severe oligohydramnios Abnormal doppler study reversed end diastolic flow (umbilical a)

4 Termination as soon as possible Prompt delivery after maternal stabilization regardless of GA if uncontrolled BP eclampsia pulmonary edema abruptio placentae disseminated intravascular coagulation evidence of nonreassuring fetal status intrapartum fetal demise

Postpartum surveillance Treatment if BP ≥ 150/100 mmHg (4-6 hrs apart) Prompt treatment if BP ≥ 160/110 mmHg

Postpartum surveillance BP monitoring for 72 hrs BP follow up 7-10 days postpartum