1. HYPERTENSIVE DISORDERS IN PREGANCY

2. OBJECTIVES At the end of this session you should be able to:
Outline diagnostic features of pre-eclampsia
Classify pre-eclampsia according to severity
Outline risk factors for pre-eclampsia
Outline maternal and fetal complications of pre-eclampsia.
Describe the management of pre-eclampsia and eclampsia.

3. I. INTRODUCTION Synonyms:
Toxemia of pregnancy, pre-eclampsia, EPH gestosis, pregnancy induced hypertension.
Pre-eclampsia commonly manifests after the 20th week of pregnancy.
Prevalence of pre-eclampsia: varies from one place to another
Severe pre-eclampsia and eclampsia
Are serious and potentially fatal
Third commonest cause of maternal mortality
Occurs prior to, during or after delivery

4. II. DIAGNOSIS OF PRE-ECLAMPSIA
When SBP > 140 mm Hg, DBP > 90 mm Hg in a woman known to be normotensive prior to pregnancy.
The diagnosis requires 2 such abnormal BP measurements recorded at least 6 hours apart.

5. III. RISK FACTORS
Young maternal age
Nulliparity: 85% of pre-eclampsia occur in primigravida.
Increased placental tissue for gestational age: Hydatiform moles, twin pregnancies
Family history of pre -eclampsia
Diabetes mellitus
Renal diseases,
Chromosomal abnormality in the fetus (eg, trisomy).

6. Worrisome signs for pre-eclapmsia development
RISK FACTORS cont
Worrisome signs for pre-eclapmsia development
Rapid increase of weight during the latter ½ of pregnancy
An upward trend in diastolic BP even while still within normal range

7. IV. CLASSIFICATION OF PRE ECLAMPSIA: ACCORDING TO SEVERITY
Mild pre-eclampsia
Moderate pre-eclampsia
Severe pre-eclampsia
Mild to Moderate Pre eclampsia
Diagnostic Features
Systolic BP is mmHg
Diastolic BP is 90 – 100 mmHg
Proteinuria up to ++

8. 2. Severe pre-eclampsia Also called – Imminent eclampsia Symptoms
Severe & persistent occipital or frontal headaches
Visual disturbance: blurred vision, photophobia
Epigastric and/or right upper-quadrant pain
Signs
Diastolic BP > 11ommHg, systolic BP > 160mmHg
Proteinuria +++ or more
Altered mental status
Hyper-reflexia
Oliguria

9. Is a severe form of pre-eclampsia
HELLP SYNDROME
Is a severe form of pre-eclampsia
Affects approx 10% of women with severe preeclampsia and 30-50% of women with eclampsia.
Characterized by:
Hemolysis,
Elevated liver enzymes
Low platelet count.
Increased mortality rate and DIC

10. V. PATHOPHYSIOLOGY
There are several theories and etiologic mechanisms.
Vasospasm theory: Most favored theory
Vasospasms → vasoconstriction → resistance → arterial BP
Eclampsia:
Cerebral arterial vasospasm → cerebral edema or infarction and/or cerebral hemorrhage

11. VI. COMPLICATIONS OF SEVERE PRE-ECLAMPSIA AND ECLAMPSIA
Maternal complications
CVS
Haemoconcentration (cause: vasoconstriction and vascular permeability)
Hamatological changes – HELLP → DIC
Kidneys
Decr RBF→ ↓GFR → RTN and RCN→ acute RF
Proteinuria – due to ⇈permeability to large protein,
Oliguria – both renal perfusion and GFR decrease.

12. COMPLICATIONS OF SEVERE PRE ECLAMPSIA AND ECLAMPSIA cont
Brain
Cerebral edema
Infarction, cerebral hemorrhage
Blindness: Due to -?retinal artery vasospasms and retinal detachment
Fever 39ºC: a grave sign, may be a consequence of intracranial hemorrhage.
Coma – may be a result of CVA

13. COMPLICATIONS OF SEVERE PRE ECLAMPSIA AND ECLAMPSIA cont
RS : Pulmonary oedema and cyanosis
Utero-placental perfusion
Vasospasms → decr perfusion → distress and death
Histological changes in the placental bed: acute artherosis – lipid rich cells of the uteroplacental arteries
Fetal complications
IUFD, IUGR

14. MAJOR CAUSES OF MATERNAL DEATH
Cerebrovascular accident (CVA)
Pulmonary oedema
Cardiac failure,
Renal failure

15. VII. WORK UP - INVESTIGATIONS
Urine analysis
Proteinuria
A 24-hour urine collection
Quantity of urine and protein
Uric acid level:
GFR and creatinine clearance decrease →in ↑uric acid levels.
LFT – Transaminases
USS – fetal wellbeing, if the GA is < 20/40 R/O moles.

16. VIII. MANAGEMENT OF PRE ECLAMPSIA
MILD - MOD PRE ECLAMPSIA
A: Dispensary & Health centre
Antihypertensives
Aldomet 250 mg 8 hourly for 7 days,
Bed rest at home
REFER within one week to Hospital for further management

17. MANAGEMENT OF PRE ECLAMPSIA
1. MILD - MOD PRE ECLAMPSIA cont
B. Hospital
Antihypertensives: Aldomet,
Bed rest at home,
Sequential work ups,
Fetal movements monitoring,
Schedule antenatal clinic every 2 weeks up to 32 wks and weekly thereafter

18. MANAGEMENT OF PRE ECLAMPSIA
1. MILD - MOD PRE ECLAMPSIA cont
B. Hospital
Strongly advice the woman to deliver in a hospital
Plan delivery at 38/40
Advice the mother to come to the health facility in case of severe headache, blurred vision, nausea or upper abdominal pain.
Manage as severe pre-eclampsia: If not responding to treatment i.e. if the systolic BP is > 160 mmHg, or the diastolic BP is > 100mmHg or there is proteinuria +++

19. MANAGEMENT OF SEVERE PRE ECLAMPSIA AND ECLAMPSIA
Note: Severe pre-eclampsia is managed like
eclampsia
Management protocol for eclampsia
Keep airway clear
Control convulsions
Control BP
Control fluid balance
Antibiotics
Investigations
Deliver the mother

20. MANAGEMENT CONT BP CONTROL
Keep SBP between mm Hg and DBP between mm Hg
?Why these levels: Avoid potential reduction in either uteroplacental blood flow or cerebral perfusion pressure.
Drugs:
Anti HPTs: Hydralazine, nifedipine, or labetalol
Diuretics are not used except in the presence of pulmonary edema

21. MANAGEMENT: CONTROL CONVULSIONS
I. An overview on MgSO4.
Mechanism:
Cerebral vasodilator → reducing cerebral vasospasm → ↓ischemia (brain).
Superior to other anti-convulsants used to control and prevent fits;
Important part of mgt of eclampsia
Recurrence rate after MgSO4 = %
Improves maternal and fetal outcome

22. CONTROL CONVULSIONS - REGIMEN
1. INTRAMUSCULAR REGIMEN
i. Loading dose
Give MgSO4 4 g (i.e. 20mls of 20% solution) + 200mls NS or sterile water I.V over 5 minutes
Follow promptly with 10g (i.e. 20ml of 50% solution), 5g in each buttock as deep I.M with 1ml of 2% lignocaine in the same syringe

23. CONTROL CONVULSIONS - REGIMEN
MANAGEMENT CONT
CONTROL CONVULSIONS - REGIMEN
1. INTRAMUSCULAR REGIMEN cont
ii. Maintenance dose
MgSO4 5 g (i.e. 10ml of 50% solution) + 1 ml lignocaine 2% 4 hourly in alternate buttocks.
NOTE:
IM inj. are painful and are complicated by local abscess formation in 0.5% of cases.
The intravenous (IV) route is therefore preferred

24. MgSO4 4 g (i.e. 20mls of 20% solution) + 200mls NS I.V over 5 minutes
MANAGEMENT CONT
CONTROL CONVULSIONS - REGIMEN
2. INTRAVENOUS REGIMEN
i. Loading dose
MgSO4 4 g (i.e. 20mls of 20% solution) + 200mls NS I.V over 5 minutes
ii. Maintenance dose
MgSO4 4 g (i.e. 20ml of 20% solution) IN 500ml NS 4 hourly for 24 hrs after the last fits

25. Recurrent fits (any regimen):
MANAGEMENT CONT
CONTROL CONVULSIONS - REGIMEN
Recurrent fits (any regimen):
Therapeutic dose may not have been reached
Give 2g (i.e. 10ml of 20% solution) i.v. over 5 minutes
Treatment duration:
Continue for 24 hours after delivery or last convulsion, whichever occurs first

26. Causes loss of deep tendon reflexes, followed by
MANAGEMENT CONT
Magnesium toxicity
Causes loss of deep tendon reflexes, followed by
respiratory depression and ultimately respiratory
arrest.
Thus, before repeating MgSO4, ensure that;
RR ≥ 16/min
Patellar reflexes are present
Urinary output is at least 30ml per hour over 4 hours
Otherwise withhold or delay MgSO4
Keep antidote ready
In case of respiratory arrest: Assist ventilation and administer calcium gluconate

27. Delivery should be within 6-8 hours of onset of fits
MANAGEMENT CONT
DELIVER THE MOTHER
Delivery should be within 6-8 hours of onset of fits
Vaginal delivery is the safest mode of delivery
Assessment
R/O contraindications to SVD
Bishop score
If the cervix is favourable - induce labour
Otherwise prepare for C/S

28. MANAGEMENT CONT Management of labour 1st stage
Relieve pain: pethidine 25 mg iv every 2-4 hours
Augmentation of labour
Monitor FHR,
2nd stage: Assist with vacuum extraction
3rd stage: Active management
Oxytocin 10 IU i.m after delivery of anterior shoulder
Cord traction
Squeezing clots after delivery of the placenta

29. MANAGEMENT CONT
Management of labour
If there is delay perform C/S
Post delivery:
Continue observation for at least 48 hrs post delivery
Record and monitor BP and urine output for at least 48 hours after delivery,
Keep the pt in hospital until BP stabilizes,
Continue with aldomet PO until BP back to normal