4
Diagnosis :
Management of mild preeclampsia
1. BP  140/90 mmHg in previous normotensive patient
2. with proteinuria  300 mg in 24 hrs or  1 + from Dipstick of random
Assess maternal status
Assess fetal status
Clinical of SPE
Admit
NST or FAS
Ix: CBC, PT, PTT, Plt count, BUN, Cr, SGOT,
+U/S for fetal growth, AF, placenta
SGPT, 24-hr urine for protein & creatinine
Non-reassuring
MPE with reassuring fetal test
fetal test
Dx SPE
GA < 37 wks
GA 37 wks
Consider delivery
 Serial maternal assessment
Terminate pregnancy
depend on GA
Symptoms & signs of SPE
Daily BW, & proteinuria
BP qid, urine output
Ripe
or wait
Unripe
Other
 Serial fetal assessment
cervix if clinical stable cervix OB indications
Clinical - fundal height, FHS
(GA  40 wks)
Daily FMC
NST/FAS twice a week , + U/S
Induction
- Beware of SPE
 Intrapartum
- Steroid for GA < 34 wks
- Continued assess mother
Not response
Response
- Beware of SPE
Maternal :develop SPE
c stable maternal
- Continuous fetal monitoring
(clinical or lab Ix)
& fetal conditn
Fetal compromise
Response
Failed
- Monitor until
Induction
If
GA  37 wks
Vaginal
C/S
any
delivery
conditions (close monitoring
for OPD case)
- ANC weekly
(clinical, BP,
proteinuria)
- NST/FAS 1-2/wk
- + U/S q 1-2 wk
 SPE management
(if develop SPE)
Stable patient
Terminate Pregnancy
Terminate Pregnancy
5
Management of severe preeclampsia
Admit
• Prevention of convulsion ( 1st line = MgSO4)
• Antihypertensive Rx if diastolic > 110 mmHg or systolic > 160 mmHg*
• Assess maternal status
• Assess fetal status
Ix : CBC, PT, PTT, Plt count,
Clinical : fundal height, FHS
BUN, Cr, LFT, U/A,
NST
+ 24-hr urine for protein & creatinine
+U/S : EFW, growth, AF volume, placenta,
(If still not done)
presentation, R/O hydrops fetalis, twins
• IV fluid : Acetar 1000 cc rate 80 – 120 cc/hr
• Record V/S q 1 hr, retain Foley catheter
• Record urine output q 1 hr & Record I/O OD
• Beware of eclampsia
• No diuretics unless pulmonary edema is developed
• Continuous fetal monitoring
GA < 24 wks
GA 24 - < 32 wks
GA > 32 wks
• Termination of pregnancy
• Optional expectant Rx
• Termination of pregnancy
(after counseling
(Only selected case **
- If GA < 34 wks :corticosteroid
Risk & benefit)
after counseling risk & benefit) - delivery within 24 hrs
• corticosteroid
0f onset of symptoms
Corticosteroid
Favorable
Other
Continued anticonvulsant for 48 hrs
cervix
OB indications
Closed monitor maternal & fetal status
or
Daily Ix : CBC, PT, PTT, Plt cont,
Induction
unfavorable
LFT, BUN, Cr
cervix
Termination of pregnancy
Response
Failed
If 1. GA > 32 wks
induction
or 2. worsening maternal
or fetal condition
Vaginal
C/S
delivery
• Continue anticonvulsant
Until 24 hrs postpartum or after seizure
• Control BP, keep diastolic 90-105 mmHg
(antihypertensive drug may be oral form)
• Beware of late postpartum eclampsia
• F/U 2 wk after discharge
6
** Expectant Rx is NOT recommended in > 1 of the followings :
1. uncontrolled severe HT
(systolic BP > 160 mmHg or diastolic BP > 105 mmHg despite max. recommended dose of antiHT)
2. eclampsia
3. platelet count < 100,000/µ1
4. AST / ALT > 2x upper normal limit with epigastric / RUQ pain
5. pulmonary edema
6. compromised renal function (rise in serum creatinine of 1 mg/dl over baseline level)
7. abruption placentae
8. persistent severe headache or visual changes
9. worsening fetal condition
10. HELLP syndrome
11. significant hematological, cerebral or liver abnormalities due to preeclampsia
- If severe preeclampsia develops before GA 34 wks, antiphospholipid syndrome should he investigate.
- If eclampsia develops, delivery should occur within 12 hrs of the onset of convulsions.
Anticonvulsant therapy
Drug Initial dose Maintenance
Antidote
Monitor
Recurrent
dose
convulsion
MgSO4
(1st line)
4-5 g
(10%
MgSO4)
iv. rate
< 1 g/min
20 g of 50% MgSO4
In 5% D/W 500 ml
iv. drip 25-50 ml/hr
(1-2 g/hr)
10% calcium
gluconate
10 ml iv.
Over 3 min
a. patellar reflex = present
b. urine output > 100 ml/ 4 hr or > 25
ml/hr.
c. RR > 14/min
Repeat 2 g of 10%
MgSO4 iv. &
recheck Mg2+ level
Remarks
- If next dose of MgSO4 cannot be given, reassess a., b. and c. q 30 mins. And retreat when a., b. and c.
meet the above criteria.
- If convulsion develops during giving maintenance dose of MgSO4 phenytoin 125 mg iv. (dose up to 250
mg iv. Over 3-5 min) or diazepam 10 mg iv. May be considered.
- Mg2+ level * Therapeutic level of Mg2+ = 4.8 – 8.4 mg/dl
* 8-10 mEq/L
patellar reflexes lost
* 10-15 mEq/L
respiratory depression
* 12-25 mEq/L
respiratory paralysis
* 25-30 mEq/L
cardiac arrest
- Renal disease * initial dose : safe
* creatinine > 1.3 mg/dl
im. Dose 50%
iv. 1 g/hr.
check Mg2+ level
(ลดลง 50% ของ dose IM)
7
Antihypertensive therapy
Dihydralazine ( Nepresal, Apresoline ®)
Preparation : 25 mg/ml.
Test dose :
1 mg iv. Over 1 min, monitor BP q 5-10 min (to avoid idiosyncratic hypotensive effect)
Treatment dose: 5-10 mg iv. Over 2-4 min monitor BP q 5 min for 20 min later
* If no effect (BP not ) : repeat dose.
* If optimal effect – not repeat dose until diastolic BP > 110 mmHg
Maximum dose : Total 30 mg – if can not control BP, then switch to another regimen
Cardepine (Nicardipine HCl)
Preparation :
2 mg/2ml ampoule
Treatment dose : I. IV. Bolus : 2 mg/2ml ampoule + saline 2 ml. (o.5mg/ml)
0.5 mg (1 ml) iv. Over 1-2 min monitor BP q 5 min for 15 min
* If no effect (BP not ) : repeat dose q 15 min
* If optimal effect – not repeat dose until diastolic BP > 110 mmHg
»» if patien’s BW > 80 kg, initial start dose @ 1 mg (2ml) ««
II. IV. Drip : 10 mg in 5% D/W 100 ml. (0.1 mg/ml) start at 2 mg./hr (20 µd/min)
* If no optimal effect (BP not ) : 2 mg/hr (20 µd/min) dose q 15 min)
Maximum dose : 10 mg/hr
Nifedipine (Adalat ®)
Preparation : 10, 20 mg/capsule
Treatment dose : 10 mg oral monitor BP q min for 15 min later
Repeat dose in 30 min if necessary
»» Beware of synergistic interaction with MgSO4 that causes severe hypotension. ««
Maximum dose : 120 mg/d
8
Management of eclampsia







Assess maternal status
(same as SPE)
Unstable
Maternal condition
Management
According to
Conditions
Eclampsia
Do not leave patient alone
Call for help
Left lateral position
Oxygen
Assess airway & breathing
Check pulse & BP
Pulse oximetry
 MgSO4 control convulsion
 Antihypertensive drugs as indicated
 Lab. Investigation
Assess fetal status
(same as SPE)
Stable
maternal condition
Reassuring
fetal status
Non-reassuring
fetal status
* Plan to deliver
(delivery within 12 hrs after onset of convulsion)
Cervix
Unripening
Ripening of cervix
* Induction of labor
* IV fluid : LRS 80 ml/hr
* Record vital signs q 1 hr
* Record I/O OD, Record urine output q 1 hr
* Beware complication of eclampsia
* Continuous electronic fetal monitoring
* GA < 34 wks : corticosteroid
Response
Failed induction
C/S
Vaginal delivery
* Continue MgSO4 : 24 hrs postpartum or after last seizure
* Control BP keep diastolic < 110 mmHg
9
เอกสารอ้างอิง
1. Cunningham FG, Leveno KJ, Bloom SL, Hauth JC, Gilstrap III L, Wenstrom KD. Williams
Obstetrics, 22nd ed. USA: McGraw-Hill; 2006.p. 761-87,1210-20.
2. Roberts JM. Pregnancy-related hypertension. In : Creasy RK, Resnik R, editors. Maternal-fetal
medicine : principles and practice. 5th ed. Philadelphia : Saunders; 2004. p. 859-93.
3. American College of Obstetricians & G7necologists. Diagnosis and management of
preeclampsia and eclampsia. ACOG Pract Bull 2002;(33).
4. American College of Obstetricians & Gynecologists. Chronic hypertension in pregnancy.
ACOG Pract Bull 2001; (29).
5. Clin Obstet Gynecol 1999;42:470-8.
6. Clin Obstet Gynecol 2004;47:118-273.
7. Gregg AR. Hypertension in pregnancy. Obstet Gynecol Clin N Am 2004;31:223-41.
8. The Royal Women’s Hospital. Clinical practice guidelines, pre eclampsia : management.
Available on line at : http://www.rwh.org.au/rwhcpg/maternity.cfm?doc-id=3403
9. Tuffnell DJ, Shennan AH, Waugh JJ, Walker JJ. The management of severe pre-eclampsia.
Royal College of Obstetricians and Gynecologists; 2006 Mar. 11 p. (Guideline; no. 1 (A))