• the presence of hypertension and proteinuria occurring after 20 th week of gestation

Indications of Severe Pre-eclampsia
Abnormality
Diastolic BP
Proteinuria
Headache
Visual disturbance
Upper abdominal pain
Oliguria
Convulsions
Serum creatinine
Thrombocytopenia
Liver enzyme
Fetal growth restriction
Pulmonary edema
Mild
< 100 mmHg
Trace to 1+
Absent
Absent
Absent
Absent
Absent
Normal
Absent
Minimal

Absent
Absent
Severe
110 mmHg
Persistent ≥ 2+
Present
Present
Present
Present
Present
Elevated
Present
Markedly

Obvious
Present

• According to Dept. of Health, Maternal Mortality
Rate (MMR)
– 162 out of 10,000 live births (Family Planning Survey
2006)
– Maternal deaths account for 14% of deaths among women
• For the past 5 years, all of the causes of maternal deaths exhibited an upward trend.
– Pre-Eclampsia showed an increasing trend of 6.89%,
20%, 40%, and 100%
– 10 women die everyday in the Philippines due to pregnancy and childbirth-related causes, such as preeclampsia

• BP 160/110 mmHg
• Proteinuria:
– at least 4 g/day or persistent > +2 on dipstick
• Oliguria:
– <400 cc/day
– Signifying decreased renal blood flow and diminished glomerular filtration rate
• Severe headache and visual disturbance
• Pulmonary edema or cyanosis
– Due to hemodynamic changes (inc. afterload)

• Abdominal pain (epigastric or RUQ location)
– distention of glisson’s capsule of the liver due to heptocellular edema and/or necrosis
• Hemolysis
– inc. serum LDH, hemoglobinuria, hyperbilirubinemi, presence of schistocytes
• Elevated liver enzymes
– Due to hepatocellular necorsis
• Thrombocytopenia
– Due to microangiopathic hemolysis induced by spasm

• Cardiovascular system: hypertension, vasoconstriction leading to cool peripheries, peripheral oedema
• Respiratory system: pulmonary edema, facial and laryngeal edema, acute respiratory distress syndrome
(ARDS)
• Renal system: proteinuria, oliguria, acute renal failure
• Central nervous system: hyperreflexia, clonus, cerebral haemorrhage, convulsions (eclampsia), papilloedema, coma
• Others: HELLP (Haemolysis, Elevated Liver Enzymes and
Low Platelets), thrombocytopenia, DIC (disseminated intravascular coagulopathy)
• Fetal signs include: CardioTocoGraphy (CTG) abnormalities, pre-term labour, and intrauterine growth retardation.

Risk factors associated with pregnant women:
• First pregnancy
• Age under 20 or above 35
• High BP before pregnancy
• Previous pre-eclamptic pregnancy
• Short interpregnancy intervals
• Family history
• Obesity
• DM, kidney disease, rheumatioud arthritis, lupus, or scleroderma
• Low socio-economic status
• Poor protein or low calcium in the diet

Risk factors associated with the fetus:
• Multifetal pregnancy
• Hydrops/triploidy
• Hydatidiform mole
Risk factors associated with the pregnant women’s husband:
• First time father
• Previously fathered a preeclamptic pregnancy

Risk factors and their odds ratio for pre-eclampsia
Nulliparity
Age >40 y
African-American race
Family history
Chronic renal disease
Chronic hypertension
Antiphospholipid syndrome
Diabetes mellitus
Twin gestation
High body mass index
Angiotensinogen gene T235
Homozygous
Heterozygous
10:1
2:1
4:1
3:1
3:1
3:1
1.5:1
5:1
20:1
10:1
20:1
4:1

• BP > 160/110 mmHg
• Proteinuria 2.0g/24 hrs or > 2+ dipstick
• Serum creatinine > 1.2 mg/dL unless previously elevated
• Platelets < 100,000 mm3
• Microangiopathic hemolysis: Elevated LDH

• Persistent headache, visual disturbance, epigastric pain
• Increase serum transaminase
• Obvious growth restriction
• Pulmonary edema: increase permeability in maternal circulation

1. Hematocrit
– Increased hematocrit levels in pre-eclampsia
2. Proteinuria
– More than 300 mg/24h or dipstick values of 1+ denotes poor prognosis
3. Serum uric acid
– Correlate with the development and severity of pre-eclampsia, and increased perinatal mortality

• Doppler velocimetry
– Diastolic notch
– Increased systolic/diastolic index (Stuart index)
– Pulsatility index
– Absence or reversed end diastolic blood flow

• 3 cardinal principles:
A. control of convulsions
B. Control of hypertension
C. Delivery at optimum time and mode

• D.O.C : MAGNESIUM SULFATE
– Versus Diazepam: reduced recurrence of convulsions; reduced maternal mortality; fewer
APGAR scores <7 at 5 mins.
– Versus Phenytoin: reduced recurrence of convulsions; fewer admissions to NICU and fewer babies who died
– Versus Lytic cocktail: reduced recurrence of convulsions; less respiratory depression; less maternal deaths

• Thus, Magnesium Sulfate:
- reduces risk of eclampsia
- Reduces risk of maternal death
• SIDE EFFECTS:
- neutropenia
- nosocomial infections in infants
- Lower fetal biophysical profile by decreasing breathing
- Increased incidence of nonreactive NST
- Decreased variability of FHR
- Disturbed fetal and maternal calcium homeostasis and bone density

• DOSE: a. Loading dose – 4 gm IV slowly over 5 mins
Maintenance dose -1-2 Gms per hour IV drip b. Loading dose – 4 Gm IV slowly over 5 mins and
10 gm IV (5gm on each buttock)
Maintenance – 5 Gms IM every 6 hours

• Monitoring:
– Presence of DTRs
– RR of >12 per minute
– Urine output at least 100cc every 4 hours
– Serum magnesium

• Use of anti-hypertensives for BP at least 160/110 mmHg – to prevent maternal CVA-Hemorrhage
– D.O.C: HYDRALAZINE
• Initial dose: 5 mg IV bolus followed by 5 mg incremental increases half-hourly if diastolic BP does not improve up to a total dose of 20mg
– Beta blockers (labetalol)
• Lowers systolic and diastolic BP
• Prevent more severe forms of PIH
• Prevent ventricular arrythmia, tachycardia and pulmonary edema
• ADVERSE EFFECTS on fetal growth and fetal hemodynamics

• Calcium-channel blocker
– Nifedipine
• Reduce maternal BP, proteinuria and improve renal function
• Given sublingually: prevent erythrocyte aggregation
– Nicardipine:
• More selective on peripheral vasculature
• Less inotropic effect: tachycardia, flushing and hot flushes
• Lower rate of placental transport with limited exposure of fetal tissues

• Sodium nitroprusside
– For signs of severe hypertensive encephalopathy
• ACE inhibitors
– Not recommended due to fetal side effects
(defective skull ossification, oligohydramnios, neonatal anuria)
• Diuretics
– Not used unless with evidence of pulmonary edema or congestion

OPTIMUM TIME AND MODE OF
DELIVERY
• 5 Factors:
1. Age of gestation
2. Severity of disease
3. Fetal status
4. Maternal condition
5. Nursery capabilities

OPTIMUM TIME AND MODE OF
DELIVERY
• General guidelines:
1. Hospitalize all patients once signs or symptoms of pre-eclampsia are evident
2. Immediate delivery done for: a) All cases of eclampsia regardless of age of gestation b) Severe pre-eclamptics at least 34 wks in presence of mature fetal lung and adequate nursery facilities;
- Complications may mandate delivery <34 wks AOG thus, steroids are advised

OPTIMUM TIME AND MODE OF
DELIVERY c. Severe maternal disease
- uncontrollable hypertension of 160/110
- oliguria <400 hours
- thrombocytopenia <100,000/cu SGPT
- pulmonary edema
- impending eclampsia d. Fetal compromise
- abnormal fetal movement counting
- CTGs
- BPS
- ARED patterns on Doppler velocimetry

OPTIMUM TIME AND MODE OF
DELIVERY
3. Presence of clinical disease at <34 wks AOG
- conservative management:
- evaluation of maternal and fetal status
- therapy with anticonvulsant, antihypertensive, low dose aspirin and high dose calcium
4. Labor and Delivery options:
- cervical ripening with oxytocin or prostaglandins
- amniotomy
- vaginal or cesarean delivery

OPTIMUM TIME AND MODE OF
DELIVERY
• Similar treatment protocol with Parkland hospital but we are more liberal on use of CS especially if:
– Intact fetus is growth restricted
– Bishop’s score <5
– Fetal BPS score <6/10
– CTG tracing shows persistent late or severe variable decelerations

• BMI > 30 increases the risk of pre-eclampsia
• Obesity  augmented placental production of leptin, adinopectin or triglycerides and inflammation
• Drinking water
• avoid salty foods, junk foods and foods that are fried
• Avoid alcohol and caffeinated beverages
• exercise

• Doses are kept at 60-80 mg/day
• Selective thromboxane
(TXL-A2) suppression with resultant dominance of endothelial prostacyclin
(PGI)
• Monitoring of platelet counts, coagulation profiles, fetal ductus arteriosus, urine production/amniotic fluid.
• Indications:
– High-risk
– Started during the 2 nd trimester to prevent fetal malformations
• Contraindications:
– Aspirin allergy or hypersensitivity (acid peptic disease or coagulopathy

• oral intake of calcium (2g/day)
• Reduction in IUGR and BP levels
• Exerts a negative feedback effect on parathyroid hormone
 decrease calcium  smooth muscle relaxation and diminished responsiveness to pressor stimuli

• Associated with higher levels of calcium excretion which is coupled with an ion exchange with magnesium sulfate
• Increased levels of magnesium sulfate  smooth muscle relaxation in blood vessels  control of hypertension