PREECLAMPSIA & ECLAMPSIA

Hypertension
Sustained BP elevation of 140/90 or greater

PIH

Gestasional
Preeclampsia

Chronic
Mild

Severe

HELLP
Synd

Effect
Impending
eclampsia

Eclampsia

20

Proteinuria (-)

Proteinuria (+)

Preeklampsia
Hipertensi kronik

Hipertensi Gestasional
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
P a t i e n t w it h H y p e r t e n s i o n
E le v a te d B P a b o v e
f ir s t t r im e s t e r
l e v e ls
5 5 -7 5 %

G e s t a t io n a l h y p e r t e n s io n
N o p r o t e i n u r ia
5 - 1 0 % o f s in g l e t o n s 25%
3 0 % o f m u lt ip le s
5 -8

P r e e c la m p s ia
H y p e r te n s io n
P r o t e i n u r ia
% o f p r o g n a n c ie s

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
Multifetal gestations
Maternal age over 35
Preeclampsia in a
previous pregnancy
Chronic hypertension
Pregestational diabetes

Vascular and connective

tissue disorders
Nephropathy
Antiphospholipid
syndrome
Obesity
African-American race

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 2-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 DTRs
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
DTRs 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
LFTs - 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.