Aboubakr Elnashar

1. PREECLAMPSIA‐ECLAMPSIA
SPECTRUM
Prof.
Aboubakr
elnashar
Benha
university
Hospital,
Egypt
ABOUBAKR
ELNASHAR
INTRODUCTION
HYPERTENSIVE
DISORDERS
OF
PREGNANCY
•
Present
in
up
to
10%
of
pregnancies
▪
In
US:
▪
The
6
th
leading
cause
of
MM
▪
9.9%
of
MM
▪
In
Egypt:
▪
2
nd
leading
cause
of
MM
▪
15%
of
MM
▪
Leading
cause
of
neonatal
mortality/morbidity,
primarily
due
to
the
effects
of
preterm
delivery
ABOUBAKR
ELNASHAR

2. ABOUBAKR
ELNASHAR
Preeclampsia‐Eclampsia
Spectrum
•
Greatest
cause
of
maternal/perinatal
morbidity&
mortality
•
Includes:
–
Preeclampsia‐specify
with
or
without
severe
features
–
Terminology
change:
mild
preeclampsia
is
no
longer
used!
–
Preeclampsia
superimposed
on
chronic
HTN
–
Eclampsia
–
HELLP
syndrome
ABOUBAKR
ELNASHAR

3. Eclampsia
•
Define:
seizures
in
a
patient
with
PET
•
Etiology:
uncertain
–
±cerebral
edema,
cerebral
ischemia
•
BP:
▪
often
significantly
elevated
▪
15%
of
cases
BP
may
be
normal
(diastolic
≤90
mm
Hg)
▪
Onset:
Can
occur
before,
during,
or
after
delivery
ABOUBAKR
ELNASHAR
HELLP
Syndrome
•
A
presentation
of
PET
with
severe
features
•
HELLP
acronym:
–
Hemolysis
–
Elevated
Liver
enzymes
–
Low
Platelets
ABOUBAKR
ELNASHAR

4. 1.
DEFINITION
❑
ACOG,
2013,
2015
▪
Syndrome
of
new
onset
of
Hypertension
and
either
Proteinuria
or
End
organ
dysfunction
after
20
w
in
a
previously
normotensive
woman
ABOUBAKR
MOHAMED
ELNASHAR
ABOUBAKR
ELNASHAR
International
Society
for
the
Study
of
Hypertension
Pregnancy
(ISSHP).2018
Hypertension
SBP
at
≥140
mm
Hg
&/or
DBP
at
≥90
mm
Hg
on
at
least
two
occasions
measured
4
hours
apart
in
previously
normotensive
women
accompanied
by
one
or
more
of
the
following
new-
onset
conditions
at
or
after
20
w:
1.
2.
3.
Proteinuria
Maternal
organ
dysfunction
Uteroplacental
dysfunction
ABOUBAKR
MOHAMED
ELNASHAR
ABOUBAKR
ELNASHAR

5. ❑Proteinuria:
▪No
longer
▪Required
alone
in
diagnosis
▪Useful
in:
▪classifying
PET
as
severe
▪deciding
whether
to
induce
{amount
not
shown
to
predict
either
maternal
or
fetal
outcomes}
(ACOG,
2013)
▪Heavy
(5
g/24
h)
has
been
eliminated
as
a
criterion
for
diagnosing
severe
PET
▪Testing
may
be
discontinued
once
significant
proteinuria
has
been
demonstrated
ABOUBAKR
ELNASHAR
2.
PATHOGENESIS
▪2
STAGES:
1
&2
▪3
TYPES:
early,
preterm,
term
▪3
MECHANISMS:
Vasospasm,
capillary
leak,
activation
of
coagulation
▪4
THEORIES:
▪Multisystem
disorder
ABOUBAKR
ELNASHAR

6. Stage
I
Impaired
endothelization
of
cytotrophoblast
Inadequate
invasian
of
the
spiral
arteries
in
to
myometrium
Placental
Ischemia
Placental
hypoxia
↓Production
of
Pro-angiogenic
factors
PLGF,
VEGF
Release
of
anti-angiogenic
factors
such
as
SFLT-1,
PGs
&
Cytokines
into
the
maternal
circulation
Stage
II
(fate
in
pregnancy)
Oxidatively
stressed
placenta
Systemic
endothelial
dysfunction
&
Inflam.
response
↑systemic
vascular
resistance
activation
of
coagulation
cascade
clinical
manifestation
like
hypertension
&
proteinuria
ABOUBAKR
ELNASHAR
hemoconcentration
edema
proteinuria
thrombocytopenia
oliguria
HTN
seizures
abruption
liver
ischemia
Endothelial
activation
Vasoactive
agents:
Prostaglandins
nitric
oxide
endothelins
Noxious
agents:
Cytokines
Lipid
peroxidases
Vasospasm
Capillary
leak
Activation
of
coagulation
Reduced
uteroplacental
perfusion
Maternal
vascular
disease
Excessive
trophoblast
Faulty
placentation
Genetic,
immunologic,
inflammatory
factors
ABOUBAKR
ELNASHAR

7. ▪
Classification
according
to
onset
*higher
risk
of
short&long-term
Morbidity
&
mortality.
(Lisonkova
et
al,
2014)
Preterm
Term
maternal&
perinatal
ABOUBAKR
MOHAMED
ELNASHAR
<34
w
34-37
w
≥37
w
Early*
Preterm
Term
Preterm
Term
ABOUBAKR
ELNASHAR
▪4
THEORIES
1.
Impaired
vascular
remodeling
of
the
fetal
maternal
interface
2.
Excessive
immune
response
to
paternal
antigen
3.
Exaggerated
systemic
inflammatory
response
4.
Placental
&
endothelial
dysfunction
ABOUBAKR
ELNASHAR

8. ABOUBAKR
ELNASHAR
3.
PREDICTION=SCREENING
NICE:
women
should
be
considered
to
be
at
high
risk
of
developing
PE
if
they
have
any
one
high-risk
factor
hypertensive
disease
in
previous
pregnancy=
7X
risk
chronic
hypertension
chronic
renal
disease
DM
autoimmune
disease
any
two
moderate-risk
factors
nulliparity
age
≥40
y
BMI
≥35
kg/m
2
,
family
history
of
PE,
or
interpregnanc
AB
y
OUB
i
A
n
KR
t
M
e
O
r
HA
v
M
a
ED
l
ELN
>
AS
1
HA
0
R
y
ABOUBAKR
ELNASHAR

9. ACOG
2015
women
with
a
history
of
early-onset
PE:
7X
risk
preterm
delivery
≤34
w,
≥one
prior
pregnancy
complicated
by
PE
ABOUBAKR
MOHAMED
ELNASHAR
ABOUBAKR
ELNASHAR
F
I
G
O
,
2
0
1
9
:
Criticism:
1.
Each
risk
factor
as
a
separate
screening
test
with
additive
detection
rate&
screen-positive
rate.
2.
Maternal
risk
factors
is
not
a
sufficient
tool
for
the
effective
prediction
of
PE.
ABOUBAKR
MOHAMED
ELNASHAR
Guidelines
Detection
rate
of
False+ve
Preterm
PE
Term
PE
NICE
39%
34%
10%
US
preventive
TF
90%
89%
64%
ABOUBAKR
ELNASHAR

10. Combined
Risk
Assessment
Patient-specific
risk
for
preterm
PE
is
calculated
using
the
Bayes-based
method.
The
risk
calculator
available
free
of
charge
on
the
webpage
https://fetalmedicine
FMF
mobile
app.
medical
records
software.
ABOUBAKR
MOHAMED
ELNASHAR
ABOUBAKR
ELNASHAR
1.
Risk
Factors:
Maternal
Age,
y
Maternal
Maternal
Maternal
Obstetric
weight,
kg
height,
cm
ethnicity:
white,
Afro-Caribbean,
South
Asian,
East
Asian,
Mixed
Nulliparous,
parous
without
prior
PE,
parous
with
prior
PE
Interpregnancy
interval
in
years
between
the
birth
of
the
last
child
Gest
age
at
delivery
birth
weight
of
previous
pregnancy
beyond
24
w
Medical:
Family
history
of
PE
(mother)
Method
of
conception:
spontaneous,
ov
induction,
Smoking
habit
IVF
History
History
History
of
of
of
chronic
hypertension
DM:
type
1,
type
2,
insulin
intake
SLE
or
anti
p
hosol
i
p
i
d
syndrome
ABOUBAKR
ELNASHAR

11. 2.
Measurement
Of
Blood
Pressure
measured
by
validated
automated&semiautomated
devices
The
measured
sBP
and
dBP
will
be
automatically
converted
to
MAP
by
the
risk
calculator.
MAP=dBP+(sBP−dBP)∕3
MAP
is
converted
to
a
multiple
of
median
(MoM),
adjusting
for
these
associated
maternal
characteristics&
gestational
age
will
be
used
for
calculation
of
patient-specific
risk.ABOUBAKR
MOHAMED
ELNASHAR
ABOUBAKR
ELNASHAR
3.
Measurement
Of
Uterine
Artery
Pulsatility
TA
US:
done
at
11+0
to
13+6
w
corresponding
to
CRL
42–84
mm
Index
Gest
age
determined
from
measurement
CRL.
UTPI
Abnormal
if
≥90th
percentile
Is
adjusted
for
associated
maternal
characteristics&
gest
age
by
converting
it
to
a
MoM
ABOUBAKR
ELNASHAR

12. Identification
of
the
uterine
artery
at
the
level
of
the
internal
os
(left)
and
typical
waveforms
of
the
uterine
artery
Doppler
in
the
first
trimester
of
pregnancy.
ABOUBAKR
MOHAMED
ELNASHAR
ABOUBAKR
ELNASHAR
4.
Measurement
Of
Biochemical
Markers
PLGF.
The
best
biochemical
marker
PAPP-A
if
measurements
of
PLGF&
UTPI
are
not
available.
ABOUBAKR
MOHAMED
ELNASHAR
ABOUBAKR
ELNASHAR

13. ABOUBAKR
MOHAMED
ELNASHAR
ABOUBAKR
ELNASHAR
ABOUBAKR
MOHAMED
ELNASHAR
ABOUBAKR
ELNASHAR

14. If
Calculated
risk:
≥1
in
100
A
woman
is
at
high
risk
The
first-trimester
combined
test
most
predictive
of
preterm
PE
but
not
term
PE.
The
best
model
is
the
one
that
combines
1.
2.
3.
4.
Risk
factors
MAP
UTPI.
PLGF
ABOUBAKR
MOHAMED
ELNASHAR
ABOUBAKR
ELNASHAR
4.
PREVENTION
FIGO,
2019
Women
at
high
risk
should
receive
aspirin
prophylaxis
Start
at
11–14+6
w
Dose:
~150
mg
minimum:
100mg/d
Every
night
Stop:
▪
36
w,
when
delivery
occurs,
or
▪
PE
is
diagnosed.
ABOUBAKR
MOHAMED
ELNASHAR
ABOUBAKR
ELNASHAR

15. In
women
with
low
calcium
intake
(<800
mg/d),
either
calcium
replacement
(≤1
g
elemental
calcium/d)
or
calcium
supplementation
(1.5–2
g
elemental
calcium/d)
may
reduce
the
burden
of
both
early&late-onset
PE.
ABOUBAKR
MOHAMED
ELNASHAR
ABOUBAKR
ELNASHAR
The
benefit
of
other
treatments,
such
as
B
e
d
r
e
s
t
❑
Heparin
Vit
C&
E
Magnesium
Folate
Metformin,
and
Statin
for
prophylaxis
of
preterm
PE
not
yet
based
on
credible
evidence
their
use
solely
is
neither
justified
nor
recommended.
ABOUBAKR
ELNASHAR

16. 5.
DIAGNOSIS
OF
PREECLAMPSIA
▪
New
onset
hypertension
after
20
weeks
with
proteinuria:
▪
Hypertension:
–
BP
≥140/90
mm
Hg
two
times,
taken
4
hours
apart
–
BP
≥160/110
mm
Hg
once
▪
Proteinuria
is
defined
by:
–
24
hour
protein
≥300
mg
–
Timed
urine
protein
level
extrapolated
out
to
24
hour
value
–
Protein/creatinine
ratio
of
≥0.3
–
Urine
dip
+
1
or
more
(only
if
other
methods
are
not
available)
–
Proteinuria
is
NOT
required
if
the
patient
has
new
onset
HTN
with
specified
findings
ABOUBAKR
ELNASHAR
▪
Diagnosing
Preeclampsia
Without
Proteinuria
•
New
onset
HTN
with
any
of
these
findings:
–
Platelets
<100,000/uL
–
Creatinine
>1.1
mg/dL
or
doubled
from
baseline
–
Transaminases
twice
the
normal
levels
–
Pulmonary
edema
–
Cerebral
or
visual
symptoms
ABOUBAKR
ELNASHAR

17. ▪
Clinical
features
of
severe
PET
▪
In
addition
to
hypertension
&
proteinuria:
▪
Severe
headache
▪
Visual
disturbance
▪
Papilloedema
▪
Liver
tenderness
▪
Epigastric
pain
▪
Vomiting
▪
Signs
of
clonus
▪
Platelet
count
<100
x
10
6
/l
▪
Abnormal
liver
enzymes
(ALT
or
AST≥
70
iu/l)
▪
HELLP
syndrome.
ABOUBAKR
ELNASHAR
▪
Clinical
Presentation
of
HELLP
•
Extremely
variable
presentation
of
symptoms
•
Common
findings:
–
RUQ
pain,
epigastric
pain,
n&v
–
85%
hypertensive
•
DD:
biliary
colic,
pancreatitis,
fatty
liver
of
pregnancy,
GERD,
hepatitis,
idiopathic
thrombocytopenic
purpura
(ITP),
thrombotic
thrombocytopenic
purpura
(TTP)
•
Timing
of
diagnosis:
30%
of
women
are
postpartum
ABOUBAKR
ELNASHAR

18. ▪
Laboratory
Findings
in
HELLP
•
Hemolysis
–
Abnormal
peripheral
smear
–
LDH
elevated
•
Liver
enzymes
–
Transaminases
>
twice
the
normal
•
Platelet
count
–
<100,000/uL
ABOUBAKR
ELNASHAR
▪
Management
of
HELLP
•
Similar
to
preeclampsia
with
severe
features
–
Stabilize
mother
–
Evaluate
fetus
for
compromise
–
Determine
optimal
timing/route
of
delivery
–
Use
continuous
fetal
monitoring
–
Manage
BP
and
fluid
status
•
All
women
should
receive
MgSO4
while
symptomatic
or
in
labor
ABOUBAKR
ELNASHAR

19. ❑Measurement
of
blood
pressure
1.
Patient:
▪
Rested
▪
Sitting
at
a
45-degree
angle.
2.
BP
cuff:
▪
appropriate
size
▪
placed
at
the
level
of
the
heart.
3.
Readings:
▪
Multiple
readings
{confirm
the
diagnosis}.
▪
Korotkoff
phase
5
for
DBP.
4.
The
method:
Automated:
used
with
caution
{underestimate
particularly
SBP}
ABOUBAKR
ELNASHAR
6.
MANAGEMENT
OF
PREECLAMPSIA
WITHOUT
Severe
Features
•
Expectant
management
before
37
w:
•
Mat:
▪
Closely
watch
for
development
of
severe
features
▪
CBC,
transaminases,
creatinine,
LDH,
uric
acid
▪
Weekly
labs
–
CBC,
transaminases
(AST,
ALT)
–
No
need
to
follow
urine
protein,
as
even
>5
g
is
not
considered
a
“severe
feature”
▪
Foetal:
Antepartum
surveillance
–
NST’s,
amniotic
fluid
measurement,
biophysical
profile
–
Growth
ultrasound
every
3
to
4
w
•
Delivery
at
37
weeks
ABOUBAKR
ELNASHAR

20. WITH
Severe
Features
•
Admit
to
hospital
&
monitor
closely
on
bedrest
•
Treatment
goals:
1.
Prevent
seizures
2.
Control
BP
to
prevent
cerebral
hemorrhage
3.
Expedite
delivery,
balancing
maternal
condition
and
fetal
maturity
ABOUBAKR
ELNASHAR
I.
Maternal
assessment
&
monitoring
II.
Foetal
assessment
III.Control
BP
IV.Prevention
of
seizures
V.
Control
of
seizures
VI.
Fluid
balance
VII.Delivery
VIII.
Postparum
ABOUBAKR
ELNASHAR

21. I.
Maternal
assessment
and
monitoring
1.
Symptoms:
▪
Important
components
of
worsening
disease,
particularly
headache&
abdominal
pain.
▪
At
least
every
8
hours
▪
For
▪
Headache,
visual
changes,
▪
RUQ
or
epigastric
pain,
retrosternal
pain
or
▪
Convulsions
ABOUBAKR
ELNASHAR
2.
Vital
signs
1.
BP:
/15
m
until
the
woman
is
stabilised
and
then
/30
m
in
the
initial
phase
of
assessment.
/4-h
if
a
conservative
management
plan
and
the
woman
is
stable
and
asymptomatic.
2.
Maternal
tendon
reflexes:
▪
Assess
Mg
toxicity
▪
Assess
risk
of
convulsion.
▪
Every
15
to
60
minutes
until
stable
ABOUBAKR
ELNASHAR

22. 3.
Continuous
oxygen
saturation
monitoring
with
a
pulse
oximeter:
▪
Valuable
▪
{give
early
signs
of
pulmonary
oedema}.
4.
Input
&
output
▪
Insert
foley
catheter
if
needed
in
acute
situation
,
especially
in
the
immediate
postpartum
period.
▪
Notify
for
<30
mL
urine
per
hour
▪
Increasing
oedema:
Not
in
itself
a
sign
that
should
determine
management.
ABOUBAKR
ELNASHAR
3.Labs
daily
1.
CBC,
liver
function,
renal
function
tests.
▪
At
least
daily
when
the
results
are
normal
▪
More
often
if
the
clinical
condition
changes
or
if
there
are
abnormalities.
2.
Clotting
studies
▪
Not
required
if
the
platelet
count
>100
x
10
6
/l.
3.
Consider
peripheral
blood
smear
4.
Type
&
screen
in
labor
ABOUBAKR
ELNASHAR

23. ▪Uric
acid:
rise
▪
Correlates
with
poorer
outcome
for
both
mother&
baby.
▪
Confirms
the
diagnosis
of
PET
▪
Should
not
be
used
for
clinical
decision-making.
▪Creatinine
▪
Elevated
early
in
the
disease
process:
underlying
renal
disease
should
be
suspected.
▪
In
severe
disease:
rise:
worsening
outcome
ABOUBAKR
ELNASHAR
▪Platelet
count
<100x10
6
:
worsening
disease
coagulation
abnormality
consideration
for
delivery.
▪Platelet
volume
may
be
of
benefit
but
are
as
yet
unproven.
ABOUBAKR
ELNASHAR

24. ▪AST
>75
iu/l
or
ALT
>70
iu/l
▪
Significant
▪
>150
iu/l:
increased
maternal
morbidity
▪Diagnosis
of
HELLP
syndrome
1.
Haemolysis:
LDH
levels,
or
blood
film
(fragmented
red
cells).
2.
Platelet
count:
<100
x
10
6
ABOUBAKR
ELNASHAR
II.
Foetal
assessment
1.
In
the
acute
setting:
▪
CTG:
assess
fetal
wellbeing
at
that
time
but
does
not
give
any
predictive
information.
2.
In
labour:
continuous
electronic
fetal
monitoring.
3.
In
Conservative
management:
Serial
assessment
will
allow
timing
of
delivery
to
be
optimized.
1.
US
a.
fetal
size:
IUGR
30%
of
PET
usually
asymmetrical:
AC
is
the
best
for
assessment
b.
liquor
volume.
▪
Reduced:
placental
insufficiency
and
IUGR.
▪
Serial
estimations:
detect
fetal
compromise.
ABOUBAKR
ELNASHAR

25. III.
Control
BP
▪
Antihypertensive
treatment
▪
Indications:
1.
SBP>
160
mmHg
or
DBP>110
mmHg.
2.
SBP
<160
plus
▪
Severe
disease
▪
Heavy
proteinuria
or
▪
Disordered
liver
or
haematological
test)
{alarming
rises
in
BP
may
be
anticipated}
▪
Objective:
▪
There
is
an
increasing
trend
toward
tighter
BP
control
▪
SBP:
below
150
mm
Hg
▪
DBP:
80-100
mm
Hg
ABOUBAKR
ELNASHAR
▪Drugs:
▪
Labetalol&hydralazine
for
acute&severe
(ACOG,
2013)
▪
Labetalol
[NICE,
2012]
▪
Acute,
severe:
▪Nifedipine:
oral
not
sublingually
▪
IR
cap:10
mg
initial;
repeat
after
30
m
if
necessary
▪
IR
cap:
10-30
mg
tid;
not
to
exceed
120-180
mg/d
ABOUBAKR
ELNASHAR

26. ▪
Hydralazine:
IV:
▪
Initial
dose:
5
mg
over
2
minutes
▪
After
20
minutes,
if
BP
remains
≥160/110
mm
Hg,
repeat
with
10
mg
▪
No
more
than
4
doses.
▪
If
not
give
Labetalol
or
Nifidipine.
▪
Maintenance:
10
mg/h
▪
Add
2ml
NS
to
reconstitute
20
mg
hydralazine.
Withdraw
0.5
ml
hydralazine
solution
and
add
9.5
ml
NS
to
give
total
10
ml
solution.
ABOUBAKR
ELNASHAR
▪Labetalol:
IV:
▪
Initial
dose:
20
mg
IV
bolus
over
2
minutes
▪
If
BP
remains
≥160/110
mm
Hg,
then
repeat
10
minutes
later
with
40
mg
IV,
and
10
minutes
later
at
80
mg
IV.
If
BP
remains
≥160/110
mm
Hg,
switch
to
hydralazine
▪
Maximum
daily
IV
dose
of
300
mg
▪
Maintenance:
40
mg/h
ABOUBAKR
ELNASHAR

27. ABOUBAKR
ELNASHAR
ABOUBAKR
ELNASHAR

28. ▪
Chronic,
moderate:
▪
Nifedipine:
SR
tab:
30-60
mg
qd;
not
to
exceed
90-120
mg/d
▪
Hydralazine:
Oral:
25
mg
tds
▪
Labetalol:
▪
100
mg
bid
▪
should
be
avoided
in
asthma.
▪
Methyldopa
▪
was
the
most
commonly
used
therapies
in
UK.
▪
safe
in
long
term
follow-up
of
the
delivered
babies
▪
some
studies
have
suggested
some
benefits
of
labetalol.
ABOUBAKR
ELNASHAR
▪Atenolol:
increase
in
IUGR.
▪ACE
inhibitors
and
ARBs:
▪contraindicated
▪{unacceptable
fetal
adverse
effects}.
▪Diuretics
▪
relatively
contraindicated
for
hypertension
▪
should
be
reserved
for
pulmonary
oedema.
ABOUBAKR
ELNASHAR

29. IV.
Prevention
of
seizures:
Mg
S
▪
Preferred
anticonvulsant
–
Slows
neuromuscular
conduction&
decreases
CNS
irritability
–
No
significant
effect
on
BP
–
Prevents
seizures
(NNT
=
100
for
all
women
with
preeclampsia;
NNT
=
400
for
preeclampsia
without
severe
features
)
–
Decreases
risk
of
placental
abruption
(NNT
=
100)
ABOUBAKR
ELNASHAR
▪Indication:
▪
Severe
PET:
when?
▪
Once
a
delivery
decision
has
been
made
&
in
the
immediate
postpartum
period.
▪
When
conservative
management
of
a
woman
with
severe
hypertension
and
a
premature
fetus
is
made
it
would
be
reasonable
not
to
treat
until
the
decision
to
deliver
has
been
made.
▪
Should
be
considered
for
women
with
PET
for
whom
there
is
concern
about
the
risk
of
E.
ABOUBAKR
ELNASHAR

30. ▪
Dosage
▪
Loading:
4
to
6
g
IV
over
15
to
20
min
▪
Maintenance:
continuous
infusion
of
1-2
g/h
▪
Continued
for
▪
24
h
following
delivery
or
▪
24
h
after
the
last
seizure,
whichever
is
the
later,
unless
there
is
a
clinical
reason
to
continue.
▪
Regular
assessment
of:
a.
Urine
output
b.
Maternal
reflexes
c.
Respiratory
rate
d.
Oxygen
saturation
.
ABOUBAKR
ELNASHAR
▪
Check
magnesium
level
if:
–
Urine
output
<30
mL/hour
–
Elevated
serum
creatinine:
MgSO4
toxicity
is
uncommon
with
normal
renal
function
–
Symptoms
of
MgSO4
toxicity
–
Loss
of
patellar
reflexes
ABOUBAKR
ELNASHAR

31. V.
Control
of
seizures
•
Avoid
anticonvulsant
polypharmacy
•
Protect
airway
to
minimize
aspiration
•
Prevent
maternal
injury
•
Administer
MgSO4
to
control
convulsions
•
When
stable,
plan
for
delivery
ABOUBAKR
ELNASHAR
I.
1.
Do
not
leave
the
patient
alone.
2.
Prevent
maternal
injury
during
the
convulsion.
3.
Call
for
help&
place
a
code
blue
call-
Medical
Emergency
call.
4.
Initiate
resuscitation.
5.
Turn
the
patient
into
left
lateral
position
when
able
to
do
so.
6.
Inform
consultant
obstetrician&
anesthetist
on
call.
ABOUBAKR
ELNASHAR

32. II.
AIRWAY
1.
Assess
&
maintain
patency,
using
oral
suction
if
necessary.
2.
Insert
a
plastic
oral
airway
if
possible
3.
Administer
oxygen
therapy
via
face
mask.
III.
BREATHING
1.
Assess
respiratory
rate
2.
Ambubag
using
facial
mask/laryngeal
mask
or
endotracheal
tube
if
necessary.
ABOUBAKR
ELNASHAR
IV.
CIRCULATION
1.
Evaluate
Pulse
&
B
P.
If
absent,
initiate
CPR.
2.
Secure
IV
access
as
soon
as
possible
▪
with
main
line
infusion
▪
with
three-way
tap
attached
▪
Hartmann's
Solution
▪
very
slow
rate,
as
fluid
intake
will
be
restricted
to
1
ml/kg/h
3.
Pulse
oximetry
is
helpful.
ABOUBAKR
ELNASHAR

33. V.
Mg
SO4
▪Therapy
of
choice
to
control
seizures.
▪Loading
dose:
4-6
g
infusion
pump
over
5–10
min
▪Maintenance:
1-2
g/h
for
24
h
after
the
last
seizure.
▪Recurrent
seizures
Further
bolus
of
2
g
Mg
SO4
or
an
increase
in
the
infusion
rate
to
1.5
g
or
2.0
g/h.
ABOUBAKR
ELNASHAR
VI.
Once
stabilized
▪Plans
should
be
made
to
deliver
the
woman
▪No
particular
hurry
&
a
delay
of
several
hours
to
make
sure
the
correct
care
is
in
hand
is
acceptable,
assuming
that
there
is
no
acute
fetal
concern
such
as
a
fetal
bradycardia.
▪The
woman’s
condition
will
always
take
priority
over
the
fetal
condition.
ABOUBAKR
ELNASHAR

34. VI.
Fluid
balance
1.
Fluid
restriction
is
advisable
{reduce
the
risk
of
fluid
overload
in
the
intrapartum&
postpartum
periods}
Total
fluids
should
be
limited
to
80
ml/h
or
1
ml/kg/h
{a.
pulmonary
oedema
has
been
a
significant
cause
of
maternal
death.
b.
No
evidence
of
the
benefit
of
fluid
expansion
c.
fluid
restriction
regimen
is
associated
with
good
maternal
outcome.
d.
No
evidence
that
maintenance
of
a
specific
urine
output
is
important
to
prevent
renal
failure,
which
is
rare.}ABOUBAKR
ELNASHAR
2.
The
regime
of
fluid
restriction
should
be
maintained
until
there
is
a
postpartum
diuresis,
as
oliguria
is
common
with
severe
pre-eclampsia.
3.
If
there
is
associated
maternal
he:
▪
fluid
balance
is
more
difficult
▪
fluid
restriction
is
inappropriate.
ABOUBAKR
ELNASHAR

35. VII.
Delivery
▪When:
•Once
the
woman
is
stable
and
with
appropriate
senior
personnel
present.
•If
the
fetus
is
<34
w&
delivery
can
be
deferred:
corticosteroids
should
be
given,
although
after
24
h
the
benefits
of
conservative
management
should
be
reassessed.
•Conservative
management
at
very
early
gestations
may
improve
the
perinatal
outcome
but
must
be
carefully
balanced
with
maternal
wellbeing.
ABOUBAKR
ELNASHAR
▪
Fetal
indications
▪
Severe
IUGR
▪
Nonreassuring
fetal
surveillance
▪
Oligohydramnios
▪
Maternal
indications
▪
Gestational
age
of
37
w
or
greater*
▪
Severe
PE:
▪
Platelet
count
below
100
×
10
3
per
mm
3
(100
×
10
9
per
L)
▪
Progressive
deterioration
of
hepatic
function
▪
Progressive
deterioration
of
renal
function
▪
Suspected
placental
abruption
▪
Persistent
severe
headache
or
visual
changes
▪
Persistent
severe
epigastric
pain,
nausea,
or
vomiting
▪
Eclampsia
ABOUBAKR
ELNASHAR

36. ▪
Method:
•Depend
on
1.
presentation
2.
fetal
condition
3.
likelihood
of
success
of
induction
of
labour
▪
Vaginal
delivery
is
preferred
due
to:
–
Lower
risk
of
bleeding,
infection,
anesthesia
reaction,
and
surgical
complications
–
Quicker
recovery
▪
CS
is
indicated
for:
–
Continuous
seizures
or
other
emergent
signs&
symptoms
–
Fetal
distress
–
Unfavorable
cervix
with
severe
prematurity(<30
w)
ABOUBAKR
ELNASHAR
▪
Anaethesia
▪
In
the
absence
of
contraindications,
all
of
the
following
are
acceptable
for
women
undergoing
CS:
▪
Epidural
▪
Spinal
▪
Combined
spinal-epidural,
and
▪
General
anaesthesia.
(A)
▪
Epidural/spinal
preferred
versus
general
▪
General
anesthesia
is
indicated
if
platelet
count
<50,000
▪
Regional
anaesthesia
for
women
on
LMWH:
▪
12
h
after
a
prophylactic
dose
▪
24
h
after
a
therapeutic
dose.
(B)
ABOUBAKR
ELNASHAR

37. ▪The
third
stage:
•5
u
IM
Syntocinon
or
5
u
IV
Syntocinon
given
slowly.
•Ergometrine
or
Syntometrine
should
not
be
given
for
prevention
of
hge
{can
further
increase
the
blood
pressure}.
ABOUBAKR
ELNASHAR
VIII.
Postpartum
management
▪
Improvement
is
usually
rapid
after
delivery
–
Risk
of
seizures
are
greatest
in
the
first
24
hours
after
birth
–
Diuresis
signals
resolving
of
the
disease
process
▪
Women
who
develop
hypertension
or
symptoms
of
PE
postnatally
(headaches,
visual
disturbances,
n&v
or
epigastric
pain):
▪
referred
for
a
specialist
opinion
▪
investigation
to
exclude
PE.
ABOUBAKR
ELNASHAR

38. ▪
In
Hospital
1.
Close
observation
▪
Postnatally
for
4
days
or
more
Women
who
deliver
with
severe
PET
(or
E):
▪
BP
and
input
&output
▪
If
blood
pressure
remains
elevated
24
hours
postpartum,
do
not
use
NSAID’s
for
pain
control
ABOUBAKR
ELNASHAR
2.
Anti-hypertensive
•Continued
as
dictated
by
BP.
•BP
should
not
exceed
160/110
mmHg
•Reduction
in
anti-hypertensive
therapy:
in
stepwise
fashion.
•Treat
persistent
HTN
•If
2
values
>150/100
mm
Hg
at
least
4
to
6
hours
apart
•Persistent
BP
>160/110
mm
Hg
(goal
is
to
treat
within
1
h)
•Avoid
alpha
methyldopa
•In
breastfeeding:
labetalol,
atenolol,
nifedipine
and
enalapril
can
be
given
ABOUBAKR
ELNASHAR

39. 3.
Magnesium
SO
▪
When
already
on
MgSO4,
continue
until
clinically
stable:
Usually
24
hours
postpartum
▪
Women
who
have
not
required
magnesium
prior
to
delivery
may
require
postpartum
initiation
of
MgSO4
if
the
following
occurs:
•
New
onset
of
HTN
with
cerebral
symptoms
(headache
or
blurred
vision)
•
PE
with
severe
HTN
(≥160/110
mm
Hg)
•
Eclampsia
ABOUBAKR
ELNASHAR
4.
Education:
▪
Signs/symptoms
of
postpartum
PET
at
the
time
of
discharge
▪
Understand
PET
may
occur
up
to
4
w
Postpartum
ABOUBAKR
ELNASHAR

40. ▪
Follow
up:
▪
BP
in
7
to
10
d
▪
BP
and
proteinuria
at
the
6
w.
▪
If
hypertension
or
proteinuria
persists
then
further
investigation
is
recommended.
▪
Preconceptional
counselling
ABOUBAKR
ELNASHAR
Thank
you
ABOUBAKR
ELNASHAR