Preeclampsia Eclampsia

Preeclampsia-Eclampsia
Dr.Sh.Pilehvari , MD
Endometrium and Endometriosis Research Center,

Hamadan University of Medical Sciences
2016-Kish
PREGNANCY-RELATED HYPERTENSIVE
DISORDERS
 Preecampsia
Eclampsia
HELLEP
 Chronic hypertension
 Preeclampsia superimposed upon chronic/ preexisting

hypertension
 Gestational hypertension
Preeclampsia
New onset hypertension and proteinuria OR

end organ dysfunction
OR both.
After 20 weeks in a normotensive woman.
Occur in 4.6 percent of pregnancies.
10 - 15% direct maternal death.
Risk factors
 Nulliparity
 Preeclampsia in a previous pregnancy
 Age >40 years or <18 years
 Family history of preeclampsia
 Chronic hypertension
 Chronic renal disease
 Autoimmune disease (eg, antiphospholipid syndrome, systemic
lupus erythematosus)
 Vascular disease
 Diabetes mellitus (pregestational and gestational)
 Multifetal gestation
Risk factors
 Hydrops fetalis
 Woman herself was small for gestational age
 Fetal growth restriction, abruptio placentae, or fetal demise in a
previous pregnancy
 Prolonged interpregnancy interval if the previous pregnancy was
normotensive. If the previous pregnancy was preeclamptic, a short
interpregnancy interval increases the risk of recurrence.
 Partner-related factors (new partner, limited sperm exposure [eg,
previous use of barrier contraception])
 In vitro fertilization
pathophysiology
 Involve maternal and fetal/placental factors.

 Abnormalities in development of placental vasculature
before clinical manifestations .
 placental under perfusion ,hypoxia and ischemia .
 Release circulating antiangiogenic factor
widespread maternal systemic endothelial dysfunction.
CLINICAL PRESENTATION
 Hypertention and proteinuria or end- organ dysfunction.
 In most ,after 34 wk ( late onset preeclampsia)
 10% before 34 wk (early onset preeclampsia)
 About 5 % post partum (48 h of delivery)
 Signs and symptoms :
• Severe HTN
• Persistent and /or hedache
• Visual abnormalities
• Nausea, vomiting
• Dyspnea,retrosternal chest pain
• Altered mental status
CLINICAL PRESENTATION
 Laboratory abnormalities
• Microangiopathic hemolytic anemia
• thrombocytopenia
• Elevated serum creatinine concentration
• Elevated liver enzymes
 Atypical peresentation
• Onset of signs/symptoms at<20 wk
• HTN or proteinuria with or without sign
• Delayed postpartum onset or exacerbation of disease>
2 days
Hepatic
 Periportal and sinusoidal fibrin deposition and microvascular
fat deposition
 RUQ or epigastric pain , coagulopathy ,elevated AST.ALT ,

subcapsular hemorrhage ,hepatic rupture
 Nausea and vomiting
 Liver tender to palpitation

course
 a progressive dis.
 Most signs in late pregnancy with gradual worsening
until delivery
 25%, especially early, HTN severe ,end organ
damage(days to weeks)
 2% eclampsia
 Preeclampsia associated with maternal/fetal sequelae
 Delivery placenta results complete resolution.
 Mobilization third-space fluid &diuresis 48 hours delivery
 HTN worsen during first and second postpartum week,
Most within four weeks postpartum normalize.
DIAGNOSIS
 SBP ≥ 140 or DBP ≥ 90 , and
Proteinuria ≥ 0.3 g in 24 hours or P/Cr ≥o.3 , or
Signs of end-organ dysfunction
 Initial assessment for proteinuria ,paper test strip ,clean midstream
urine≥ +1 that confirm by quantitative assessment.
 Mildly HTN ,at least two measurements ,four hours apart
 If asymptomatic , BP reassessed within three to seven days.
 If SBP≥160 mmHg or DBP ≥ 110 mmHg within minutes sufficient .
 when evaluating for preeclampsia , a new onset HTN in pregnancy is
preeclampsia even if criteria is not fulfilled.
DIAGNOSIS
 Post-diagnostic evaluation,purpose determine severity
of Dis and assess maternal and fetal well-being.
 History and physical examination
evaluate.(headache,visual abnormalities, epigastric
pain, nausea,vomiting, dyspnea,altered mental status )
 Minimum lab/imaging evaluation (Plt,Cr,AST or
ALT,Obstetrical ultrasound,Fetal assessment )
 Additional tests ,blood smear, LDH, Bill .
 Coagulation tests (Pt,PTT,fibrinogen) not checked
routinely , except thrombocytopenia or liver dis.
Differential diagnosis
 Preexisting HTN
 Superimposed preeclampsia
 Exacerbation of preexisting renal Dis.
 Antiphospholipid syn
 AFLP,TTP,HUS,SLE
 Mirror syn
EVLUATION
 Hospitalization
 Detailed examination as headache , visual disturbance
…….
 Weight daily
 Proteinuria
 Measurment Crt, AST , ALT, PLT , LDH, Uric Acid
 Evalution Fetus
Manangement
 in managing preeclamptic patients three basic tenets
considered:
• First ,Delivery always appropriate therapy for maternal not
always for fetus .
• Second , Signs and symptoms pathogenetically not
important .
• Third , pathgenetic changes occur long before
manifestations .
 Delivery is based gestational age, severity Disease,
maternal and fetal condition
Management
 in preeclampsia with features severe ,Indication of
delivery :
• Before fetal viability
• At ≥ 34wk
• Maternal or fetal condition is unstable ,regardless GA.

Management
preeclampsia without features severe disease
• Delivery in ≥ 37 weeks even in absence severe
disease.( mild preeclampsia)
• Used in cervical ripening agents in unfavorable cervices.
• Optimum management in without severe 34- 36
uncertain.
• < 34 weeks recommend expectant management .
Management
In patient versus outpatient care :
• Close maternal monitoring to establish severity.
• Be able to comply frequent maternal and fetal

evaluations.
Management
 Minimum laboratory evaluation include PLT,Cr, liver
enzymes.
 Repeated weekly
 Other tests ,HCT ,LDH ,indirect bilirubin ,blood smear
 Treatment HTN
 Assessment of fetal well-being ,fetal growth
 Antenatal corticosteroids
Interpartum Manangment
 Continuous maternal-fetal monitoring
 Fluids balance monitor, maintenance of 80 ml/ hour in
absence ongoing fluid loss.
 Diuretics in pulmonary edema.
 management of HTN.
 management of thrombocytopenia.
 Anesthesia.
 Invasive hemodynamic monitoring.
Management
Seizure prophylaxis ,Magnesium sulfate
• Dosing
• Duration of therapy
• Complications and side effects

Management
POSTPARTUM MANANGMENT
• NSAIDS for pain control avoided.
• Monitor vital signs every two hours and repeat tests
until two sets.
• treatment of severe HTN until BP normal
• Control HTN 72 hours postpartum and again 7-10 days
post-delivery.
prevention
 Antiplatelet agents
 Calcium supplementation
 Antioxidants
 Vitamins C and E
 fish oil
 Nitric oxide, l-arginine
prevention
 Vitamin D supplements
 weight loss
 folic acid supplementation
 ANTIHYPERTENSIVE DRUGS
 STATINS
 OTHER
• Exercise
• Physical activity
Long term maternal risks
Cardiovascular disease
Diabetes mellitus
End- organ renal disease
Subclinical hypothyroidism
Cancer
other
Eclampsia
 In 2-3 % severe preeclampsia without anti-seizure
 In 0.06 % preeclampsia without severe features
 Risk factors similar to preeclampsia
 Precise cause of seizure in these is not clearly
understood
 Two models based on central role of hypertension
• breakdown of auto regulatory system cerebral
circulation, edema.
• activation of auto regulatory system, ischemia.
clinical presentation
 Most women have signs/symptoms hours before initial
seizure:
• Hypertension (75%)
• Headache (66%)
• Visual disturbances (27%)
• Right upper quadrant or epigastria pain(25%)
 Asymptomatic (25%)
 Generalized tonic-clonic seizure or coma
 Most begin to recover within 10 to 20 min after
convulsion
clinical presentation
 Fetal bradycardia at least 3-5 min in during ,
immediately seizure.
 FHR pattern improves maternal and fetal therapeutic
interventions .
 Other finding
EEG
Neuroimaging
Neurologic histopathology
DIAGNOSIS
Diagnosis Typically clinical

In atypical cases such as persistent neurologic
deficits ,consciousness prolonged ,>48 hours
delivery , before 20 weeks,…
evaluate for other causes seizures .
Differential diagnosis
Molar pregnancy ,seizure unrelated to
pregnancy
Anatomic abnormality in persistent nourologic
deficits
Metabolic abnormality
TTP or HUS
Management
key principles :
• Prevention of maternal hypoxia and trauma
• Treatment of severe hypertension
• Prevention of recurrent seizures
• Evaluation for prompt delivery
Administration of magnesium sulfate
• Loading dose
• Maintenance dose
Management
 Management of persistent seizures
• Diazepam – 5to 10 mg IV /5 to 10 min
• Lorazepam- 4 mg IV –MAX 2mg/min
• Midazolam - 1to2 mg bolus IV 2mg/min
 Not improve within 10-20 min evaluate by
neurologist .
 If FHR pattern not improve within 10-15 min after resuscitation
,occult abruption and emergent delivery .
Management
Definitive treatment is prompt delivery.
Mode of delivery based on GA ,cervix

,fetal condition &position in laber.
Eclampsia
 POSPARTUM CARE
 PREGNANCY OUTCOME
• Maternal
• Fetal and neonatal
 LONG-TERM PROGNOSIS
 Outcome of future pregnancies
 Long-term maternal health
CAN ECLAMPSIA PREDICTED AND PREVENTED
?
THANKS FOR ATTENTION

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Preeclampsia-Eclampsia

Endometrium and Endometriosis Research Center,

 Preeclampsia superimposed upon chronic/ preexisting

New onset hypertension and proteinuria OR

 Involve maternal and fetal/placental factors.

 RUQ or epigastric pain , coagulopathy ,elevated AST.ALT ,

 Nausea and vomiting

 Liver tender to palpitation

• Maternal or fetal condition is unstable ,regardless GA.

• Close maternal monitoring to establish severity.

• Be able to comply frequent maternal and fetal

• Complications and side effects

Diagnosis Typically clinical

Definitive treatment is prompt delivery.

Mode of delivery based on GA ,cervix

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