1. PRE-ECLAMPSIA & ECLAMPSIA
DEFINITION:
It is pregnancy-induced hypertension i.e. diastolic BP >90 mm Hg/ systolic>140mm Hg on two
separate occasions, 4 to 6 hours apart, along with proteinuria (> 0.3 g in 24 hours) after 20 weeks
of gestation in a woman who is previously normotensive and settles after 6 weeks of delivery
HISTORY:
Headache, visual disturbance, epigastric pain, vomiting, oliguria, abdominal pain,may have
previous history / family history of pre-eclampsia (mother or sister).
EXAMINATION:
Pulse, Temp, R.R.,B.P. :If B.P. is raised greater than 140/90 mm Hg
GPE then repeat after 4 hours, edema,deep tendon reflexes,& signs of
clonus
P/A HOF , lie, Presenting Part , Fetal Heart Sounds, liver tenderness
Fundoscopy (if available) Papilledema
Urinary proteins Proteinuria (> 0.3 g in 24 hours)
ASSESSMENT AND DIAGNOSIS
Senior obstetric and anaesthetic staff and experienced midwives should be involved in the
assessment and management of women with severe pre-eclampsia and eclampsia.
HOW SHOULD THE BLOOD PRESSURE BE TAKEN?
When taking blood pressure, the woman should be rested and sitting at a 45-degree angle. The BP
cuff should be of the appropriate size and should be placed at the level of the heart. Multiple
readings should be used to confirm the diagnosis. Korotkoff phase 5 is the appropriate measurement
of diastolic blood pressure. The method used should be consistent and documented.
HOW SHOULD PROTEINURIA BE MEASURED?
The usual screening test is visual dipstick assessment.
A two plus dipstick measurement can be taken as evidence of proteinuria
Ideally a more accurate test (either a spot protein creatinine ratio or ideally a 24-hour urine
collection) is required to confirm this.
Diagnosed significant proteinuria if the urine protein: creatinine ratio is greater than
30mgmmol or validated 24 hr urine collection result shows greater than 300mg
protein.
HOW SHOULD THE WOMAN BE MONITORED?
,The blood pressure should be checked every 15 minutes until the woman is stabilized Every 30
minutes in the initial phase of assessment.
The blood pressure should be checked 4-hourly if a conservative management plan is in place and
the woman is stable and asymptomatic
INVESTIGATIONS
Blood group and save
Complete blood count ( Alert if Platelet count <100000 per cubic millimeter)
Renal function test
Serum Uric Acid.
LFTs (ALT or AST rising to above 70 iu/l)
Coagulation Screen ( if Platelet count <100000 per cubic millimeter )
Urine: urine for albumin / protein.
MANAGEMENT FOR MILD PRE-ECLAMPSIA
GENERAL:
Expectant treatment of mild preeclampsia may be used with patients at <37 weeks gestation.
Patients may be treated at home.
TREATMENT:
Tab: Labetalol 100 mg x B.D or Methyldopa ( mg ) can be considered
Bi weekly fetal surveillance. May be done more often if indicated.
Blood pressure checks at least twice per week.
Baseline coagulation, renal, and liver function tests - to be repeated on clinical indication
Daily urine protein checks with dipstick. Do 24-hour collection if 1+ or more.
Anti platelet agent:
Advise women at high risk for preeclampsia to take 75 mg of aspirin daily from 12 weeks until the
birth of the baby.
Women at high risk are those with any of the following
Hypertensive disease during a previous pregnancy
Chronic kidney disease
Autoimmune disease such as systemic lupus erythematosis or anti phospholipid syndrome
Type 1 or Type 2 diabetes
Chronic hypertension
Advise women with more than one moderate risk factor for pre-eclampsia to take 75 mg of aspirin*
daily from 12 weeks until the birth of the baby. Factors indicating moderate risk are:
First pregnancy
Age 40 years or older
Pregnancy interval of more than 10 years
Body mass index (BMI) of 35 kg/m2 or more at first visit
Family history of pre-eclampsia
2 Procedure/ Protocol/SOP’s Obstetrics & Gynecology
, Multiple pregnancy.
INDICATIONS FOR TERMINATION OF PREGNANCY
Gestational age >37 weeks
Offer birth to women who have preeclampsia with mild or moderate hypertension at 34 +0 to
36+6 weeks depending on maternal and fetal condition
Fetal deterioration
Maternal deterioration
Any associated condition dictating delivery (post dates, IUGR, etc.)
In general, in the presence of an immature fetus, overriding considerations must be present to
terminate pregnancy in patients with mild pre-eclampsia.
If BP more than 160/110 mm hg OR with Sign and Symptoms treat as Severe Pre Eclampsia
CLASSIFICATION:
The classical distinction between mild and severe preeclampsia is still useful from the therapeutic
point of view. Preeclampsia is classified as severe if any one of the following signs or symptoms is
present:
1. Blood pressure of 160 or more systolic or 110 or more diastolic
2. Proteinuria of 5 gm or more/24hours
3. Oliguria (400 ml or less/24 hours)
4. Cerebral or visual disturbances
5. Pulmonary edema or cyanosis
6. HELLP syndrome
HELLP SYNDROME WILL BE DIAGNOSED IN THE PRESENCE OF:
Haemolysis, defined by abnormal peripheral smear, increased bilirubin, >1.2 mg per
decilitre, and increased lactic dehydrogenase, > 900 units per litre.
Elevated liver enzymes, defined as increased SGPT >70 units per litre.
Low platelets, defined as platelet count < 150 x 103 per mm3
MANAGEMENT OF SEVERE PRE - ECLAMPSIA
Consider admission when
Diastolic BP greater than or equal to 110 mmHg, or if
Hypertension and Proteinuria ++
Presence of symptoms, e.g., epigastric pain, with hypertension +/- proteinuria
1-Counsel the patient & husband regarding:
3 Procedure/ Protocol/SOP’s Obstetrics & Gynecology
, Outcome and Mode of delivery
Prognosis of the Baby and NICU admission need for ventilator support
Patient may need ICU care
2- I / V antihypertensive
● Inform and Alert Consultant Obstetrician, Consultant Pediatrician, Consultant Anesthetist
Monitor BP 1/2 hourly till patient stabilizes and then 4 hourly
Reflexes +/- clonus
Test urine for albumin
Urinary output I/O charting urine output should be >30ml/hr
IV fluids not exceeding 80 ml/hr.
Fetal cardiotocograph & ultrasound scan on admission
Doppler Ultrasound studies to rule out placental insufficiency.
3-Antihypertensives
AGENT DOSAGE
Hydralazine 5 mg iv bolus, then 5 - 10 mg every 20 to 30
(preferred) minutes to a maximum of 25 mg,repeat as
necessary
20 mg iv bolus, then 40 mg 10 minutes later, 80
Labetalol mg every 10 minutes for 2additional doses to a
maximum of 220 mg
Nifedipine 10 mg p.o repeat every 20 minutes to a
maximum of 30 mg
Antihypertensive treatment should be started in women with a systolic blood pressure over 160
mmHg or a diastolic blood pressure over 110 mmHg.
In women with other markers of potentially severe disease, treatment can be considered at
lower degrees of hypertension.
Labetalol, given orally or intravenously,
Nifedipine given orally or
Intravenous hydralazine can be used for the acute management of severe hypertension.
In moderate hypertension, treatment may assist prolongation of the pregnancy.
Atenolol, angiotensin converting enzyme (ACE) inhibitors, angiotensin receptor-blocking drugs
(ARB) and diuretics should be avoided.
Nifedipine should be given orally not sublingually.
Labetalol should be avoided in women with known asthma.
4 Procedure/ Protocol/SOP’s Obstetrics & Gynecology
DEFINITION:
It is pregnancy-induced hypertension i.e. diastolic BP >90 mm Hg/ systolic>140mm Hg on two
separate occasions, 4 to 6 hours apart, along with proteinuria (> 0.3 g in 24 hours) after 20 weeks
of gestation in a woman who is previously normotensive and settles after 6 weeks of delivery
HISTORY:
Headache, visual disturbance, epigastric pain, vomiting, oliguria, abdominal pain,may have
previous history / family history of pre-eclampsia (mother or sister).
EXAMINATION:
Pulse, Temp, R.R.,B.P. :If B.P. is raised greater than 140/90 mm Hg
GPE then repeat after 4 hours, edema,deep tendon reflexes,& signs of
clonus
P/A HOF , lie, Presenting Part , Fetal Heart Sounds, liver tenderness
Fundoscopy (if available) Papilledema
Urinary proteins Proteinuria (> 0.3 g in 24 hours)
ASSESSMENT AND DIAGNOSIS
Senior obstetric and anaesthetic staff and experienced midwives should be involved in the
assessment and management of women with severe pre-eclampsia and eclampsia.
HOW SHOULD THE BLOOD PRESSURE BE TAKEN?
When taking blood pressure, the woman should be rested and sitting at a 45-degree angle. The BP
cuff should be of the appropriate size and should be placed at the level of the heart. Multiple
readings should be used to confirm the diagnosis. Korotkoff phase 5 is the appropriate measurement
of diastolic blood pressure. The method used should be consistent and documented.
HOW SHOULD PROTEINURIA BE MEASURED?
The usual screening test is visual dipstick assessment.
A two plus dipstick measurement can be taken as evidence of proteinuria
Ideally a more accurate test (either a spot protein creatinine ratio or ideally a 24-hour urine
collection) is required to confirm this.
Diagnosed significant proteinuria if the urine protein: creatinine ratio is greater than
30mgmmol or validated 24 hr urine collection result shows greater than 300mg
protein.
HOW SHOULD THE WOMAN BE MONITORED?
,The blood pressure should be checked every 15 minutes until the woman is stabilized Every 30
minutes in the initial phase of assessment.
The blood pressure should be checked 4-hourly if a conservative management plan is in place and
the woman is stable and asymptomatic
INVESTIGATIONS
Blood group and save
Complete blood count ( Alert if Platelet count <100000 per cubic millimeter)
Renal function test
Serum Uric Acid.
LFTs (ALT or AST rising to above 70 iu/l)
Coagulation Screen ( if Platelet count <100000 per cubic millimeter )
Urine: urine for albumin / protein.
MANAGEMENT FOR MILD PRE-ECLAMPSIA
GENERAL:
Expectant treatment of mild preeclampsia may be used with patients at <37 weeks gestation.
Patients may be treated at home.
TREATMENT:
Tab: Labetalol 100 mg x B.D or Methyldopa ( mg ) can be considered
Bi weekly fetal surveillance. May be done more often if indicated.
Blood pressure checks at least twice per week.
Baseline coagulation, renal, and liver function tests - to be repeated on clinical indication
Daily urine protein checks with dipstick. Do 24-hour collection if 1+ or more.
Anti platelet agent:
Advise women at high risk for preeclampsia to take 75 mg of aspirin daily from 12 weeks until the
birth of the baby.
Women at high risk are those with any of the following
Hypertensive disease during a previous pregnancy
Chronic kidney disease
Autoimmune disease such as systemic lupus erythematosis or anti phospholipid syndrome
Type 1 or Type 2 diabetes
Chronic hypertension
Advise women with more than one moderate risk factor for pre-eclampsia to take 75 mg of aspirin*
daily from 12 weeks until the birth of the baby. Factors indicating moderate risk are:
First pregnancy
Age 40 years or older
Pregnancy interval of more than 10 years
Body mass index (BMI) of 35 kg/m2 or more at first visit
Family history of pre-eclampsia
2 Procedure/ Protocol/SOP’s Obstetrics & Gynecology
, Multiple pregnancy.
INDICATIONS FOR TERMINATION OF PREGNANCY
Gestational age >37 weeks
Offer birth to women who have preeclampsia with mild or moderate hypertension at 34 +0 to
36+6 weeks depending on maternal and fetal condition
Fetal deterioration
Maternal deterioration
Any associated condition dictating delivery (post dates, IUGR, etc.)
In general, in the presence of an immature fetus, overriding considerations must be present to
terminate pregnancy in patients with mild pre-eclampsia.
If BP more than 160/110 mm hg OR with Sign and Symptoms treat as Severe Pre Eclampsia
CLASSIFICATION:
The classical distinction between mild and severe preeclampsia is still useful from the therapeutic
point of view. Preeclampsia is classified as severe if any one of the following signs or symptoms is
present:
1. Blood pressure of 160 or more systolic or 110 or more diastolic
2. Proteinuria of 5 gm or more/24hours
3. Oliguria (400 ml or less/24 hours)
4. Cerebral or visual disturbances
5. Pulmonary edema or cyanosis
6. HELLP syndrome
HELLP SYNDROME WILL BE DIAGNOSED IN THE PRESENCE OF:
Haemolysis, defined by abnormal peripheral smear, increased bilirubin, >1.2 mg per
decilitre, and increased lactic dehydrogenase, > 900 units per litre.
Elevated liver enzymes, defined as increased SGPT >70 units per litre.
Low platelets, defined as platelet count < 150 x 103 per mm3
MANAGEMENT OF SEVERE PRE - ECLAMPSIA
Consider admission when
Diastolic BP greater than or equal to 110 mmHg, or if
Hypertension and Proteinuria ++
Presence of symptoms, e.g., epigastric pain, with hypertension +/- proteinuria
1-Counsel the patient & husband regarding:
3 Procedure/ Protocol/SOP’s Obstetrics & Gynecology
, Outcome and Mode of delivery
Prognosis of the Baby and NICU admission need for ventilator support
Patient may need ICU care
2- I / V antihypertensive
● Inform and Alert Consultant Obstetrician, Consultant Pediatrician, Consultant Anesthetist
Monitor BP 1/2 hourly till patient stabilizes and then 4 hourly
Reflexes +/- clonus
Test urine for albumin
Urinary output I/O charting urine output should be >30ml/hr
IV fluids not exceeding 80 ml/hr.
Fetal cardiotocograph & ultrasound scan on admission
Doppler Ultrasound studies to rule out placental insufficiency.
3-Antihypertensives
AGENT DOSAGE
Hydralazine 5 mg iv bolus, then 5 - 10 mg every 20 to 30
(preferred) minutes to a maximum of 25 mg,repeat as
necessary
20 mg iv bolus, then 40 mg 10 minutes later, 80
Labetalol mg every 10 minutes for 2additional doses to a
maximum of 220 mg
Nifedipine 10 mg p.o repeat every 20 minutes to a
maximum of 30 mg
Antihypertensive treatment should be started in women with a systolic blood pressure over 160
mmHg or a diastolic blood pressure over 110 mmHg.
In women with other markers of potentially severe disease, treatment can be considered at
lower degrees of hypertension.
Labetalol, given orally or intravenously,
Nifedipine given orally or
Intravenous hydralazine can be used for the acute management of severe hypertension.
In moderate hypertension, treatment may assist prolongation of the pregnancy.
Atenolol, angiotensin converting enzyme (ACE) inhibitors, angiotensin receptor-blocking drugs
(ARB) and diuretics should be avoided.
Nifedipine should be given orally not sublingually.
Labetalol should be avoided in women with known asthma.
4 Procedure/ Protocol/SOP’s Obstetrics & Gynecology
