‘If you can not explain it simply, you do not understand it well enough’

Albert Einstein
 HERMAN KRISTANTO
Maternal Fetal Medicine Division
Department of Obstetrics & Gynecology
Faculty of Medicine – Diponegoro University
Leading Cause of Maternal Mortality :
• Preeclampsia
• Hemorrhage
• Infection
Leading Cause of Maternal Mortality :
• Preeclampsia
• Hemorrhage
• Infection
Hypertensive Disorders of Pregnancy :

• Chronic Hypertension
• Gestational Hypertension
• Preeclampsia
• Superimposed Preeclampsia
Hypertensive Disorders of Pregnancy :

• Chronic Hypertension
• Gestational Hypertension
• Preeclampsia
• Superimposed Preeclampsia
Preeclampsia
New onset hypertension (≥ 140/90 mmHg, at least
twice, 6 hours apart in the absence of chronic
hypertension) and proteinuria (300 mg in 24 hours in
women without prior proteinuria) that begins after
20 weeks gestation
 Hypertensive Disorders of Pregnancy :

Chronic Gestational
Clinical Findings Preeclampsia
Hypertension Hypertension
Time of onset Usually in third
< 20 weeks ≥ 20 weeks
hypertension trimester
Degree of
Mild or severe Mild Mild or severe
hypertension
Proteinuria Absent Absent Usually present
Serum urate > 5.5 Present in almost
Rare Absent
mg/dl (0.33 mmol/L) all cases
Hemoconcentration Absent Absent Severe disease
Thrombocytopenia Absent Absent Severe disease
Hepatic dysfunction Absent Absent Severe disease
Clinical Spectrum of Preeclampsia :

• Non-severe Preeclampsia
• Severe Preeclampsia
• Eclampsia
• HELLP syndrome
Severe preeclampsia
• Blood pressure ≥160 mmHg systolic or ≥ 110 mmHg on two occasions
at least 6 hours apart while the patient is on bed rest
• Oliguria (< 500 mL in 24 hours)
• Cerebral or visual disturbances
• Pulmonary edema or cyanosis
• Epigastric or right upper quadrant pain
• Impaired liver function (AST and or ALT ≥ 70 U/L)
• Thrombocytopenia (<100.000/mm3) and or evidence of
microangiopathic hemolytic anemia
Eclampsia
• The occurrence of seizures or coma (not attributable
to any other cause) in women with preeclampsia
HELLP Syndrome

The diagnosis is based on laboratory findings :

• Hemolysis

• Elevated liver enzym levels

• Low platelet count
Pathophysiological process
• Genetic predisposition
• Inadequate throphoblast invasion of spiral arteries
• Reduced uteroplacental perfusion
• Placental damage (leading to apoptosis)
• Release of circulating factors or placental
syncytial fragments
• Exaggerated maternal immune response
• Endothelial cell dysfunction
Preeclampsia signs & symptoms :
Cerebral Headache
Dizziness
Tinnitus
Drowsiness
Change in respiratory rate
Tachycardia
Fever
Preeclampsia signs & symptoms :
Visual Diplopia
Scotoma
Blurred vision
Amaurosis
Preeclampsia signs & symptoms :

Gastrointestinal Nausea
Vomiting
Epigastric pain
Hematemesis
Preeclampsia signs & symptoms :
Renal Oliguria
Anuria
Hematuria
Hemoglobinuria
Preeclampsia complications
Complications depend on :
• Gestational age at time of diagnosis
• Severity of disease
• Presence of other medical conditions
• Management
Preeclampsia complications (maternal)
• HELLP syndrome
• DIC
• Pulmonary edema
• Abruptio placentae
• Renal failure
• Eclampsia
• Cerebral hemorrhage
• Liver hemorrhage
• Death
Preeclampsia complications (fetal)
• Preterm birth
• Fetal growth restriction
• Perinatal death
• Hypoxemia-neurological injury
• Long-term cardiovascular morbidity
(fetal origin of adult disease)
Management of preeclampsia complications
The primary aim is immediate elimination of the
disease phenotype
• Termination of pregnancy with the least possible
trauma to mother and fetus
• Birth of an infant who subsequently thrives
• Complete restoration of health to the mother
Delivery is the only current cure
Management of preeclampsia complications
Timing of delivery
• ≥ 34 weeks
There is universal agreement that all patients should
be delivered
• < 34 weeks
Delivery vs expectant management ?
Although delivery is always appropriate for the
mother it may not be optimal for the fetus
Management of preeclampsia complications
Magnesium sulphate
Intravenous 4 gr loading dose over 20 minutes is
given followed by the maintenance dose of 1-2 gr
per hour
Management of preeclampsia complications
Antihypertensive agents
• Labetalol
20 – 40 mg IV every 10 – 15 minutes
as needed for a maximum of 220 mg
• Nifedipine
10 – 20 mg orally may repeat in 30 minutes
for a maximum dose of 50 mg
• Hydralazine
5 – 10 mg IV every 20 minutes for a maximum dose of 20 mg
• Sodium nitroprusside
Rarely needed
Start at 0.25 µg/kg/min to a maximum of 5 µg/kg/min
Management of preeclampsia complications
Antihypertensive agents
• Labetalol
20 – 40 mg IV every 10 – 15 minutes
as needed for a maximum of 220 mg
• Nifedipine
10 – 20 mg orally may repeat in 30 minutes
for a maximum dose of 50 mg
• Hydralazine
5 – 10 mg IV every 20 minutes for a maximum dose of 20 mg
• Sodium nitroprusside
Rarely needed
Start at 0.25 µg/kg/min to a maximum of 5 µg/kg/min
Management of preeclampsia complications
Management of delivery
• Choice of mode of delivery
• Continuous fetal monitoring
• Intravenous access
• Fluid balance chart
• Reguler blood pressure monitoring
• Good analgesia
• Active management of the 3rd stage
• If requires CS, regional anesthesia is preferable
Management of preeclampsia complications
Immediate postpartum care
• Reguler blood pressure monitoring
• Strict input-output chart
• Magnesium sulfate infusion continued for 24 hours
• Anti-hypertensive should be continued or reduced slowly
• Diuretics should only be given if there is evidence of
pulmonary edema
• Check full blood count, clotting function, renal function,
liver enzymes and urate
Prevention is the best practice
Prevention is the best practice

• Pre-conception care
• Antepartum care
• Intrapartum care
• Postpartum care and follow up
Prevention is the best practice

Pre-conception care
Pre-existing risk factors :
• Family history of preeclampsia
• Previous history of preeclampsia
• Increased maternal age
• Low socioeconomic status
• Obesity
• Hypertension
• Diabetes mellitus
• Renal disease
• Cardiac disease
• Thrombophilia
• Autoimmune disease
Prevention is the best practice

Pre-conception care
Pregnancy related factors :
• Primigravida
• First pregnancy with new partner
• Pregnancies conceived with ART
• Multiple pregnancy
Risk factors Frequency of occurrence
Previous preeclampsia 20-30%
Previous preeclampsia at ≤ 28 weeks 50%
Chronic hypertension 15-25%
Severe hypertension 40%
Renal disease 25%
Pregestational diabetes mellitus 20%
Class B/C diabetes 10-15%
Class F/R diabetes 35%
Thrombophilia 10-40%
Obesity/insulin resistance 10-15%
Age > 35 years 10-20%
Family history of preeclampsia 10-15%
Primiparity 6-7%
Prevention is the best practice

Pre-conception care
Investigations
• Blood pressure
• Urinalysis
• Further specific investigations will be required if additional
disorders are suspected
Counselling
• Risks of preeclampsia and its effects
• Drugs, antihypertensive with fetotoxicity should be stopped before
pregnancy
• Early referral for obstetric care
• Consider prophylaxis against preeclampsia
Prevention is the best practice

Pre-conception care
Prophylaxis against preeclampsia
• Aspirin
• Calcium supplementation
• Antioxidants
• Fish oil Supplemantation
• Antihypertensives
Prevention is the best practice

Pre-conception care
Prophylaxis against preeclampsia
• Aspirin
• Calcium supplementation
• Antioxidants
• Fish oil Supplemantation
• Antihypertensives
Management of preeclampsia complications

Remote prognosis
Patients with preeclampsia should be
counseled regarding risks for :
• Chronic hypertension
• Coronary artery disease
• Renal disease
 HERMAN KRISTANTO
Maternal Fetal Medicine Division
Department of Obstetrics & Gynecology
Faculty of Medicine – Diponegoro University