Pre-eclampsia

• Mild Pre-eclampsia

  1 ) Hypertension (BP ≥ 140 / 90 mmHg) on 2 occasions at least 6 hours apart

  2 ) Proteinuria: >300 mg / 24 hours urine (1+) on 2 random urine samples at least 6 hours apart

  3) No evidence of end-organ damage

  4) Normotensive before 20 weeks POG
• Severe pre-eclampsia

  Presence of 1 of the following criteria:

  • SBP ≥ 160, DBP ≥ 110 on 2 occasions at least 6 hours apart
  • Proteinuria > 500 mg / 24 hour collection or >3+ on 2 random urine samples collected at least 6 hours apart
• Moderate pre-eclampsia

  1 ) BP: ≥ 150 / 100 mmHg

  2 ) Proteinuria: 400 mg / 24 hr urine (2+) on 2 random urine samples in at least 6 hours apart
• Categories of hypertensive disorder in Pregnancy

  1 ) Gestational hypertension

  • no proteinuria
  • BP ≥ 140 / 90

  2) Preeclampsia & Eclampsia

  • Proteinuria & BP ≥ 140 /90

  3) Chronic Hypertension

  4) Preeclampsia Superimposed on Chronic Hypertension

  • CHT + preeclampsia
• Hypertensive disorders in pregnancy

  Occur in women with pre-existing primary or secondary chronic hypertension, and in women who develop new onset hypertension in the second half of pregnancy
• Hypertension in pregnancy

  Blood pressure more than 140/90 mm Hg, systolic blood pressure more than 140 mm Hg, diastolic BP more than 90 mm Hg
• Hypertensive disorders in pregnancy categorised as

  • Gestational hypertension (PIH)
  • Preeclampsia and eclampsia
  • Chronic hypertension
  • Preeclampsia superimposed on chronic hypertension
• Gestational hypertension (PIH)


  Maternal blood pressure of systolic 140 or diastolic 90 mm Hg or more on two occasions observed for the first time in pregnancy, with no proteinuria
• Chronic hypertension

  Hypertension that is present at the booking visit or on antihypertensive before 20 weeks or if the woman is already taking medication when referred to maternity services, can be primary or secondary in aetiology
• Associated conditions with hypertension

  • Oedema
  • Proteinuria
• Oedema

  Common in pregnancy, rapidly developing oedema, rapid weight gain (more than 0.750 kg per week)
• Proteinuria

  Normal up to 300mg/24hrs in pregnancy, proteinuria > 300mg/24 hours is considered significant
• Preeclampsia grading

  • Mild preeclampsia: BP 140/90mm Hg, proteinuria 300 mg/ 24 hr urine (+)
  • Moderate preeclampsia: BP 150/100 mm Hg, proteinuria 400 mg/24 hr urine (++)
  • Severe preeclampsia: BP 160/110 m Hg, proteinuria 500 mg/24 hr urine (+++)
• Significant proteinuria

  Urinary albumin:creatinine ratio is greater 0.3 mg/dL or a validated 24-hour urine collection result shows greater than 300 mg protein
• Pre-eclampsia (in the absence of proteinuria)

  One of the following: platelet count less than 100,000/mL, impaired liver function (transaminase double the normal), doubling of serum creatinine, pulmonary oedema, new onset of cerebral/visual disturbances
• Pathophysiology of preeclampsia

  Primarily a disorder of placental dysfunction leading to a syndrome of endothelial dysfunction with associated vasospasm, failure of villi to invade spiral arterioles in early pregnancy leading to ischemia and damage, release of chemical mediators into maternal circulation, generalized vasospasm due to increased sensitivity of vascular system to circulating catecholamine, multiple endothelial damage leading to leakage of albumin and fluid into interstitial space resulting in tissue edema
• Preeclampsia superimposed on chronic hypertension

  Chronic hypertension and proteinurea, in chronic hypertension proteinuria occurs after 20 weeks of gestation or sudden increase in BP, proteinuria and low platelet count in a patient who had high BP and proteinuria before 20 weeks of gestation
• Physiological changes of blood pressure in pregnancy

  Blood pressure decreases in the first half of pregnancy and increases in the second half
• Risk factors for pre-eclampsia

  • Nulliparity
  • Maternal age <16 or >40yrs
  • Multiple pregnancy
  • Family history of pre-eclampsia or eclampsia
  • Chronic (pre-existing) hypertension
  • Genetic predisposition
  • Chronic renal disease
  • Antiphopholipid syndrome (APLS)
  • Diabetes mellitus
  • Angiotensin gene T235
  • Molar pregnancy
  • Foetal anomalies- hydrops
  • Maternal obesity
• Predisposing factors for pre-eclampsia

  • Multiple pregnancy
  • Diabetes
  • Trophoblastic disorders
• Placental growth factor (PLGF)

  Serum and urinary PLGF is found to be decreased in women both at the time of diagnosis with pre-eclampsia and well in advance of syndrome onset, in women who will develop pre-eclampsia, PLGF is low in the first trimester
• NICE guidelines for prediction of preeclampsia -2019

  • Previous history of preeclampsia
  • Chronic hypertension
  • Autoimmune disease
  • Diabetes mellitus
  • Chronic kidney disease
• Symptoms of pre-eclampsia

  • Frontal headache
  • Visual disturbances –flashing of light and scotomata
  • Pain over the liver area
  • Sudden swelling of the face, hands or feet
  • Nausea and vomiting
• Signs of severe preeclampsia

  • Hyper reflexia- reflexes are exaggerated
  • Tenderness in the right upper quadrant of the abdomen due to stretching of liver capsule
  • High blood pressure
  • Generalised non dependent oedema
  • Fundoscopy- retinal vasospasm, retinal oedema, papilloedema
• Maternal complications of preeclampsia

  • Eclampsia
  • Cerebro-vascular accidents and congestive cardiac failure due to high blood pressure
  • Renal failure
  • Liver failure – HELLP syndrome
  • Coagulation disturbances – DIC
  • Abruptio placenta
  • Microangiopathic haemolytic anaemia
• Fetal complications of preeclampsia

  • IUGR
  • Oligohydramnios
  • Intra uterine death
  • Preterm labour
• Eclampsia

  A convulsive condition associated with pre-eclampsia, eclampsia is seizures in preeclampsia after excluding other causes of fits
• In 20% of cases, BP can be normal in eclampsia, eclampsia can occur before, during or after delivery, 1/3 are post-delivery
• Eclampsia can occur without hypertension in 16% and without proteinuria in 14%
• Premonitory symptoms of impending eclampsia

  • Persistent frontal headache
  • Visual disturbances
  • Epigastric pain (due to hepatic swelling and inflammation)
  • Rapidly increasing or non-dependent edema
  • Rapid weight gain- > 2.5 kg in 1 week
  • Decreased urine output (renal sodium and fluid retention)
• Drug used in impending eclampsia

  Magnesium sulfate
• Onset of eclamptic fit

  • During pregnancy (antepartum period) 50%
  • During labour (intrapartum period) 30%
  • Postpartum (puerperium) 20%
• During pregnancy, eclamptic fits mostly occur in 3rd trimester, may occur for the first time during labour or after delivery
• Stages of eclamptic convulsion

  • Premonitory stage
  • Tonic stage
  • Clonic stage
  • Coma
• Proteinuria

  Presence of protein in the urine
• Premonitory symptoms of impending eclampsia

  • Persistent frontal headache
  • Visual disturbances
  • Epigastric pain (due to hepatic swelling and inflammation)
  • Rapidly increasing or non-dependent edema
  • Rapid weight gain (> 2.5 kg in 1 week)
  • Decreased urine output (renal sodium and fluid retention)
• Maternal mortality rate for eclampsia is 4%
• Perinatal mortality rate for eclampsia is 40%
• Magnesium sulfate

  Drug used in impending eclampsia
• Stages of eclamptic convulsion

  1. Premonitory stage

  2. Tonic stage

  3. Clonic stage

  4. Coma