Collage of health sciences

School of nursing and midwifery

Title – severe preeclampsia in pregnancy
Prepared by

1. Halima

Submitted to – Mr. Kerebih A.

Date-
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Table of Contents
ACKNOWLEDGEMENT.................................................................................................................................2
Preeclampsia in pregnancy..........................................................................................................................3
Diagnostic criteria....................................................................................................................................3
Clinical types............................................................................................................................................4
Clinical features.......................................................................................................................................5
Signs........................................................................................................................................................6
Management of preeclampsia in pregnancy...........................................................................................7
Intrapartum management..............................................................................................................8
Postpartum management....................................................................................................................9
Case on preeclampsia................................................................................................................................11
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ACKNOWLEDGEMENT
First and for most we would like to forward our gratitude to almighty of GOD
who allowed us to successfully complete this assignment. Next we would like
to thank our Ob II lecturer Mr. Kerebih for preparing this seminar which
allowed us to explore and more about severe preeclampsia. We also wanted to
give our heartfelt gratitude for Dr. Tewodros, Dr. Zerubabel, Mw. Abrham, Mw.
Dawit and Mw. Habtewerk for their support and appreciation. Finally, for all
those who provided us with resources that supplement for this assignment,
thank you for your cooperation.
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Preeclampsia in pregnancy
Preeclampsia is a multisystem disorder of unknown etiology characterized by
development of hypertension to the extent of 140/90 mm Hg or more with
proteinuria after the 20th week in a previously normotensive and
nonproteinuric woman.

Some amount of edema is common in a normal pregnancy. Edema has been

excluded from the diagnostic criteria unless it is pathological. The
preeclamptic features may appear even before the 20th week as in cases of
hydatidiform mole and acute polyhydramnios.

The term, “Pregnancy-induced hypertension (PIH)” is defined as the

hypertension that develops as a direct result of the gravid state.

 It includes
o (i) gestational hypertension
o (ii) preeclampsia and
o (iii) eclampsia.

Diagnostic criteria
Hypertension and proteinuria are the hallmark features of preeclampsia.

Severity features of preeclampsia are:

• Headache, blurred vision, oliguria (<400 ml/24 hours), epigastric pain or

pain in right

upper quadrant, difficulty breathing (pulmonary edema)

• Low platelet count (<100,000/µl)

• Elevated liver enzymes more than twice the upper limit of normal

• Serum creatinine higher than 1.1mg/dl or a doubling or higher of the

baseline serum creatinine concentration in the absence of other renal disease
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 Laboratory tests such as urine protein, CBC, liver enzymes, LDH

and renal function test
 should be determined.
 Ultrasound is used to monitor fetal growth andto assess fetal
wellbeing.

Risk Factors for Preeclampsia

 Primigravida: Young or elderly (fi rst time exposure to chorionic villi)

 Family history: Hypertension, preeclampsia
 Placental abnormalities:
o Hyperplacentosis: Excessive exposure to chorionic villi—(molar
pregnancy twins, diabetes)
o Placental ischemia.
 Obesity: BMI >35 kg/m2, Insulin resistance.
 Pre-existing vascular disease
 New paternity
 Thrombophilias :antiphospholipid syndrome, protein C, S deficiency,
Factor V Leiden ].

Clinical types
The clinical classification of preeclampsia is arbitrary and is principally
dependent on the level of blood pressure for management purpose. But
proteinuria is more significant than blood pressure to predict fetal outcome.

Mild: This includes cases of sustained rise of blood pressure of more than
140/90 mm Hg but less

than 160 mm Hg systolic or 110 mm Hg diastolic without significant

proteinuria.
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Severe:
 A persistent systolic blood pressure above or equal to 160 mm Hg or
diastolic pressure above 110 mm Hg.
 Protein excretion of more than 5 g/24 h
 Oliguria (<400 mL/24 h).
 Platelet count less than 100,000/mm3.
 HELLP syndrome.
 Cerebral or visual disturbances.
 Persistent severe epigastric pain.
 Retinal hemorrhages, exudates or papilledema.
 Intrauterine growth restriction of the fetus.
 Pulmonary edema.

From the prognostic point of view, a diastolic rise of blood pressure is

more important than the systolic rise.

Clinical features
Preeclampsia frequently occurs in primigravidae (70%). It is more often
associated with obstetrical– medical complications such as multiple
pregnancy, polyhydramnios, pre-existing hypertension, diabetes etc. The
clinical manifestations appear usually after the 20th week.

The onset is usually insidious and the syndrome runs a slow course. On rare
occasion, however, the onset becomes acute and follows a rapid course.

SYMPTOMS: Preeclampsia is principally a syndrome of signs and when

symptoms appear, it is usually late.

 Mild symptoms: Slight swelling over the ankles which persists on

rising from the bed in the morning or tightness of the ring on the finger
is the early manifestation of edema due to preeclampsia. Gradually, the
swelling may extend to the face, abdominal wall, vulva and even the
whole body.
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 Alarming symptoms: The following are the ominous symptoms, which

may be evident either singly or in combination. These are usually
associated with acute onset of the syndrome.
o Headache — either located over the occipital or frontal region
o Disturbed sleep
o Diminished urinary output— Urinary output of less than 400 mL
in 24 hours is very ominous
o Epigastric pain—acute pain in the epigastric region associated
with vomiting, at times coffee color, is due to hemorrhagic
gastritis or due tosubcapsular hemorrhage in the liver
o Eye symptoms—there may be blurring, scotomata, dimness of
vision or at times complete blindness. Vision is usually regained
within 4–6 weeks following delivery. The eye symptoms are due
to spasm of retinal vessels (retinal infarction), occipital lobe
damage (vasogenic edema) or retinal detachment. Reattachment
of the retina occurs following subsidence of edema and
normalization of blood pressure after delivery.

Signs
1. Abnormal weight gain: Abnormal weight gain within a short span of time
probably appears even before the visible edema. A rapid gain in weight of
more than 5 lb a month or more than 1 lb a week in later months of pregnancy
is significant.

2. Rise of blood pressure: The rise of blood pressure is usually insidious but
may be abrupt. The diastolic pressure usually tends to rise first followed by
the systolic pressure.

3. Edema: Visible edema over the ankles on rising from the bed in the
morning is pathological. The edema may spread to other parts of the body in
uncared cases Sudden and generalized edema may indicate imminent
eclampsia.

4. There is no manifestation of chronic cardiovascular or renal pathology.

5. Pulmonary edema—due to leaky capillaries and low oncotic pressure.

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6. Abdominal examination may reveal evidences of chronic placental

insufficiency, such as scanty liquor or growth retardation of the fetus. Thus,
the manifestations of preeclampsia usually appear in the following order—
rapid gain in weight → visible edema and/or hypertension → proteinuria.

Management of preeclampsia in pregnancy

Delivery is the only known treatment.

At term (37 weeks’ gestation), delivery is recommended.

Route of delivery
 Vaginal delivery is preferable to cesarean delivery, which should be
reserved for the usual obstetric indications.
 Cesarean delivery may be preferred in cases of severe preeclampsia
remote from term with an unfavorable cervix.
 Some evidence suggests that preeclampsia may expedite cervical
ripening and labor induction.

Antepartum treatment (before 37 weeks)

 Mild preeclampsia may be managed expectantly using the following

interventions. It is controversial whether in- or outpatient management
is preferable. a. Bed r est b. Blood pressure and urinary protein
monitoring c. Twice-weekly nonstress tests d. Laboratory surveillance
Stable severe preeclampsia

a. Before 24 weeks. Pregnancy termination should be offered.

b. Before 32 weeks. Delivery is always a legitimate course of

action, but expectant management with blood pressure control is
an option.

 Expectant management requires intensive fetal and maternal

surveillance.
 Antenatal corticosteroids are recommended.
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 Delivery is mandatory if the patient develops thrombocytopenia,

abnormal liver function tests, uncontrollable hypertension, pulmonary
edema, oligohydramnios, or abnormal fetal testing.
 Presence of proteinuria or controllable hypertension does not require
immediate delivery.

C. After 32 weeks: Delivery is appropriate after documentation of fetal

lung maturity.
 If fetal lung maturity is negative, antenatal steroids should be given
before 34 weeks.
 Alternatively, steroids can be given to all patients between 32 and 34
weeks. Delivery may be effected 48 hours later without documenting
fetal lung maturity. (3) Unstable severe preeclampsia. Treatment at any
gestational age involves prompt delivery.

Intrapartum management
Seizure prophylaxis because there are no signs that accurately predict
seizures, prophylaxis is most effective if all women with preeclampsia
are treated.
a. Magnesium sulfate is superior to other antiepileptic medications for
preventing eclampsiarelated seizures and seizure-related morbidity and
mortality.
o An intravenous loading dose of 4 to 6 g is usually followed by a
maintenance infusion of 2 to 4 g/hr.
o Patients must be monitored for signs of magnesium toxicity, such
as hyporeflexia and respiratory depression.
o Magnesium toxicity may be confirmed by testing serum levels. It
can be reversed with 1 g of calcium gluconate.
o In instances in which magnesium sulfate cannot be used (e.g.,
myasthenia gravis, end-stage renal disease [because of impaired
magnesium clearance]), phenytoin is safe.

Antihypertensive therapy

Indications
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 Therapy should be considered for:

o Persistent diastolic blood pressure of over 100 to 110 mm Hg
o Persistent systolic blood pressure of over 150 to 160 mm Hg
 Therapy is certainly indicated for systolic blood pressure of over 180
mm Hg or diastolic blood pressure of over 110 mm Hg.

Pharmacologic agents

 Hydralazine (preferred agent) reduces afterload but compensates by

increasing heart rate; therefore, uterine perfusion is not usually
compromised.
 Nefidipine
 Labetalol does not reduce afterload. c. Invasive cardiac monitoring
should be considered in the presence of oliguria or pulmonary edema.

Postpartum management
1. Magnesium sulfate should be continued for 24 hours but may be
discontinued earlier in the presence of pronounced diuresis, because
therapeutic levels are not likely attainable.

2. Indications for acute antihypertensive therapy are the same as for the
antepartum or intrapartum period.

3. Women who continue to have hypertension but have a persistent diastolic

blood pressure of less than 100 mm Hg may be discharged on oral therapy.

4. PIH usually disappears completely by 2 weeks postpartum.

Anti hypertensive drugs

• Antihypertensive drugs:- If the diastolic pressure is 110 mm Hg or
more

• hydralazine 5 mg IV slowly (3-4 minutes).

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• Repeat the dose at 30 minute intervals until diastolic BP is around <110

mmHg.

• Do not give more than 20 mg in total

• Nifedipine 5 mg under the tongue: - 5-10 mg

sublingually as initial dose followed by 5-10
mg if response is inadequate(in 30 minutes)
continue 10-20 mg p.o q6hrs.

• Side effect – edema, flushing, headache palpitation.

• Methyldopa – drug of choice for maintenance therapy ,has minimal side

effective and safe in pregnancy.

• The concern needs additional drugs to control B/P.

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Case on preeclampsia
Identification
Patient name – BelayneshAbere

Card no- 173425

This is a 25 years old woman .she is admitted on 13/8/2013 at 12:30am at

labor ward. She is gravida 1 para 0 woman.she is 38wk +2 days by 13+2 day
ultrasound.

Chief compliant
She came to TASH with the complain of pushing down sensation, back pain,
headache, edema of lower leg and hand .

History of present pregnancy and illness

She is gravida 1 para 0 woman , her LMNP was unknown and 38+2 days by
early ultrasound. She has 3 ANC followup at local health center. During
abdominal examination fetal heart beat was positive and lie is longitudinal
presentation is cephalic.

Past obstetric history

She has no past obstetric history.

Past gynecological history

She has no previous abortion and gynecological operation; her sexual history
has no risk to sexually transmitted diseases and HIV .she has history of normal
menstrual flow stayed for 5 days.

Past medical history

she has no medical complications like DM, epilepsy, chronic HTN, CVD and
respiratory disorders.
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Physical assessment(assessment)
 She has no severe illness and good posture.
 Vital sign _163/118mmHg
 Pulse rate – 96bt/min
 Temperature – ATT
 Weight- 89kg
 She has no abnormalities on her head, ear, eye, nose and no glandular
enlargement on her neck.
 She has edema on her leg and hand.
 There is no abnormal mass and lymph node enlargement on her breast.
 No complication on her respiratory system like chest pain, shortness of
breath, and cough.
 Her CNS was also in good condition because she has good memory ,
orientation and sleep pattern.

Abdominal examination
 The fetus has longitudinal lie.
 cephalic presentation
 FHB 136
 Contraction was 2 moderate within 10 min

Genitourinary system
 There is no varicosities, warts, sore and circumcision scar on
external genital
 No vaginal bleeding
 Her vaginal condition was also good.
 Her cervix also dilate

Diagnostic data
This is 25 years old woman who come to labor ward on 13/8/13at 3:30am
withcomplaining of pushing down sensation, headache, back pain, edema of
leg and hand.
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During urine analysis she has +1 protein.

Firstly she was admitted to Ob Gyneemergency department with the complain

of the above conditions. During vital sign measurement and physical
examination her BP is 163/118mmHg on severe range and she has the
headache and edema of hand and leg. She has 2moderate contraction and
cervical dilation was 3 cm.

She was diagnosed with severe preeclampsia + gestational HTN.

On the emergency ward she has started loading dose of MgSo4 and
hydralazine. Then she was admitted to labor ward.

Intrapartum care
Plan
 To lower the BP within mild range
 To deliver the baby within 12 hrs
 To prevent fetal and maternal complications
 To maintain good maternal condition to deliver with SVD.
 To prevent the severity of imminent signs of sever preeclampsia.

After the admission to labor ward we have followed her vital sign ever 30 min.

Nefidipine 5mg- sublingually for every 6 hrs.

Magnesium sulphate – maintenance dose was given at 4:30am

At 5:10 am her uterine contraction was progressively increased to 4c/10min

for 30-35sec, cervical dilation to 6cm and fetal heart beat was 142bt/min. her
BP was 147/96mmHg.station- 0 , position- posterior.

At 7:15 she is fully dilated, station +3. Then she is entered to second stage
room. The second stage lasts for 20 minutes and she has deliver 3500gm male
neonate, APGAR 8/9 by doctor Tewodros at 7:35am.
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10 IU oxytocin IM was given. The placenta was delivered by CCT and the
uterus was well contracted. Immediate new born was given successfully and
the mother to child attachment was good.

Post partum care

Plan
 To continue the maintenance dose of magnesium sulphae up to 24 hrs
of post partum.
 To continue nefidipine supplement QID for 2 days.
 To monitor maternal and fetal condition every 30 min.
 To examine for protein urea.