Hypertensive states at pregnancy:

modern methods of classification,

diagnostics and treatment
 Определения
Gestosis - pathological symptom that is typical
for some pregnant women; the most typical
symptoms are the following triad: hypertension,
proteinuria and edemas (it is diagnosed in 50-
60% of cases)

2
 GESTOSIS –
is the complication of pregnancy, that is
characterized by deep disorder of functions
of the vital organs and systems, and by
damage of fetoplacental complex
 Gestosis –
is symptom of polyorganic functional
insufficiency, that is pathogenically
connected to pregnancy, and
characterized by generalized
vascular spasm and percussive
disorders in vital organs and
placenta
 Preeclampsia – universal
multiendothelial insufficiency, in the base of
which there’s syndrome of systemic
inflammatory reaction (SSIR) with further
development of polyorganic insufficiency

(Кулаков В.И., 2005 г.)

 Terminology
•Late toxicosis of pregnant women (dropsy,
nephropathy, preeclampsia, eclampsia) - USSR
•Toxaemia of pregnant women (USA)
•Preeclampsia-eclampsia (USA, 1972 г.)
•EPH-gestosis (edema, proteinuria, hypertension)
– Europeaan union
•EPH-gestosis (edema, proteinuria, hypertension)
– USSR (1985 г.)
•Gestosis – Russia(1996 г.)
 Relevance of gestosis problem
Gestosis – on of the cause of maternal death
(2nd-3d place)

Gestosis – one of the causes of perinatal

losses

Gestosis – on of the cause of maternal and

infant diseases
 Etiopathogenesis of gestosis
1. Infectious theory
2. Intoxication theory
3. Cortico-visceral theory
4. Endocrine theory, stress theory
5. Immunological theory
6. Genetic theory
7. Placental theory, disorder of placentation
8. Endotheliosis (immune inflammation of endothelium)
Role of spiral arteries in gestational processes

Pregnancy without
complications:
•Enlargement of lumen of
spiral arteries
•Absence of muscular spasm
•Athrombic state of
endothelium
+ absence of
hypercoagulation

The best conditions for

circulation of blood and gas
exchange in the
fetoplacental system
 Main elements of pathogenesis of
gestosis
•Generalized spasm of vessels
•Hypovolemia
•Disorder of rheological and coagulative features of blood
•Endotoxaemia
•Hypoperfussion of tissues
•Disorder of structural and functional peculiarities of
cellular membranes with change of cellular life-activity
•Ischemic and necrotic changes in tissues of vital organs
with change of their functions
 Classification of gestosis МКБ-Х
(1998 г.), класс XV, II блок
ОТЕКИРОТЕИНУРИЯ И ГИПЕРТЕНЗИВНЫЕ РАССТРОЙСТВА ВО
ВРЕМЯ БЕРЕМЕННОСТИ, РОДОВ И В ПОСЛЕРОДОВОМ ПЕРИОДЕ
O10-O16)
O10 Hypertension before pregnancy, which complicates pregnancy, delivery and
postpartum period
O10.0 Earlier essential hypertension, complicating pregnancy, delivery and postpartum
period
O10.1 Earlier cardiovascular hypertension, complicating pregnancy, delivery and
postpartum period
O10.2 Earlier renal hypertension, complicating pregnancy, delivery and postpartum period
O10.3 Earlier cardiovascular and renal hypertension, complicating pregnancy, delivery
and postpartum period
O10.4 Earlier secondary hypertension, complicating pregnancy, delivery and postpartum
period
O10.9 Earlier unclear hypertension, complicating pregnancy, delivery and postpartum
period
O11 Earlier hypertension, with later joined proteinuria
O12 Edema and proteinuria caused by pregnancy without hypertension
O12.0 Edema caused by pregnancy
O12.1 Proteinuria caused by pregnancy
O12.2 Edema and proteinuria caused by pregnancy
O13 Hypertension caused by pregnancy without significant proteinuria
O14 Hypertension caused by pregnancy with significant proteinuria
O14.0 Preeclampsia of moderate degree
O14.1 Severe preeclampsia
O14.9 Unclear preeclampsia
O15 Eclampsia
O15.0 Eclampsia during pregnancy
O15.1 Eclampsia during delivery
O15.2 Eclampsia during postpartum period
O15.9 Unclear eclampsia
O16 Unclear hypertension of mothers
 Correspondence of gestosis
classifications

Gestosis of O12.0 Edema caused by pregnancy (?)

mild form O13 Hypertension caused by pregnancy without
significant proteinuria

Gestosis of O11 Earlier hypertension, with later joined proteinuria

moderate O12.1 Proteinuria caused by pregnancy
O12.2 Edema and proteinuria caused by pregnancy
degree O14.0 Preeclampsia of moderate degree

Gestosis of O11 Earlier hypertension, with later joined proteinuria

severe form O14.1 Severe preeclampsia
O14.9 Unclear preeclampsia
 Correspondence of gestosis
classifications

O14.9 Unclear preeclampsia

Preeclampsia

O15 Eclampsia
Eclampsia O15.0 Eclampsia during pregnancy
O15.1 Eclampsia during delivery
O15.2 Eclampsia during postpartum period
O15.9 Unclear eclampsia
 Hypertensive conditions during pregnancy are
represented by a group of diseases: those that
existed before pregnancy and developed
directly in connection with pregnancy .
They distinguish 4 types of AH:
1. Chronic AH (hypertonic disease and
secondary and symptomatic AH)
2. Gestational AH
3. Preeclampsia/eclampsia
4. Preeclampsia at the background of CAH
In Russia, hypertension occurs in 5-30% of cases, and over the
past decades, there has been a tendency to an increase in this
indicator .

According to WHO, in the structure of maternal

mortality, the share of hypertensive syndrome is 20-30% [1,2],
more than 50,000 women worldwide die annually during
pregnancy due to complications of hypertension [1,2].
 The criterion for hypertension in pregnant
women is systolic blood pressure > 140 mm Hg. and
/ or diastolic blood pressure> 90 mm Hg.

Earlier, hypertension in pregnant women was also

diagnosed with an increase in the SBP level by 30 mm Hg.
and / or DBP at 15 mm Hg. compared to the data recorded
initially .

Currently, this diagnostic criterion is excluded

from all international recommendations!!!
 Hypertensive states at pregnancy

AH connected to
AH before pregnancy gestational stage
 Chronic arterial hypertension

Chronic hypertension is hypertension diagnosed

before pregnancy or before 20 weeks of pregnancy.
Hypertension that occurs after 20 weeks of gestation
but does not disappear after delivery within 12 weeks
is also classified as chronic hypertension .
 GESTATIONAL ARTERIAL
HYPERTENSION (GAH)
• GAH – this is an increase in blood pressure
induced by pregnancy, manifested after 20 weeks
of pregnancy and is not accompanied by
proteinuria
• If blood pressure remains elevated 12 weeks after
delivery, then you should think about CAH.
 PREECLAMPSIA (PE)
• ПЭ - A SYNDROME SPECIFIC FOR
PREGNANCY, WHICH ARISES AFTER 20
WEEKS OF GESTATION, DEFINED BY AN
INCREASE IN AP ALONG WITH THE
DEVELOPMENT OF PROTEINURIA (MORE
THAN 300 (0.3g) MG IN 24-HOUR URINE) AND
/ OR EDEMA. THERE ARE TWO FORMS OF
PE: MODERATE AND SEVERE
 Preeclampsia - pregnancy-specific syndrome that
occurs after the 20th week of gestation is determined by the
presence of hypertension and proteinuria (more than 300
mg of protein in daily urine) .
Lack of enzymes - vascular spasm - decreased placental
blood flow - decreased blood supply to the fetus -
developmental delay .

Enzyme deficiency - vascular spasm - decreased renal blood

flow - ischemia and damage to the glomeruli
There are 2 forms of PE: moderate and severe
The presence of edema is not a diagnostic criterion
for PE. With physiological pregnancy, the frequency of
edema reaches 60-80%
 CRITERION OF PE(in RF)

• Systolic AP  140 mmHg

• Diastolic AP ≥ 90 mmHg
•.
• Proteinuria ≥ 300 mg in daily urine
• Edema?
 PREECLAMPSIA (PE) AT THE
BACKGROUND OF CAH
• PE AT THE BACKGROUND OF CAH – the
onset of symptoms of PE after 20 weeks, or
a sharp increase in proteinuria or blood
pressure in women who previously did not
have proteinuria or whose blood pressure
was easily controlled .
 ECLAMPSIA

• ECLAMPSY IS DIAGNOSED IN CASES OF

WOMEN WITH PREECLAMPSY
CONVULSION/SEIZURES WHICH CANNOT BE
EXPLAINED BY OTHER CAUSES
 ICD-10
• 011 Earlier hypertension, with later joined
proteinuria (PE at the background of H)
• 012.2 Edema and proteinuria caused by
pregnancy
• 013. Hypertension caused by pregnancy without
significant proteinuria (gestational AH)
• 014. Hypertension caused by pregnancy with
significant proteinuria
• 014.0. Preeclampsia of moderate degree
• 014.1. Severe preeclampsia
• О15 Eclampsia
 Criterion of hypertension, caused by pregnancy (ГВБ) О13 – О15
по МКБ-10
Code AH Proteinuria Complaints and symptoms
МКБ-10 (after 6 hour of relax) (daily)

О13 = or > 140/90 mmHg Not more 0,3 gr/l no

but still less than
160/110 mmHg

О14.0 = or > 140/90 mmHg more 0,3, but no

but still less than less 5.0 gr/l
160/110 mmHg

О14.1 160/110 mmHg and more 5.0 gr/l There may be a headache,
higher blurred vision, pain in the right
hypochondrium and epigastric
region, the sudden appearance
of edema of the face and hands.
Delay in fetal development

О15 one or more seizures attack at the background of preeclampsia(О14.1) 27

 Criterion of PE severity

Index Moderate Severe

AHГ ≥ 140/90 mmHg > 160/110 mmHg
Proteinuria >0,3 gr/day, but < 5 > 5gr/day
gr/day
Creatinine normal > 90 mcm/l
Oliguria no <500 ml/day
Disorder of liver no Increase of
functioning ALT, AST
thrombocytes normal <100х103/l
Hemolysis no +
Neurological symptoms no +

Fetal growth retardation -/+ +

 Measurement of blood pressure should be carried out in a
pregnant woman at rest after a 5-minute relax .
During the previous hour, the woman should not perform heavy
physical activity.
Measurement of blood pressure is carried out in the position of the
pregnant woman "sitting", in a comfortable position, or "lying on the
left side" .
The cuff is applied to the arm in such a way that its lower edge is 2
cm above the elbow bend, and the rubber part of the cuff covers at
least 80% of the shoulder circumference .
Measurement of blood pressure is carried out twice, with an
interval of at least a minute, on both hands .
If an elevated blood pressure level is detected in a pregnant
woman, it is advisable to conduct daily blood pressure monitoring
(DBPN) to confirm the diagnosis of hypertension
 Preeclampsia. Clinical monitoring.

• Monitoring of AP, pulse

• Control of HR - every hour
• Parameters of saturation. In case of decreased
saturation– to exclude the edema of lung.
• Monitoring of liquid balance
• Monitoring of diuresis
• Control of proteinuria every 4 hours. In case of
conservative therapy – daily proteinuria.
• Examination of fundus of eye (to exclude
extravasation)
• Thermometry every 4 hours
Лабораторные Изменения при развитии ПЭ
показатели
Hemoglobin Increase in the values of indicators due to
and hematocrit hemoconcentration. It is characteristic of PE and is an
indicator of the severity of the process.
Leukocytes Neutrophilic leukocytosis
Thrombocytes Decrease to less than 100 х 10 3 /l points at severe PE

Blood smear Presence of fragments of erythrocytes points at

hemolysis at the background of severe PE
INR, PTI Increase at DIC-syndrome
Creatinine, uric Increase
acid
AST,ALT,LDH Increase points at severe state
Proteinuria It should be estimated as PE, till the opposite diagnosis s
not proved
Albumin of Decrease (points at increase of endothelium permiability,
blood typical for PE).
 The purpose of treatment of pregnant women with
hypertension of various origins:

1. prevent the development of complications caused by high

blood pressure

2. ensure the preservation of pregnancy, physiological

development of the fetus and normal delivery .

3. pharmacotherapy, if possible, should be pathogenetic and

provide organoprotection.

4. adequate therapy during pregnancy will help reduce the

overall risk of cardiovascular disease in the long term period.
 Administration tactics for pregnant women with
chronic hypertension

In pregnant women with severe chronic hypertension in the first

trimester without antihypertensive therapy, fetal loss is observed in 50%
of cases, there is also a significant maternal mortality.

Antihypertensive therapy promotes prolongation of pregnancy and

increases fetal maturity.

Effective blood pressure control helps to reduce the risk of fetal

death by 10 time.

Women with well-controlled hypertension before pregnancy can

continue treatment with the same drugs (with the exception of ACE
inhibitors and AT blockers - angiotensin II receptors).

In chronic hypertension in the first half of pregnancy, a physiological

decrease in blood pressure to normal values is possible .
 Change of way of life:
You should not increase physical activity and follow a diet to
reduce body weight
In case of uncomplicated course of chronic and gestational
hypertension, aerobic exercise, walking in the fresh air can be
recommended.
It is advisable to avoid stressful situations that contribute to an
increase in blood pressure.
In the case of severe hypertension, bed rest on the left side is
recommended. Bed rest is also indicated for gestational
hypertension, while the patient is in the hospital .
A diet rich in vitamins, trace elements, proteins. Salt
restriction during pregnancy is not indicated. In PE, a
decrease in salt intake does not contribute to a decrease in blood
pressure, but can contribute to a decrease in circulating blood
volume, impairment of placental perfusion.
In all cases, smoking, alcohol is strictly prohibited !!!!!
 Management of pregnant women with gestational
hypertension

It requires hospitalization of the patient for observation,

clarification of the diagnosis, exclusion of the possible
development of PE.

Antihypertensive therapy starts immediately.

In the absence of disease progression and with stable

functional parameters of the fetus, moderate hypertension,
effective antihypertensive therapy, further monitoring of the
patient can be carried out on an outpatient basis with weekly
monitoring of her condition.
 Treatment –
only symptomatic?
• Etiological treatment – delivery.
• Pregnancy is prolonged as long as an adequate state of
the intrauterine environment is maintained, which is
necessary to maintain the growth and development of
the fetus without endangering the health of the mother.
• Treatment should be carried out simultaneously by an
obstetrician-gynecologist and an anesthesiologist-
resuscitator, preferably in a specialized intensive care
unit.
• Intensive care for severe preeclampsia:
- anticonvulsant / sedative,
- antihypertensive,
- infusion-transfusion.
 Antihypertensive drugs used for routine
therapy of hypertension during pregnancy
Criteria for initiation of antihypertensive therapy in various types of
hypertensive syndrome of pregnant women

Form AH Criterion for beginning of therapy

Chronic AH without POM, ACC ≥150/95 mmHg

Chronic AH with POM, ACC ≥140/90 mmHg
Gestational AH ≥140/90 mmHg
PE ≥140/90 mmHg.

Target blood pressure in the treatment of hypertension in pregnant women

(taking into account both the safety of the mother and the needs of the fetus)

Systolic AP 130 mmHg.

Diastolic AP 80 mmHg
 Central α2-agonists

Methyldopa(В) 1500 mg – 2000 mg per First line drug in most countries. There were no
day, in 2-3 doses(max unfavourable effects in animal experiments and
dose in the US the relationship between the drug and birth
recommendation
3000mg, in the
defects when used in the first trimester in
European 4000mg) humans. In terms of 16-20 weeks of pregnancy,
the use is not desirable, due to the possible effect
on the dopaminergic receptors of the fetus. When
used, severe liver dysfunction in the mother is
possible, 22% of women have drug intolerance.

Clonidinum(С) 0.075 3 times a day, Safety data are inconsistent. There were no
maximum single dose unfavourable effects in the fetus, however, there
0.3 mg, maximum daily are few observations, especially in the I
2.4 mg
trimester, for the final conclusion. There are
reports of embryotoxicity. A small study reported
hyperactivity and sleep disturbance in children.
US guidelines indicate that it is possible to use
clonidine as a third-line drug for refractory
hypertension .
 Calcium antagonists
Nifedipinum(С) Average daily dose 40- The most studied representative of the CA group,
90 mg in 1-2 doses, is recommended for use in pregnant women in all
depending on the form international recommendations as a first or second
of release (max daily
dose 90 mg)
line drug for hypertension in pregnant women.
Wide experience of using the drug as a tocolytic
has been accumulated. In an experiment on
animals, a teratogenic effect was revealed, but
this has not been confirmed when used in
humans. It is recommended to use with caution
simultaneously with magnesium sulfate
(neuromuscular blockade is possible)

Amlodipinum(С) 5-10 mg, 1 time per day In an experiment on animals, no teratogenicity was
revealed. An observational study involving a small
number of women showed the safety of the drug in the
treatment of hypertension

Felodipinum(С) 2.5-10 mg, once a day Teratogenic in rabbits. There are single reports (3 cases)
(maximum daily dose for use during pregnancy
20 mg)

Verapamil(С) 40-480mg, 1-2 times a In an experiment on animals, no teratogenicity was

day depending on the revealed. There are isolated studies on use during
form of release, max pregnancy, including in the first trimester
dose 480 mg / day
 β-adrenoblockers
Atenolol(D) 25-200mg, 2 times a Not recommended for use in pregnant women in Canada,
day, average dose Germany, Australia, due to the syndrome of delayed fetal
100mg / day, max development identified in a study and a retrospective
200mg / day comparative review

Metoprolol(С) 25-200mg, 1-2 times a The studies did not report symptoms and signs of β-
day (1 time - blockade in fetuses and newborns. In a placebo-controlled
prolonged), max study when using metoprolol, no data were obtained
200mg / day indicating a negative effect of the drug on fetal
development

Bisoprolol 5-10mg, once a day, There are isolated reports of use in women during
max 20mg / day pregnancy
Betaxolol(С) 5-10mg, once a day, A report on successful use in pregnant women with
max 20mg / day hypertension has been published in Russia; long-term
consequences for the development of children have been
studied.
Nebivolol(С) 2.5-10mg, 1 time per There is data on the use in humans in the domestic
day, max 10mg / day literature, including the study of long-term consequences
in relation to the development of children.
Propranolol(С) 80-320mg / day in 2-3 Many undesirable fetal and neonatal effects have been
doses, max 320mg / described when taking the drug (delayed fetal
day development, hypoglycemia, bradycardia, polycythemia,
etc.)
 Management of pregnant women with PE / EC.
For women with moderate PE before 34 weeks of gestation,
medical therapy can be used, which is carried out in a hospital
setting .

If signs of deterioration of the mother or fetus are detected,

immediate delivery is indicated.

In the development of PE against the background of chronic

hypertension, the same principles apply as for PE without pre-
existing hypertension.

In 28 experiments, antihypertensive therapy was compared with

placebo or no treatment (3200 women). There was a two-fold
reduction in the risk of developing severe forms of hypertension
with the use of antihypertensive therapy, however, there was no
significant effect on the incidence of preeclampsia, premature
birth, perinatal outcomes.
In 2 meta-analyzes conducted, it was found that a decrease in
maternal blood pressure is associated with low birth weight. It
has been shown that a decrease in blood pressure by 10 mm
Hg. Art. associated with a decrease in fetal weight by 176
grams.

An acceptable range of blood pressure values in the

treatment of hypertension in pregnant women should be
considered as systolic blood pressure values of 130-150
mm Hg. and diastolic blood pressure 80-95 mm Hg.

In the foreign literature there are similar recommendations,

which indicate that one should strive to maintain the blood
pressure level of 140-55 / 90-05 mm Hg
 Antihypertensive drugs contraindicated for use during pregnancy

ACEI and blocker of АТI receptors

Spironolactone(D)
Diltiazem(C)
Reserpin (С)
 HOSPITALIZATION:
Severe AH (≥160/110 mmHg
Clinical sym p toms of PE
Threatening PE, prodromal symptoms.
Proteinuria
clinical signs of HELLP – syndrome.
AH or proteinuria with other risk factors:
- previous somatic pathology of the mother (for example, diabetes mellitus)
- threatened premature birth (before 34 weeks)
- poor outpatient supervision (late visits of doctor, rare visits to the doctor, non-
compliance with recommendations, etc. .)
Fetal pathology:
- suspicion/signs of fetal hypoxia
- signs of impaired uteroplacental blood flow and / or fetoplacental
 DELIVERY

The most effective treatment for PE is delivery

At moderate PE without signs of fetal growth retardation and blood

flow abnormalities according to Doppler ultrasound, it is possible to
try to prolong pregnancy up to 37 weeks.

For severe PE, immediate delivery is performed regardless of

gestational age.

Absolute indications for emergency delivery, regardless of

gestational age: eclampsia (after an attack); manifestation of
neurological symptoms (developing eclampsia); critical
complications of preeclampsia;
 Infusion-transfusion therapy
• Crystalloids • Currently, there is no proven
benefit of any of the plasma
substitutes in the intensive care of
• Glucose severe PE for the outcome of
pregnancy and childbirth
solutions
• Colloids
• FFP
• Solutions of
HES
 Infusion-transfusion therapy
• Moderate dehydration is better than overhydration. Volume
about 1-1.2 liters per day.
• Infusion (crystalloids only - Ringer's solutions).
• Infusion rate no more than 40-45 (maximum bolus - 80) ml /
hour or 1 ml / kg / hour (level C) .
• Control over the ongoing infusion therapy is carried out by
assessing the rate of diuresis.
• Diuretics are used only for pulmonary edema.
• Albumin transfusion is only possible with hypoalbuminemia <25
g / l, better after delivery.
• Infusion loading is necessary for epidural blockade, parenteral
antihypertensive therapy, intravenous magnesium
administration, oliguria or signs of central dehydration.
 Anticonvulsant therapy
• Magnesium sulfate (FDA Group A) - the main
drug for the treatment of severe preeclampsia
and prevention of eclampsia.
• Effects of magnesium sulfate: sedative and
anticonvulsant, tocolytic, prolongs the action of
muscle relaxants, hypotensive (through NO
production). Magnesium sulfate is superior to
benzodiazepines, phenytoin, and nimodipine in
preventing eclampsia (Cochrane Review), does
not increase the incidence of caesarean section,
bleeding, infectious disease, and neonatal
depression (grade A)
 Magnesia therapy protocol

DOSES:
When using a 25% solution:
• A loading dose - 4 g slowly over a period of
15-20 minutes (16.0 ml of a 25% solution of
magnesium sulfate )
• When using a pump - 60 drops / min (≥20 min
• Maintenance dose: 1.5-2 g / hour
intravenously for 24 hours (7-8 ml / hour)
 Magnesia therapy protocol

They carry out:

• Continuous pulse-oximetry
• Hourly diuresis
• Hourly RR control
• Examination of deep tendon reflexes
 Magnesia therapy protocol

The infusion is stopped when:

• diuresis - 100 ml in 4 hours
or
• Lack of knee reflexes unrelated to regional
block or
• RR < 16 per min
or
• Saturaion < 90%
 Magnesia therapy protocol

Side effects:
•Motor paralysis
•Absence of tendon reflex
•Decrease of RR
•Progressive disorder of cardiac rythm
These effects are minimized with close monitoring
of the woman and a slow infusion rate
Antidote – 10%-10.0 calcium gluconate
(injected intravenously slowly)
 PE: Delivery
• Steroids - up to 34 weeks of pregnancy (dexamethasone 6 mg
intramuscularly after 12 hours x 4 times or betamethasone 12 mg i / m
after 12 hours 2 r / d )
• Before delivery, it is necessary to stabilize the state of women
• Delivery is best done during the working day (especially in the case of
preterm labor)
• If gestation <32 weeks, caesarean section is preferred
• After 34 weeks - vaginal delivery at cephalic presentation. Vaginal use of
prostaglandins increases the chances of a successful delivery
• Antihypertensive therapy should be carried out throughout the entire
period of delivery and in the postpartum period
• The second stage of labor should be shortened - vaginal operative
delivery
• In the third period - 5 ml of oxytocin, but not methylergometrine (causing
an increase in blood pressure)
• The use of epidural analgesia is highly recommended
• Adequate thromboprophylaxis is advisable
 PE: Delivery
Indications for emergency delivery:
• Abruption of placenta
• Antenatal fetal death
• High proteinuria (>5 gr/day)
• Antihypertensive therapy-resistant hypertension (AP
more than 180/110 mm Hg)
• Terminal state of the fetus (according to Doppler and
CTG) after 28 weeks of gestation
• HELLP – syndrome
• Acute fatty hepatosis of pregnant women
• DIC-syndrome
• Acute violation of cerebral circulation
• Eclampsic coma
 Anesthesia at PE?
• All cases of severe preeclampsia require prenatal (preoperative)
preparation for 6-24 hours (grade B).
• To prevent the development of eclampsia during labor, all
women with conservative delivery must be anesthetized with
epidural analgesia (grade A).
• For caesarean section for women with moderate preeclampsia,
regional (spinal, epidural) anesthesia is the treatment of choice
(grade A).
• For caesarean section for women with severe preeclampsia and
eclampsia, general anesthesia is the treatment of choice (grade
B).
 Anesthesia at CS
• RA is preferable over general. Recent studies have shown that spinal and
combined spinal-epidural anesthesia is as safe as epidural.

• Benefits of RA - blood pressure control, increased renal and uteroplacental

blood flow, prevention of convulsive syndrome.

• The dangers of GA are hemodynamic instability during induction, intubation

and extubation of the trachea. Hypertension and tachycardia can cause
increased intracranial pressure.

• The risk of RA is usually associated with the development of epi- and

subdural hematomas - extremely rare complications in obstetric
anesthesiology, therefore, if the platelet count is> 100 thousand, RA is not
contraindicated. The number of platelets 50-100 thousand is a risk zone in
which it is necessary to weigh the specific risks / benefits of RA and GA
(difficulties with intubation, defect in platelet function, depression of
breathing in newborns, other markers of DIC syndrome.
 Tactics for imminent eclampsia

• А ( airway ) – put the woman on her left side and

provide air access
• В ( breathing )- provide a high flow of oxygen and
assess breathing after a seizure, pulse oximetry,
auscultation of the lungs to exclude aspiration or
pulmonary edema
• С ( circulation) – measurement of blood pressure
and pulse
• If the fetus does not suffer (there is no
bradycardia), then it is better to stabilize the
woman's condition before delivery
 Intensive therapy at eclampsia
The goal of intensive care for eclampsia in the
prenatal period is only to stabilize the condition,
achieve an anticonvulsant effect and lower blood
pressure.
Manipulations:
• Airway management
• Turn to the left sideна левый бок.
• Peripheral vein catheterization.
• Non-invasive (if necessary - invasive) monitoring: blood
pressure, heart rate, SpO2,
• Hourly diuresis control.
• Inhalation of humidified oxygen
 Intensive therapy at EC
• before delivery (first 4-6 hours)
• First line drugs:
• Intravenous magnesium sulfate 5-6 g (25% -20-24 ml)
slowly over 5-10 minutes, and then a maintenance dose
at a rate of 2 g / h (25% - 8 ml), including the period of
delivery (level A) .
• Benzodiazepines (diazepam 10-20 mg) (level B).
• Barbiturates (phenobarbital 0.2 mg, while maintaining
convulsive readiness, thiopental sodium 100-200 mg IV
drip, and in this case, transfer to mechanical ventilation
is necessary) (level B).
• Infusion therapy up to 40-45 ml / h (crystalloids only)
(level C).
• Antihypertensive therapy (grade B).
 Intensive therapy at EC
• In case of recurrence of seizures or the failure of the
previous measure, inject an additional 2 to 4 g of
magnesium sulfate (25% -8-16 ml) intravenously over 5
minutes, seduxen 10-30 mg intravenously and / or
barbiturates (thiopental, hexenal) 250-400 mg
intravenously, if necessary, muscle relaxants with the
transfer of the pregnant (postpartum woman) to
mechanical ventilation.
• With preserved consciousness after an attack of
seizures, continue conservative therapy for 4-6 hours
with saturation with magnesium sulfate and monitoring
the neurological status. Within the same time frame, it is
necessary to resolve the issue of delivery.
• In the absence of consciousness after an attack of
seizures - coma, it is necessary to transfer the patient to
mechanical ventilation under conditions of induction
anesthesia with sodium thiopental followed by urgent
delivery
 Maintaining the function of external
respiration
• In case of recurrent convulsive syndrome, mechanical
ventilation is carried out with an oxygen-air mixture with
an oxygen content of at least 40% in mandatory
ventilation mode (CMV), followed by switching to
auxiliary ventilation (SIMV) under normal ventilation
conditions (PA CO2 30-40 mm Hg) independently from
the presence or absence of external respiration. Initial
ventilation parameters: ДО – 7-8 мл/кг, МОД – 8-10
л/мин, Рвд – не более 20 см водного столба, Рвыд –
1:2 без использования ПДКВ. Respirator
synchronization is achieved based on respiration rate .
 Criteria for transferring patients to
spontaneous breathing:
• Complete restoration of consciousness
• Absence of seizures and seizure readiness without the
use of anticonvulsants
• Termination of the action of drugs that depress breathing
(muscle relaxants, narcotic analgesics, hypnotics)
• The ability to hold the head above the pillow
independently for at least 5 seconds
• Stable and easily controlled state of hemodynamics
• SO2 more 95%, PAО2 more 80 mmHg, at FiO2 more
0,4
• Restoring the cough reflexкашлевого рефлекса
 Correction of AP

• The average blood pressure should be at

least 80 mm Hg. According to indications -
controlled hypotension with adenosine,
labetalol, hydrolazine or sodium
nitroprusside. In case of hypotension,
vasopressors.
 Infusion therapy
• Infusion therapy on the first day should not
exceed the volume of 10-15 ml / kg / day, which
is necessary for the administration of
antihypertensive drugs, taking into account the
indicators of central hemodynamics (blood
pressure, CVP, heart rate, etc.). The
composition of the infusion therapy: crystalloids
and ГЭК (stabizol). If there are signs of blood
clotting disorders, transfusion of СЗП and
cryoprecipitate. Stimulation of diuresis only after
delivery with saluretics against the background
of adequate infusion therapy. Osmotic diuretics
are contraindicated.
 Neuroprotection
• Primary neuroprotection should be started from
the first minutes of the eclamptic coma and
should be continued for 5-10 days, especially in
the first 12 hours: magnesium sulfate, calcium
antagonists with a cerebral effect (nimodipine
(nimotop)), starting from 2 mg / h up to 30 mg /
day.
• Secondary neuroprotection after 6-12 hours
(tocopherol acetate (600 mg / day), emoxipin
(10-15 mg / kg / day), riboxin (10ml).
 Delivery
• Eclampsia itself is one of the indications for delivery.
Caesarean section is the preferred method of delivery
after an episode of eclampsia. The operation of
obstetric forceps is absolutely indicated if an eclampsia
attack occurred during the period of exhaustion.
Conservative completion of labor against the
background of eclampsia is possible only when the
head of the fetus has cut into the genital slit .
• With a gestational age of less than 34 weeks, it is
recommended, in the absence of a critical condition in a
woman, to prepare the fetus with corticosteroids for 24
hours, but in practice this is extremely rare.
 Intensive care and anesthetic management of
eclampsia at the stage of delivery

• For caesarean section in women with eclampsia, general

anesthesia is the treatment of choice (level B). General
anesthesia is performed as follows:
• Introductory anesthesia, taking into account the risk of
developing high arterial hypertension: sodium thiopental 6-7
mg / kg and fentanyl 50-100 μg. To prevent the progression
of arterial hypertension at the stage of surgery before fetal
extraction, parenteral nifedipine, clonidine, inhalation
anesthetics can be used: enflurane up to 1.0 vol%, isoflurane
up to 1.0 vol% or sevoflurane up to 1.5 vol%%.
• Immediately after the operation, the administration of
magnesium sulfate at a dose of 2 g / h begins / continues to
achieve an anticonvulsant effect.
Postpartum intensive care management
• After the end of the caesarean section, the patient is transported on
prolonged mechanical ventilation under conditions of total myoplegia
sedation. There are no time standards for extended mechanical
ventilation, since no more than 50% of women with eclampsia really
need it .
Indications for prolonged mechanical ventilation in severe
preeclampsia and eclampsia:
• coma;
• cerebral hemorrhage;
• combination with coagulopathic bleeding;
• combination with shock (hemorrhagic, septic, anaphylactic, etc..);
• ОЛП, ARDS, alveolar pulmonary edema;
• unstable hemodynamics;
• progressive polyorganic insufficiency.
 After delivery:
• Antihypertensive therapy continues during
postpartum period as blood pressure may
rise 24 hours after delivery
• Reducing the intensity (dose) of
antihypertensive therapy should be done
gradually
• Blood pressure usually returns to normal
within 3 months. During this period of time,
blood pressure should not exceed 160/110
mm Hg
 Stabilization of a woman's condition
before transportation
1. Blood pressure must be within acceptable limits
2. All major examinations must be completed and the
results are clearly recorded in accompanying documents
or communicated by telephone
3. The condition of the fetus should be assessed, and RDS
prevention carried out
4. Must be accompanied by qualified personnel, at least a
senior midwife
5. It is necessary to warn in advance all specialists of the
receiving hospital about the transfer (chief physician,
obstetrician, neonatologist, anesthesiologist )