HYPERTENSION IN PREGNANCY

Clinical Practice Guidelines

BEA JOI JAVELLANA

POST GRADUATE INTERN
EPIDEMIOLOGY OF HYPERTENSION IN
PREGNANCY
 MATERNAL RISK FACTORS

1. Primiparity
2. Primipaternity
3. History of preeclampsia
4. Obesity (body mass index ≥ 30)
5. Family history of preeclampsia
6. Ethnicity
7. Maternal age
8. Smoking
 MATERNAL RISK FACTORS

Other unresolved risk factors:

• Interpregnancy intervals <2years or >10years
• Previous miscarriage and induced abortions
• Environmental risk factors
MATERNAL MEDICAL RISK FACTORS

1. Underlying medical conditions

a. Diabetes mellitus
b. Antiphospholipid antibody syndrome
c. Systemic lupus erythematosus (SLE)
d. Renal disease
2. Maternal infection
PLACENTAL/FETAL RISK FACTORS

1. Multiple pregnancies
2. Molar pregnancy
CLASSIFICATION OF HYPERTENSION IN
PREGNANCY
FOUR CATEGORIES OF HYPERTENSION

1. Preeclampsia-eclampsia
2. Chronic hypertension (of whatever cause)
3. Chronic hypertension with superimposed preeclampsia
4. Gestational hypertension
 BLOOD PRESSURE CRITERIA

• Elevated blood pressure

– Systolic and diastolic BPs ≥ 140 and ≥90 mmHg occurring
after 20 weeks of gestation
– Korotkoff phase V is used to define diastolic pressure
• Incremental changes in BP no longer a recommended
criterion
DIAGNOSTIC CRITERIA FOR PREECLAMPSIA
Blood pressure • ≥140mmHg systolic or ≥90mmHg diastolic on two occasions at least 4 hours apart after
20 weeks of gestation in a woman with previously normal BP
• ≥160mmHg in systolic or ≥110mmHg diastolic, hypertension can be confirmed within a
short interval (minutes) to facilitate timely antihypertensive therapy
And
Proteinuria • ≥300mg/24hours urine collection (or this amount extrapolated from a timed collection)
• Protein/creatinine ratio ≥0.3mg/dL
• 1+ urinary protein dipstick reading (used only if other quantitative methods not
available)
Or in the absence of proteinuria, new-onset hypertension with new onset of any of the following:
Thrombocytopenia • Platelet count <100,000/µL
Renal insufficiency • Serum creatinine >1.1mg/dL or a doubling of the serum creatinine concentration in the
absence of other renal diseases
Impaired liver function Elevated blood concentration of liver transaminases to 2x normal
Pulmonary edema
Cerebral or visual symptoms
 PREDICTORS OF PREECLAMPSIA

• What is the significance of mean arterial pressure (MAP) in

detecting or predicting preeclampsia?
MAP is better than systolic or diastolic BP alone in
predicting preeclampsia. Combined testing by maternal
characteristics and BP at 30-33 weeks could effectively identify
women at high risk for subsequent development of
preeclampsia
 PREDICTORS OF PREECLAMPSIA

• What biochemical markers can be used to predict preeclampsia?

– The concentration of placental growth factor (PIGF) and vascular
entothelial growth factor (VEGF) were lower in women who developed
preeclampsia
– PIGF, Sflt-1, and sENG = different concentrations before 30 weeks AOG
in women who developed preeclampsia (too poor for accurate prediction)
 PREDICTORS OF PREECLAMPSIA

• What biochemical markers can be used to predict preeclampsia?

Placental protein 13 (PP13) expressed by the
syncitiotrophoblast → lower level in the 1st trimester in women
who later develop early-onset preeclampsia
PREDICTORS OF PREECLAMPSIA
PREDICTOR SPECIFICITY (%) SENSITIVITY (%)
AFP 96 9
Fibronectin 94 65
Total fetal DNA 88 50
Hcg 89 24
Inhibin A 95 30
Activin A 89 61
PAPP-A 94 10
Kallikreinuria 98 83
 PREDICTORS OF PREECLAMPSIA

• What is the role of uterine artery Doppler studies in the prediction

of preeclampsia?
– Pulsatility Index (PI): peak systolic flow minus end diastolic flow divided
by mean flow
– Resistance Index (RI): peak systolic flow minus end diastolic flow divided
by peak systolic flow
– Presence of uterine notching is not expected in normal pregnancy, and is
50% predictive of developing preeclampsia (30% of the cases have a
higher probability of IUGR)
 PREDICTORS OF PREECLAMPSIA

• What is the best combined method for the prediction of

preeclampsia?
– A combination of biochemical and ultrasonographic markers → better
than a single predictor
– PP13 + uterine artery Doppler → 90% sensitivity, 90% specificity (severe
preeclampsia, high risk population)
– MAP + uterine artery PI + PAPP-A + PIGF → 93% sensitivity, 95%
specificity (1st trimester)
PREVENTION
OF PREELAMPSIA
 PREVENTION OF PREECLAMPSIA

• Should aspirin be given to all women for prevention of

hypertensive disorders of pregnancy?
Aspirin should be given to patients at high risk for development of
hypertensive disorders of pregnancy
• Should aspirin be started to prevent hypertensive disorders of
pregnancy?
Aspirin should be given <16 weeks age of gestation
• Should high dose calcium be used in the prevention of
hypertensive disorders?
High dose calcium is recommended for patients with adequate and
inadequate calciuim intake.
 PREVENTION OF PREECLAMPSIA

• Should progestogens be used for prevention of hypertensive

disorders of pregnancy?
Progestogens should not be used for prevention of hypertensive disorders
of pregnancy and its complications
• Should low salt intake versus normal salt intake be used for the
prevention of hypertensive disorders of pregnancy?
Restriction of salt intake is not recommended during pregnancy.
• Should vitamin C and E be used for prevention of hypertensive
disorders of pregnancy?
Vitamin C and E supplementation should not be given in patients to
prevent hypertensive disorders of pregnancy.
 PREVENTION OF PREECLAMPSIA

• Should regular aerobic exercise versus normal physical activity

be used for prevention of hypertensive disorders of pregnancy?
Exercise does not decrease the risk for hypertensive disorders of
pregnancy.
• Should bed rest be used for prevention of hypertensive disorders
of pregnancy?
Bed rest is not recommended to prevent preeclampsia.
• Should folic acid be used to prevent hypertensive disorders of
pregnancy?
The use of folic acid could not be recommended at this time.
 PREVENTION OF PREECLAMPSIA

• Should marine oil supplementation be given for the prevention of

hypertensive disorders of pregnancy?
Fish oil or marine oil supplementation is not recommended for
the prevention of hypertensive disorders of pregnancy.
GESTATIONAL HYPERTENSION AND
PREECLAMPSIA WITHOUT SEVERE FEATURES
 USE OF ANTIHYPERTENSIVES

• Use of antihypertensives in mild to moderate hypertension in

pregnancy decreases the risk of severe hypertension
• Use of antihypertensives in mild to moderate hypertension in
pregnancy does not significantly decrease the development of
preeclampsia
• Use of antihypertensives in mild to moderate hypertension in
pregnancy does not show any significant difference in the
development of fetal or neonatal death, preterm birth, small for
gestational age babies
 USE OF ANTIHYPERTENSIVES

• Hydralazine, compared to labetalol, had lower rates of persistent

severe hypertension
• Hydralazine, compared to nifedipine, had higher rates of
persistent severe hypertension
• Hydralazine, compared to nifedipine, was associated with more
maternal hypotension
 USE OF ANTIHYPERTENSIVES

• For women with mild gestational hypertension or preeclampsia

with a persistent BP <160mmHg systolic or 110mmHg diastolic, it
is suggested that antihypertensive medications not be
administered
• Oral nifedipine and intravenous (IV) labetalol regimens are
similarly effective in the acute control of severe hypertension in
pregnancy
 MAGNESIUM SULFATE
• For women with preeclampsia with systolic BP <160mmHg and a
diastolic BP<110mmHg and no maternal symptoms, ti is
suggested that magnesium sulphate (MgSO4) not be
administered universally for the prevention of preeclampsia
• There was no excess in neuromuscular weakness or severe
maternal hypotension in patients who received nifedipine with
MgSO4 as compared to controls who received placebo or other
antihypertensives with MgSO4
• The lower risk of eclampsia following prophylaxis with MgSO4
was not associated with a clear difference in the risk of death or
disability with children at 18months
 ANTIPLATELET THERAPY

Low dose aspirin has not been shown to

significantly decrease the incidence of
preeclampsia in patients with gestational
hypertension
 WORK UP

• The close monitoring of women with gestational hypertension or

preeclampsia without severe features with serial assessment of
maternal symptoms and fetal movement (daily by the woman)
and serial measurements of BP (twice weekly), and assessment
of platelet counts and liver enzymes (weekly) is suggested
• Weekly assessment for proteinuria is recommended
 WORK UP

• Fetal growth assessment and antenatal testing is recommended.

If evidence of growth restriction is noted, Doppler studies should
be done
• Uric acid is weak in predicting preeclampsia
• Platelet count <100,000, elevated transaminases, creatinine
>110mmol/L predicts adverse maternal but not fetal outcomes
 PROTEINURIA

• Measurement of protein/creatinine ratio has potential diagnostic

value for significant proteinuria in cases of suspected
preeclampsia
• Urine protein/creatinine ratio had a sensitivity of 80-94% and
specificity of 74-100%
 PROTEINURIA

• Proteinuric women with preeclampsia, as compared to those

without proteinuria, were significantly more likely to
– Deliver prior to 37weeks
– Develop severe hypertension
– Have a higher perinatal mortality
• …and less likely to develop
– Thrombocytopenia (<100,000 or <150,000)
– Liver disease
 PROTEINURIA

• Non-proteinuric women with preeclampsia, as compared to those

with gestational hypertension, were significantly more likely to
– Deliver prior to 37weeks
– Develop severe hypertension
– Have small for gestational age babies
 TIMING OF DELIVERY

• For women with gestational hypertension or preeclampsia without

severe features and no indication for delivery at less than 37
weeks of gestation, expectant management with maternal and
fetal monitoring is suggested
• For women with gestational hypertension or preeclampsia without
severe features at or beyond 37weeks of gestation, delivery
rather than continued observation is suggested
• Induction of labor vs. expectant management monitoring for
gestational hypertension between 34-37 weeks: HELLP
syndrome, Respiratory distress, NICU admission
PREECLAMPSIA WITH SEVERE FEATURES
 INCIDENCE

• 10% of all pregnancies worldwide (5-10% severe)

• US: leading cause of maternal and perinatal morbidity and
mortality
• 2-5% locally
• 2nd most common cause of maternal death
 PREECLAMPSIA WITH SEVERE FEATURES
Blood pressure • ≥160mmHg in systolic or ≥110mmHg diastolic, on two occasions at least 4 hours apart
while the patient is on bed rest
Thrombocytopenia • Platelet count <100,000/µL
Impaired liver function Elevated blood concentration of liver transaminases to 2x normal, severe persistent
epigastric pain unresponsive to medications and not accounted for by alternative
diagnoses, or both
Progressive renal • Serum creatinine >1.1mg/dL or a doubling of the serum creatinine concentration in the
insufficiency absence of other renal diseases
Pulmonary edema
Cerebral or visual symptoms

• Two criteria (massive proteinuria, fetal growth restriction) were removed as findings indicative of
severe preeclampsia
• Amount of proteinuria does not affect pregnancy outcome
• Management of fetal growth restriction is similar in pregnant women with or without
preeclampsia
PREECLAMPSIA WITH SEVERE FEATURES

• Distinction between mild and severe preeclampsia

– Mild preeclampsia may progress rapidly to severe disease
• Terms “mild”, “non-severe”, or “less severe” are misleading
– “Preeclampsia without severe featutes”: mild disease
– “Preeclampsia with severe features”: severe disease
MANAGEMENT OF PREECLAMPSIA
 MANAGEMENT
• Main objective: safety of mother and fetus
• Initial management: stabilization of the mother’s condition,
confirmation of gestational age, assessment of fetal well-being
• Once diagnosis of severe preeclampsia is established: focus on
maternal safety with expedited delivery
– Associated with high rates of morbidity and mortality (mother) and
potetrial risks (fetus) → agreed to delver patient if the disease
develops ≥34 weeks of gestation
– Prompt delivery is safest option for the woman and fetus if there is
evidence of: pulmonary edema, renal failure, abruption placenta,
DIC, persistent cerebral symptoms, and/or eclampsia,
nonreassuring fetal testing, or fetal demise (irrespective of
gestational age in severe preeclampsia)
 MANAGEMENT

– Complications for prematurity: RDS, intraventricular

haemorrhage, necrotizing enterocolitis, sepsis, and death
• Premature infants born after severe preeclampsia have
complications and mortality similar to other premature nfants
of similar gestational age
• Rate of admission to NICU is higher
• Have no accelerated lung or neurologic maturition
MANAGEMENT
MANAGEMENT
 MANAGEMENT

– Maternal assessment
• Vital signs, fluid intake, urine output monitored at least 8 hours
• Symptoms of severe preeclampsia (headache, visual changes,
retrosternal pain or pressure, shortness of breath, nausea and
vomiting, epigastric pain) monitored at least 8 hours
• Presence of contractions, rupture of membranes, abdominal pain,
bleeding monitored at least 8 hours
• Laboratory testing (CBC and assessment of platelet count, liver
enzyme, and serum creatinine levels) should be performed daily (can
be spaced to every other day if they remain stable and the patient
remains asymptomatic)
 MANAGEMENT

– Fetal assessment
• Kick count and NST with uterine contraction monitored daily
• Biophysical studies twice weekly
• Serial fetal growth should be performed every 2 weeks, and umbilical
artery Doppler studies every 2 weeks if fetal growth restriction is
restricted
 MANAGEMENT

– Maternal indications for delivery

• Recurrent severe hypertension
• Recurrent symptoms of severe preeclampsia
• Progressive renal insufficiency (serum creatinine >1.1mg/dL or
doubling of serum creatinine in the absence of other renal diseases)
• Persistent thrombocytopenia or HELLP syndrome
• Pulmonary edema
• Eclampsia
• Suspected abruption placenta
• Progressive labor or rupture of membranes
 MANAGEMENT

– Fetal indications for delivery

• Gestational age of 34 weeks
• Severe fetal growth restriction (<5th percentile by ultrasound)
• Persistent oligohydramnios (maximum vertical pocket <2cm)
• Biophysical profile of 4/10 or less on at least 2 occasions 6 hours apart
• REDF on umbilical artery Doppler studies
• Recurrent variable or late decelerations during NST
• Fetal death
 MANAGEMENT

– Perinatal complications
• During expectant management of patients with severe preeclampsia:
– Rate of perinatal death: 0–16.6%
– Abruptio placenta: 4.1–22.9%
– Delivery for nonreassuring fetal status: 26–75%
• Intensive fetal monitoring for early detection of fetal compromise is
recommended
 MANAGEMENT

– Maternal complications
• If remote from term: main aim is prolonging gestation without
jeopardizing maternal safety
• Progressive deterioration in maternal condition during the clinical
course of severe preeclampsia may occur
– HELLP syndrome: 4.1–27.1%
– Pulmonary edema: 0–8.5%
– Eclampsia and acute renal failure: <1%
• Heightened surveillance to ensure adequate maternal oxygenation,
provide intervention for hepatic dysfunction, and provide evaluation of
the fetal status and maternal presentation (risk of abruption placenta)
 MANAGEMENT

– Severe preeclampsia before the limit of fetal viability

• High perinatal mortality and morbity rates (71–100%); few newborn
infant surviving without handicap
• Aggressive treatment: immediate delivery results in high neonatal
mortality rate
– If the fetus survives, significant neonatal complications are
expected + prolonged hospitalization in the NICU
• Attempts to prolong pregnancy: may result in fetal death and exponse
the mother to severe morbidity
• Expectant management: explicit counselling regarding poor perinatal
outcomes (severe RDS, chronic lung disease, severe intraventricular
hemorrhage) and maternal complocations (HELLP sundrome,
pulmonary edema, renal failure)
 MANAGEMENT

– For women with severe preeclampsia ≥34 weeks of gestation, and

with those with unstable maternal or fetal conditions irrespective of
gestational age, delivery soon after maternal stabilization is
recommended
– For women with severe preeclampsia at <34 weeks of gestation
with stable maternal and fetal conditions, it is recommended that
continued pregnancy be undertaken only at facilities with adequate
maternal and neonatal intensive care resources
– For women with severe preeclampsia receiving expectant
management at 34 weeks or less of gestation, the administration of
corticosteroids for fetal lung maturity benefit is recommended
 MANAGEMENT
– It is recommended that corticosteroids be given if the fetus is viable
and 33 6/7 weeks or less of gestation, but the delivery not be
delayed after initial maternal stabilization regardless of gestational
age for women with severe preeclampsia that is complicated further
with any of the following:
• Uncontrolled severe hypertension
• Eclampsia
• Pulmonary edema
• Abruptio placenta
• DIC
• Nonreassuring fetal status
• Fetal death
 MANAGEMENT

– Recommended to administer corticosteroids and delivery deferred

for 48 hours if maternal and fetal conditions remain stable for
women with severe preeclampsia and a viable fetus at 33 6/7
weeks or less of gestation of any of the following:
• Preterm prelabor rupture of membranes (PPROM)
• Labor
• Thrombocytopenia
• IUGR <5th percentile
• Severe oligohydramnios
• REDF in Doppler
• Renal dysfunction
 MANAGEMENT

– For women with severe preeclampsia (sustained systolic BP of at

least 160mmHg or diastolic BP of at least 110mmHg), the use of
anti-hypertensive therapy is recommended
 MANAGEMENT
Emergent Therapy for Acute-onset Severe Hypertension in Pregnancy
DRUG (FDA RISK) DOSE AND ROUTE PRECAUTION & ADVERSE EFFECT
Labetalol (C) • 10-20mg IV, then 20-80mg • Considered a first line agent
every 20-30 minutes, maximum • Tachycardia is less common and
of 300mg fewer adverse effects
• For infusion: 1-2mg/min IV • Contraindicated in patients with
asthma, heart disease, or
congestive heart failure
Hydralazine (C) • 5mg, IV or IM, then 5-10mg • Higher or frequent dosage
every 20-40 minutes; once BP associated with maternal
controlled repeat every 3 hours hypotension, headaches, and
• For infusion: 0.5-10.0mg/hr fetal distress – may be more
• If no success with 20mg IV or common than other agents
30mg IM, consider another
drug
 MANAGEMENT
Emergent Therapy for Acute-onset Severe Hypertension in Pregnancy
DRUG (FDA RISK) DOSE AND ROUTE PRECAUTION & ADVERSE EFFECT
Nifedipine (C) • Tablets recommended only: 10- • May observe reflex tachycardia
20mg orally, repeat in 30 and headaches; can be safely
minutes if needed; then 10- used with magnesium sulfate
20mg PO every 2-6 hours
IV Nicardipine (C) • D5W 90mL + Nicardipine 10mg • Can be safely used with
in soluset magnesium sulfate
• Concentration: 0.1mg/mL
• Start drup at 10µgtts/min
(equivalent to 1mg/hr)
• Titrate every hour (increments
of
• 1mg/hr)
• Maximum dose 10mg/hr
• Note: IV infusion site must be
changed every 12 hours
 MANAGEMENT
Emergent Therapy for Acute-onset Severe Hypertension in Pregnancy
DRUG (FDA RISK) DOSE AND ROUTE PRECAUTION & ADVERSE EFFECT
Thiazide Diuretics (C) • Depends on the agent • Can be used in pregnancy, dose
Second line agent adjustment to minimize adverse
effects and risks such as
hypokalemia
 MANAGEMENT
Common Oral Antihypertensive Agents in Pregnancy
DRUG (FDA RISK) DOSE AND ROUTE PRECAUTION & ADVERSE EFFECT
Labetalol (C) • 200–2,400mg/day orally 2-3 • Well tolerated
divided doses • Potential bronchoconstrictive
effects
• Avoid in patients with asthma and
congestive heart failure
Nifedipine (C) • Tablets recommended only: 30- • Do not use sublingual form
120mg/day orally of a slow
release preparation
Thiazide Diuretics (C) • Depends on the agent
Second line agent
 MANAGEMENT

– For women with eclampsia, the administration of parenteral MgSO4

is recommended
– For women with severe preeclampsia, the administration of
parenteral MgSO4 during expectant management is recommended
– For women with severe preeclampsia, the administration of
intrapartum-postpartum MgSO4 to prevent eclampsia is
recommended
– For women with severe preeclampsia undergoing caesarean
delivery, the continued intraoperative administration of parenteral
MgSO4 to prevent eclampsia is recommended
 MANAGEMENT

– MgSO4 can be given in 2 ways:

• Continuous Intravenous Infusion
1. Give 4 to 6g loading dose of MgSO4 diluted in 100mL of IV fluid
administered over 15-20min
2. Begin 2g/hr in 100mL of IV maintenance infusion (some recommend
1g/hr)
3. Monitor for magnesium toxicity
a) Assess DTRs periodically
b) Some measure serum magnesium level at 4-6hr and adjust infusion
to maintain levels between 4-7 mEq/L (4.8–8.4mg/dL)
c) Measure serum magnesium levels if serum creatinine ≥1.0mg/dL
4. MgSO4 is discontinued 24hr after delivery
 MANAGEMENT
– MgSO4 can be given in 2 ways:
• Intermittent Intramuscular Injections
1. Give 4g MgSO4 as a 20% solution intravenously at a rate not to exceed 1g/mn
2. Follow promptly with 10g of 50% MgSO4 solution, one-half (5g) injected deeply
in the upper outer quadrant of both buttocks through a 3 inch long 20 gauge
needle (addition of 1mL of 2% lidocaine minimizes discomfort). If convulsions
persist after 15min, give up to 2g more intravenously as a 20% solution at a
rate not to exceed 1g/min. If the woman is large, up to 4g may be given slowly
3. Every 4hr therafter give 5g of a 50% solution of MgSO4 injected deeply in the
upper outer quadrant of alternating buttocks, but only after ensuing that:
a) The patellar reflex is present
b) Respirations are not depressed
c) Urine output the previous 4hr exceeded 100mL
4. MgSO4 is discontinued 24hr after delivery
 MANAGEMENT
– For women with severe preeclampsia, it is suggested that a delivery
decision should not be based on the amount of proteinuria or change in
the amount of proteinuria
– For women with severe preeclampsia and before fetal viability, delivery
after maternal stabilizations is recommended. Expectant management is
not recommended
– For women with preeclampsia, it is suggested that the mode of delivery
need not be caesarean delivery. The mode of delivery should be
determined by fetal gestational age, fetal presentation, cervical status,
and maternal and fetal conditions
– For women with preeclampsia who require analgesia for labor or
anesthesia for caesarean delivery and with a clinical situation that permits
sufficient time for establishment of anesthesia, the administration of
neuraxial anesthesia (either spinal or epidural) is recommended
 MANAGEMENT

– For women with severe preeclampsia, it is suggested that invasive

hemodynamic monitoring not be used routinely
– For women in whom gestational hypertension, preeclampsia, or
superimposed preeclampsia is diagnosed, it is suggested that BP
be monitored in the hospital or that equivalent outpatient
surveillance be performed for at least 72 hours postpartum and
again 7-10 days after delivery or earlier in women with symptoms
– NSAIDs tend to increase BP, therefore for women with hypertension
that persists for more than 1 day postpartum, it is suggested that
these pain relief agents be replaced by other analgesics (usually
opioid drugs)
 MANAGEMENT
– For all women in the postpartum period (not just women with
preeclampsia) it is suggested that discharge instructions include
information about the signs and symptoms of preeclampsia as well as the
importance of prompt reporting of this information to their health care
providers
– For women in the postpartum period who present with new-onset
hypertension associated with headaches or blurred vision or
preeclampsia with severe hypertension, the parenteral administration of
MgSO4 is suggested
– For women with persistent postpartum hypertension, BP of 150mmHg
systolic of 100mmHg diastolic or higher, on at least 2 occasions that are
at least 4-6hrs apart, antihypertensive therapy is suggested. Persistent
BP of 160mmHg systolic or 110mmHg diastolic or higher should be
treated within 1hr.
ECLAMPSIA
 BASIC OBJECTIVES

• Maternal support of vital functions

• Control of convulsions and prevention of recurrent convulsions
• Correction of maternal hypoxemia and/or acidemia
• Control of severe hypertension to a safe range
• Initiate process of delivery
• Postpartum surveillance
 BASIC OBJECTIVES
• Eclamptic convulsions must always be considered as a life-threatening
emergency
– During convulsions, measures must be taken to prevent maternal injury
– Most urgent part of therapy is the assessment of airway patency (ensure
oxygenation and minimize risk of aspiratuin)
– Most eclamptic convulsions resolve in 60–90 seconds
• There are no recommended protocols for conservative management
of patients with severe preeclampsia and eclampsia
– Management is based on retrospective observations and empirical
clinical experience
– Primary aim to secure safety of the mother first
– Secondary goal of safe delivery and survival of the newborn
 MANAGEMENT

A. Hospitalization
• Required for all patients with eclampsia
B. Control of convulsions and prevention of recurrent convulsions
• Parenteral MgSO4 is the drug of choice to control convulsions
• Recommended dose of MgSO4 is similar to that for severe preeclampsia
• Administration of MgSO4 requires proper monitoring:
1. UO of at least 30mL for 1 hour (or 100mL for 4 hours)
2. Presence of patellar reflex
3. Respiratory rate of not less than 12/min
4. IV Calcium gluconate (10mL of 10% solution) available at bedside for
toxicity
 MANAGEMENT

B. Control of convulsions and prevention of recurrent convulsions

5. If available, serum Mg levels should be taken at certain intervals to monitor
MgSO4 toxicity
6. If a patient is to be transferred to another hospital, the full loading does
must have been given and the patient should be conducted by a
responsible health personnel with provisions for control of seizures and
other complications, if they occur, while on transit

For settings where it is not possible to administer the full MgSO4 regimen,
the use of MgSO4 loading dose followed by immediate transfer to a higher
level health care facility is recommended for women with severe
preeclampsia and eclampsia
 MANAGEMENT

B. Control of convulsions and prevention of recurrent convulsions

• If MgSO4 is contraindicated or not available, other anti-convulsants may
be used:
1. Diazepam
• Loading dose: 10mg slow IV over 2mins, repeated if convulsious recur
• Maintenance dose: IV infusion of 40mg in 500mL normal saline for first 24hrs
• Infusion rate must be titrated based on the level of consciousness, with the aim
of overcoming restlessness and keeping the patient sedated but arousable
• Next 24hrs: IV infusion of 20mg in 500mL normal saline, titrated accordingly
and slowly reduced
• May be used with phenytoin in the absence of MgSO4
 MANAGEMENT

B. Control of convulsions and prevention of recurrent convulsions

2. Phenytoin
• No consensus on ideal dosage regimen, but dose may be varied according to
the patient’s weight
• Recommended only for prevention of convulsions, which necessitates the use
of diazepam to control the convulsions
• After giving diazepam 10mg IV: an initial dose of phenytoin (1g slow IV over
20mins) must be given while continuous cardiac monitoring, followed by
succeeding doses of 100mg every 6 hours for the next 24hrs
 MANAGEMENT
C. Antihypertensive therapy
• Patients with severe hypertension should be staretd on IV hypertensive
therapy with the following recommended agents:
1. Hydralazine (drug of choice)
• IV bolus of 5 or 10mg at 20–30min interval until desired BP is attained
• Due to instability of preparation of hydralazine, an IV drip is not recommended
2. Clonidine
• IM injection of 75–150mcg is the next recommended drug\
3. Nifedipine
• If given orally at 10–20mg, this drug takes effect within 15–50mins
• Must not be given sublingually to pregnant patients because of the associated
acute BP fluctuations and the absence of good studies on fetal effects of
calcium antagonists
 MANAGEMENT
C. Antihypertensive therapy
• Patients with severe hypertension should be staretd on IV hypertensive
therapy with the following recommended agents:
1. Hydralazine (drug of choice)
• IV bolus of 5 or 10mg at 20–30min interval until desired BP is attained
• Due to instability of preparation of hydralazine, an IV drip is not recommended
2. Clonidine
• IM injection of 75–150mcg is the next recommended drug\
3. Nifedipine
• If given orally at 10–20mg, this drug takes effect within 15–50mins
• Must not be given sublingually to pregnant patients because of the associated
acute BP fluctuations and the absence of good studies on fetal effects of
calcium antagonists
 MANAGEMENT
D. Delivery after control of convulsions
• Continuation of pregnancy in women with eclampsia imposes a
significant threat to the well-being of both the mother and the fetus
→ necessitates termination of the pregnancy
• Induction of labor / CS as soon as the patient regains
consciousness is recommended since temporization to gain fetal
maturity in eclampsia is always considered risky
• Labor inductuin even with a poor Bishop score and assisted
delivery can be performed because it’s observed that the uterus is
sensitive to oxytocin among this group of women
• In carefully selected cases, and with close supervision, pregnancy
may be allowed to continue in women with preeclampsia and
eclampsia to increase fetal maturity
 MANAGEMENT

D. Delivery after control of convulsions

• Cesarean section can be decided if:
1. Vaginal delivery does not appear to be easy and imminent
2. There is failure of progress after induction
3. There is fetal compromise

• It is recommended that anticonvulsant therapy be continued for at

least 24hrs after delivery. In comatose patients, a neurologic
evaluation with possibly a CT scan or MRI should be performed
CHRONIC HYPERTENSION
 DEFINITION

• Presence of hypertension before pregnancy or before 20 weeks of

gestation

MILD TO MODERATE SEVERE

Systolic (mmHg) 140–159 ≥160
Diastolic (mmHg) 90–109 ≥110
 RECOMMENDATIONS

1. Referral to an internist
• For investigation and management
2. Antihypertensive therapy in severe, chronic hypertension
• Pregnant women with chronic hypertension (BP≥160/105mmHg) or
evidence of target organ damage should be given antihypertensive
therapy
3. Antihypertensive therapy for mild to moderate chronic hypertension
• Pregnant women with chronic hypertension (BP<160/105mmHg) and
with no evidence of target organ damage should not be routinely given
antihypertensive therapy
 RECOMMENDATIONS
4. Antihypertensive for continuous therapy in chronic hypertension in
pregnancy
• Methyldopa is the primary oral medication recommended
5. Second line antihypertensives for continuous therapy in chronic
hypertension in pregnancy
• Labetalol and Nifedipine are second-line oral medications that can be
used for chronic hypertension
6. Antihypertensive drugs that should not be used in pregnancy
• ACE inhibitors and ARBs should not be given before conception and
during the 1st trimester of pregnancye due to evidence of teratogenicity.
They should also not be used during 2nd and 3rd trimester due to
fetopathy.
 RECOMMENDATIONS

7. Antihypertensive drugs for use in urgent control of severe chronic

hypertension in pregnancy
• Parenteral form of Labetalol and Hydralazine and oral form of Nifedipine
can be safely used in the urgent control of urgent severe chronic
hypertension. Choice should be based on availability, familiarity, and
experience of use
8. Fetal surveillance for IUGR in chronic hypertension
• Serial ultrasonography to screen for IUGR is recommended
 RECOMMENDATIONS

9. Surveillance for fetal well-being in chronic hypertension in pregnancy

with IUGR
• Umbilical artery Doppler velocimetry is recommended for cases
where IUGR has been confirmed
10. Timing of delivery complicated by mild to moderate chronic
hypertension in pregnancy
• In uncomplicated chronic hypertension, delivery before 38 weeks is not
recommended
CHRONIC HYPERTENSION WITH
SUPERIMPOSED PREECLAMPSIA
 DEFINITION

• A sudden increase in BP in a pregnant woman with a previously

well-controlled chronic hypertension associated with new onset
proteinuria, or
• A sudden increase in proteinuria in a chronic hypertensive
woman who already has preconceptional proteinuria
 RECOMMENDATIONS

1. Where do we manage cases of chronic hypertension complicated by

superimposed preeclampsia?
• The antenatal and delivery of women with chronic hypertension with
superimposed preeclampsia regardless of gestational age should be
done in facilities with adequate maternal and neonatal intensive care
specialists and resources
2. Should MgSO4 be given to women with chronic hypertension with
superimposed preeclampsia with severe features?
• MgSO4 therapy is given to prevent eclampsia once there is the need,
and is continued to the intrapartum or even postpartum period
 RECOMMENDATIONS

3. When do you give antenatal corticosteroids?

• Antenatal steroids to enhance fetal lung maturity is given to those with
<34 weeks gestation and who are being managed expectantly
• For those being managed expectantly, antenatal steroids may be given
to those >34 weeks but <36 weeks
 RECOMMENDATIONS

4. When do you deliver those with chronic hypertension with

superimposed preeclampsia?
• Delivery is recommended when any one of the following conditions are
present, once the maternal condition is stabilized regardless of
gestational age or completion of antenatal steroids:
• Uncontrolled hypertension
• Eclampsia
• Pulmonary edema
• Abruptio placenta
• DIC
• Nonreassuring fetal status
 RECOMMENDATIONS

5. When do you deliver patients with superimposed preeclampsia

without severe features?
• For women with chronic hypertension with superimposed preeclampsia
without severe features, expectant management up to 37 weeks is
suggested
6. Can you do conservative management in pregnancies complicated
by chronic hypertension with superimposed preeclampsia with severe
features <34 weeks?
• Expectant management can be offered to women with chronic
hypertension with superimposed preeclampsia with severe features
before 34 weeks, provided that both maternal and fetal conditions are
stable and the patient is admitted in a hospital capable of providing
intensive maternal and neonatal care
 RECOMMENDATIONS

7. Can the antihypertensives used during pregnancy be continued

during breastfeeding if needed for continuous BP control?
• The antihypertensives used during pregnancy can be used postpartum
and lactation if needed for continuous BP control. With the exception of
diuretics, other antihypertensives not used for pregnant women can be
used as well
ABRUPTIO PLACENTA
 DEFINITION

• Separation of the normally located placenta before delivery of the

fetus. May be concealed or overt.
• Frequently presents as vaginal bleeding associated with
abdominal pain, uterine contractions, and uterine tenderness in
the seond half of pregnancy.
• Associated with increased perinatal mortality and morbidity. Also
a cause of significant maternal morbidity.
• When placental separation exceeds 50%, acute DIC and fetal
death are common.
• Hypertensive disorder is a major risk factor.
 DEFINITION

• Other risk factors are smoking, trauma, and cocaine use.

• Diagnosis of abruption placenta is made clinically.
• A retroplacental blood clot is the classic ultrasound finding of
abruption placenta, but is not always present.
 MANAGEMENT
• Prompt evaluation and stabilization of the mother
– Includes insertion of large-bore cannulas, blood exams for anemia, blood type,
Rh, and coagulopathy, monitoring of maternal vital signs, continuous FHR
monitoring, and replacement of blood products as needed
• Any patient suspected of having abruption palcenta should undergo
continuous FHR monitoring until her status is clear
• Management is determined on a case-by-case basis and depends on
gestational age, degree of placental separation, and condition of
mother and fetus
• When there is fetal demise: goal is to minimize morbidity to the mother
→ vaginal delivery is recommended as long as maternal status is
stable
 MANAGEMENT
• Expedite deliver at any gestational age complicated by severe
abruption placenta (i.e. unstable gravida) or when FHR is
nonreassuring
• Expedite delivery for live foetuses at >34 weeks:
– Vaginal delivery can be attempted if fetal heart tracing is reassuring and
mother is stable. This should only be attempted if there is access to
immediate caesarean delivery, if necessary
– Prompt CS is recommended when there is evidence of fetal compromise,
if maternal status is unstable, if vaginal delivery is contraindicated, or
when there is failure to progress in labor
– If Couvelier uterus is detected during CS, aggressive management of
atony is needed to prevent DIC
 MANAGEMENT

• For live fetuses ≤34 weeks, conservative management may be

attempted if the mother is stable and fetal well-being is good. A
single course of corticosteroids to enhance fetal lung maturity is
administered before expediting delivery.
• Postaprtum: maternal vital signs, blood loss, urine output, uterine
size and consistency, and laboratory results (haemoglobin /
haematocrit, coagulation studies) are monitored closely to ensure
that bleeding has been controlled and coagulopathy is resolving,
and to guide replacement of fluids and blood products as needed
STEP BY STEP DIAGNOSTIC APPROACH

1. History and Physical Examination

– Common symptoms are abdominal pain, uterine contractions, and uterine
tenderness
– Vaginal bleeding is also considered a classic symptom, but may not be
present in cases of concealed abruption, particularly when the placenta is
located posteriorly (back pain may be the only presenting symptom)
2. Fetal Monitoring
– FHR should be monitored continuously
– Abnormalities in the tracings that suggest an abruption: late
decelerations, loss of variability, variable decelerations, sinusoidal FHR
tracing, fetal bradycardia (<110bpm)
STEP BY STEP DIAGNOSTIC APPROACH

3. Laboratory tests
– Hemoglobin, haematocrit, and coagulation studies (PT, PTT, fibrinogen,
and fibrinogen breakdown products) should be ordered immediately in all
patients with bleeding in whom abruption is suspected → when severe
blood loss has occurred over a period of time, haemoglobin and
haematocrit levels may be low (<10mg/dL, and <30%, respectively)
– A simple test to confirm DIC is to take some blood in a plain tube (without
anticoagulants) and invert the tube at 1 minute intervals. The blood
should clot within 8-10 minutes; failure to do so may be taken as
evidence of DIC. In DIC, fibrinogen levels are low, and PT is prolonged
– A Kleihauer-Betke test should also be ordered initially (indicated feto-
maternal transfusion); however, is rarely positive in cases of abruption. It
is used t oassess the need for additional Rh immune globulin in Rh-
negative women
STEP BY STEP DIAGNOSTIC APPROACH

4. Ultrasound
– May not be helpful in diagnosis abruption placenta but is useful in initial
investigation (detection rates of 12–25%)
– In skilled hands, high rates of diagnosis have been reported
– Retroplacental hematomas are associated with the worst prognosis
– Crucial for excluding other causes for the bleeding or pain (such as
placentra previa or fibroids)
– Helpful ultrasound signs:
1. Retroplacental hematoma (hyperechoic, isoechoic, hypoechoic)
2. Pre-placental hematoma (jiggling appearance with a shimmering effect of
the chorionic plate with fetal movement)
STEP BY STEP DIAGNOSTIC APPROACH

4. Ultrasound
3. Increased placental thickness and echogenicity
4. Subchorionic collection
5. Marginal collection
– Placenta in the lower uterine segment reaching the internal os suggests
placenta previa rather than abruption
• Although a previa may separate prematurely, these are usually not regarded as
abruptions
• Caution is necessary to not mistake a clot overlying the vervix for a placenta previa
 INITIAL MANAGEMENT

1. Preferably two IV access with wide bore cannulas

2. Blood extraction for CBC, blood type and Rh, coagulation profile
3. Monitoring of hemodynamic status: BP, pulse rate, urine output,
volume intake
• Urine output should be maintained above 30mL/hour and monitored with
a foley catheter
4. Continuous fetal monitoring
5. Keep maternal oxygen saturation >95% and thermoregulation
 INITIAL MANAGEMENT

6. Estimate extent of blood loss in a volumetric container and/or by

weighing pads/towels used to absorb vaginal bleeding
7. Anti-D immunoglobulin for Rh-negative women
8. Fluid, blood, or blood by-product replacement, as indicated
9. Notify the anesthesia team

• Goals are to prevent hypovolemia, anemia, and DIC. Keep

haemoglobin levels >100g/L, and haematocrit >30%
 INITIAL MANAGEMENT

• In women with DIC, minimum levels are:

– Platelet count ≥50,000/µL
– Fibrinogen ≥100mg/L
– PT and PTT <1.5 times control
– Hematocrit 25–30%
• Transfusions given as needed (proactive in giving blood)
– FFP given early if there is any sign of DIC
– Aggressively replace volume, blood, and blood products
 FETAL DEMISE

• Management is similar to when fetus is alive

– Expeditious delivery, preferably by vaginal route
• If mother is not in active labor, may be induced by amniotomy
and oxytocin
• Women who had abruption sufficient to cause fetal demise are
highly likely to have DIC
• If maternal condition is worsening with severe haemorrhage,
caesarean delivery may be indicated (rarely)
• Blood and blood products replaced before and during the surgery
• Uterotonic agents or hemostatic interventions given post-
placental delivery to control hemorrhage
 LIVE FETUS, SEVERE ABRUPTION
(ANY GESTATIONAL AGE)

• Expeditious delivery is recommended for pregnancies (any

gestational age) complicated by severe abruption, defined as:
1. Unstable gravida (significant coagulopathy, hypotension, and/or ongoing
major blood loss)
2. Non-reassuring FHR tracing
 LIVE FETUS >34 WEEKS GESTATION

TERM / NEAR TERM

FETUS ALIVE FETUS DEAD

CONTRAINDICATIONS VAGINAL CONTRAINDICATIONS

REASSURING TO VAGINAL DELIVERY TO VAGINAL DELIVERY
FETAL STATUS DELIVERY,
NONREASSURING
FETAL STATUS, FAILURE TO
UNSTABLE MOTHER PROGRESS,
UNSTABLE
MOTHER
VAGINAL CESAREAN CESAREAN
DELIVERY DELIVERY DELIVERY
 LIVE FETUS ≤34 WEEKS GESTATION

• Conservative management aiming to deliver a more mature fetus

– Corticosteroids to promote fetal lung maturation (pregnancies between
24-34 weeks)
– Tocolytics may be used with extreme caution in cases where there are
uterine contractions in pregnancies >24 weeks
– FDA warned against off-label use of injectable terbutaline for long term
(>72hrs) treatment of prevention of preterm labor → increased risk of
maternal cardiovascular adverse effects
• Oral terbutaline is contraindicated for this indication
 LIVE FETUS ≤34 WEEKS GESTATION

• Occasionally, mother may be discharged and managed as

outpatient
– Should be instructed to report immediately if with bleeding, severe
abdominal pain, contractions, or reduced fetal movements
– Mother is monitored in the hospital until bleeding has subsided for at least
48 hours, FHR tracings and ultrasound examinations are reassuring, and
the patient is asymptomatic
• Delivery is recommended by 37-38 weeks AOG because of the
increased risk of stillbirth
 FETAL PROGNOSIS

TERM / NEAR TERM

FETUS FETUS FETUS

ALIVE, ALIVE, DEAD
<24 WEEKS >24 WEEKS

ASSESS ASSESS DELIVER GIVE STEROIDS,

TOCOLYTICS AS
INDICATED, CLOSELY
MONITOR FETUS
UNSTABLE STABLE NONREASSURING REASSURING
AND MOTHER,
MOTHER MOTHER FETAL STATUS, FETAL STATUS,
MONTHLY GROWTH
UNSTABLE STABLE
ULTRASONOGRAMS
MOTHER MOTHER

MANAGE
DELIVER DELIVER MANAGE DELIVER BETWEEN
CONSERVATIVELY
CONSERVATIVELY 37 AND 38 WEEKS
 MATERNAL PROGNOSIS

• Linked primarily to severity of abruption, amount of blood lost,

and presence/absence of associated coagulopathy
• Increased risk for blood transfusions, surgical, and anesthetic
complications, and caesarean hysterectomy
• Outcome is excellent in cases where there is no massive blood
loss nor coagulopathy
• Increased risk of abruption in subsequent pregnancies related to
the underlying cause of abruption
• Women with abruption have increased risk for ischemic placental
disease (abruption, preeclampsia, IUGR) in subsequent
pregnancies
 SUBSEQUENT PREGNANCIES

• Should be monitored carefully

• Risk of recurrence: 5-15%
• After two consecutive abruptions, risk of a third is 20-25%
• Risk is higher after a severe abruption compared to a mild one
• Patient’ ssisters have a greater risk of having abruption (odds
ratio 1.7-2.1)
• No interventions have been shown to be helpful
HELLP SYNDROME
 DEFINITION

• Hemolysis with microangiopathic blood smear, Elevated Liver

enzymes, and Low Platelet count
• Develops in <1% of all pregnancies, but in 10-20% of
pregnancies with severe preeclampsia/eclampsia
• Variable presentation and rapid onset
• Differentials: acute fatty liver of pregnancy, gastroenteritis,
hepatitis, appendicitis, gallbladder disease, immune
thrombocytopenia, lupus flare, antiphospholipid syndrome,
haemolytic-uremic syndrome, thrombotic thrombocytopenic
purpura, and non-alcoholic fatty liver disease
 DEFINITION
• Most cases are diagnosed between 27-37 weeks of gestation,
but symptoms may present up to 7 days postpartum
• May present with significant diagnostic and therapeutic
challenges because only 80-85% of affected patients present
typically with hypertension and proteinuria
• Should be considered in any pregnant patient presenting in the
second half of gestation or immediately postpartum with
significant new onset epigastric/upper abdominal pain until
proven otherwise
• There is co consensus regarding the laboratory criteria diagnostic
of HELLP syndrome. The Mississippi and Tennessee
classifications are used to diagnose HELLP syndrome
 DEFINITION

• May be classified as complete or partial, though partial HELLP

can progress to complete HELLP syndrome
• Laboratory values may initially worsen 24-48hrs following delivery
• Outcome is generally good, but serious complications such as
abruption placenta, DIC, acute renal failure, subscapular liver
hematoma, pulmonary edema, and retinal detachment may occur
• Fetal/neonatal and long-term prognosis are most strongly
associated with gestational age at delivery and birth weight
• Future pregnancies are at increased risk of HELLP,
preeclampsia, and gestational hypertension
 RECOMMENDATIONS
1. Once diagnosis is confirmed, initial steps in management are to
stabilize the mother, assess the fetal condition, and decide
whether prompt delivery is indicated
2. Cornerstone of therapy is delivery. Delivery is curative and is the
only effective treatment
3. Severe hypertension is treated with antihypertensive therapy
and MgSO4 is given to prevent convulsion and for
neuroprotection of foetuses at 24-32 weeks of gestation
4. Management of patients with HELLP requires availability of
neonatal and obstetric intensive care units and personnel with
special expertise → should receive care at a tertiary care center
 RECOMMENDATIONS

5. For women with HELLP syndrome before the gestational age of

fetal viability, it is recommended that delivery be undertaken
shortly after initial maternal stabilization
6. Prompt delivery is indicated at any age of gestation if there is
DIC, liver infarction of haemorrhage, renal failure, pulmonary
edema, suspected abruption placenta, or nonreassuring fetal
status
7. For women with HELLP syndrome at ≥34 weeks age of
gestation, it is recommended that delivery be undertaken soon
after initial maternal stabilization
 RECOMMENDATIONS
8. For women with HELLP syndrome from 24 to 33 6/7 weeks age
of gestation, it is suggested that delivery be delayed for 24-
48hrs if maternal and fetal condition remain stable to complete a
course of corticosteroids for fetal benefit
9. For gestations less than 30-32 weeks with an unfavourable
cervix, caesarean delivery is suggested to avoid a potentially
long induction
10.Vaginal delivery is desirable for women in labor or with ruptured
membranes and a vertex-presenting infant, regardless of
gestational age. Cesarean delivery is performed for the usual
obstetrical indications
 RECOMMENDATIONS

11.Actively bleeding patients with thrombocytopenia should be

transfused with platelets. If caesarean delivery is planned,
platelet transfusion may be required to achieve a preoperative
platelet count greater than 40,000-50,000 cells/µK. The decision
depends on patient specific factors; consultation with the
Hematology Service may be helpful
12.Dexamethasone therapy for HELLP syndrome is currently not
recommended. It does not accelerate resolution of laboratory
abnormalities or reduce the risk of maternal complications.
 RECOMMENDATIONS
13.Early detection and aggressive management with a combination
of IV MgSO4, control of BP to prevent or minimize systolic
hypertension, replacement of blood products as needed, and
timely delivery of the fetus and placenta, appear to be the best
and safest ways to arrest disease progression and reduce
adverse outcomes. Maternal outcomes are improved
considerably with this management; perinatal outcome depends
predominantly upon the gestational age when delivery occurs
14.Plasma exchange or phasmapheresis for HELLP is not
recommended, particularly within the first four days postpartum
15.There is no evidence that any therapy prevents recurrent
HELLP syndrome
 CLINICAL PRESENTATION
SIGN/SYMPTOM FREQUENCY (%) SIGN/SYMPTOM FREQUENCY (%)
Proteinuria 86-100 Visual changes 10-20
Malaise 90 Bleeding 9
RUQ tenderness 90 Ascites 8
Hypertension 82-88 Pulmonary edema 6
RUQ/epigastric pain 40-90 Jaundice 5
Nausea/vomiting 29-84 Shoulder/neck pain 5
Headache 33-61

• Common pitfall that results in maternal death or morbidity is mistaking

abdominal pain, nausea, vomiting, and malaise for a viral illness
• Symptoms continually progress and intensity changes spontaneously
• Exacerbated during the night and recovers during the day
 MATERNAL COMPLICATIONS
ASSOCIATED WITH HELLP SYNDROME
COMPLICATION INCIDENCE (%)
DIC 15-56
Abruptio placenta 10-20
Marked ascites 10-15
Wound hematoma / infection 14
Pulmonary edema 3-10
Pleura leffusion 6-10
Eclampsia 4-9
Acute renal failure / acute tubular necrosis 3-36
Subscapular liver hematoma / infarction / failure <2
Liver rupture 1.8
Laryngeal edema 1-2
Retinal detachment, vitreous hemorrhage, cortical blindness 1
 FETAL COMPLICATIONS
REPORTED IN HELLP SYNDROME

COMPLICATION INCIDENCE (%)

Perinatal death 7.4-34
IUGR 38-61
70 (15%, <28
Preterm delivery
gestational weeks)
Neonatal thrombocytopenia 15-50
RDS 5.7-40

• Clinical course of women with HELLP is often characterized by progressive

and sometimes sudden deterioration in maternal and fetal conditions
 CLINICAL PRESENTATION

• Laboratory thresholds that indicate >75% risk of serious maternal

morbidity:
– LDH concentration >1400U/L
– AST >150U/L
– ALT >1000U/L
– Uric acid >7.8mg/199mL
• Epigastric pain and nausea/vomiting are better predictors of
adverse maternal outcome than laboratory parameters
DIAGNOSIS, LABORATORY CRITERIA

• Diagnosis of HELLP syndrome is most certain in the presence of

signs and symptoms of preeclampsia-eclampsia in a pregnant
patient along with a triad of laboratory abnormalities:
– Microangiopathic hemolysis
– Liver dysfunction
– Thrombocytopenia
• Currently, there are 2 major criteria for diagnosing HELLP
syndrome. There is no consensus as to which criteria to use
DIAGNOSIS, LABORATORY CRITERIA

• Tennessee Classification System

– Intravascular hemolysis is diagnosed by abnormal peripheral blood
smear, increased serum bilirubin (≥20.5µmol/L or ≥1.2mg/100mL) and
elevated LDH levels (>600units/L)
• Mississipi – Triple Class System
– Based on the nadir (low point) platelet count any time during the course
of the disease. Class 3 HELLP syndrome is considered as a clinically
significant transition stage or a phase of the HELLP syndrome which has
the ability of progression
 CLASSIFICATION FOR
LABORATORY DIAGNOSIS
MISSISSIPPI CLASSIFICATION TENNESSEE CLASSIFICATION
Class 1 Complete or True
Platelets <50,000 Platelets <150,000
AST or ALT >70 IU/L AST >70 IU/L
LDH >600 IU/L LDH >600 IU/L
Class 2 Partial or Incomplete
Platelets =50,000-100,000 Severe preeclampsia with any
AST or ALT >70 IU/L one of the following:
LDH >600 IU/L Absence of hemolysis,
Absence of low platelets,
Elevated liver function, or
Low platelets
Class 3
Platelets =100,000-150,000
AST or ALT >40 IU/L
LDH >600 IU/L
DIAGNOSIS, LABORATORY CRITERIA

• A modification of the laboratory criteria for the diagnosis of

HELLP was syndrome was reported in the review by Moussa, et
al. Liver enzyme levels should be more than twice the upper limit
of normal for the laboratory.
DIAGNOSIS, LABORATORY CRITERIA
MOUSSA LABORATORY CRITERIA FOR HELLP SYNDROME
I. Hemolysis
1. Abnormal peripheral blood smear (Burr cells,
schistocytes)
2. Elevated bilirubin ≥1.2mg/dL
3. Low serum haptoglobulin
4. Significant drop in haemoglobin level unrelated to blood
loss
II. Elevated liver enzymes
1. Elevated AST or ALT ≥2x the upper limit of normal for the
laboratory
2. Increased LDH >2x the upper limit of normal for the
laboratory
III. Low platelet count
<100,000/mm3
 MANAGEMENT

• Initial Approach
– Initial steps: stabilize the mother, assess fetal condition, and decide
whether prompt delivery is indicated
– Pregnancies <34 weeks of gestation, or unstable mothers should be
managed with a maternal-fetal specialist
• Antihypertensive drugs similar to that for preeclampsia are used
to treat severe hypertension
• MgSO4 is used to prevent convulsions, and for fetal/neonatal
neuroprotection in pregnancies between 24-32weeks gestation
 MANAGEMENT

• Mississippi protocol
– Uniform early initiation of corticosteroids, MgSO4, and systolic BP control
– Effective in inhibiting HELLP syndrome disease progression and severity
– Out of 190 patients (between 2000-20007) who received this protocol,
there was no maternal death, stroke, or liver rupture
• Only 39 out of 163 (24%) of non-Class 1 progressed to Class 1
disease
• Only 18.2% of Class 1 and 2.4% of Class 2 developed major maternal
morbidity
 TIMING OF DELIVERY

• Because this syndrome is associated with increased rates of

maternal morbidity and mortality, many consider its presence to
be an indication for immediate delivery
• If HELLP syndrome develops before 24 weeks gestation,
termination of pregnancy should be strongly considered
• Prompt delivery is indicated for the following:
1. Pregnancies ≥34 weeks of gestation
2. Presence of severe maternal disease: multiorgan dysfunction, DIC, liver
infarction/haemorrhage, renal failure, pulmonary edema, suspected
abruption placenta
3. Nonreassuring tests of fetal status
 TIMING OF DELIVERY

• For pregnancies <34 weeks gestation:

– If both maternal and fetal status are reassuring, corticosteroids should be
given in foetuses between 24 to 33 6/7 weeks of gestation (benefit in
preeclamptic patients with devere features)
– No evidence demonstrating improvement in overall perinatal outcome
with expectant management
 PLATELET TRANSFUSION

• Actively bleeding patients with thrombocytopenia should be

transfused
• May be indicated to prevent excessive bleeding during delivery if
the platelet count is <20,000cells/µL
• For patients needing caesarean delivery, some recommend
platelet transfusion to achieve >40,000-50,000cells/µL
• Platelet count should be maintained at >20,000 and 40,000 for
vaginal and caesarean delivery, respectively
• Indicated in patients with significant bleeding / platelet count
<20,000 irrespective of the intended mode of delivery
 PLATELET TRANSFUSION
MODE OF DELIVERY
PLATELET COUNT
CESAREAN DELIVERY VAGINAL DELIVERY
<20 x 109/L  
20 to 49 x 109/L Consider in presence of:
• Excessive active bleeding
 • Known platelet dysfunction
• Platelet count falling rapidly
• Coagulopathy
≥50 x 109/L Consider in presence of: Consider in presence of:
• Excessive active bleeding • Excessive active bleeding
• Known platelet dysfunction • Known platelet dysfunction
• Platelet count falling rapidly • Platelet count falling rapidly
• Coagulopathy • Coagulopathy
Regardless of No platelets should be transfused if there is a strong suspicion of Heparin-Induced
platelet count Thrombocytopenia or Thrombotic Thrombocytopenic Purpura – Hemolytic Uremic
Syndrome
 ROUTE OF DELIVERY

• Vaginal: recommended for women in labor or with ruptured

membranes and a vertex-presenting infant, regardless of
gestational age
• Labor can be induced in women with favourable cervices or
pregnancies at least 30-32 weeks of gestation
• Cesarean delivery: performed for the usual obstetrical indications
(breech, nonreassuring fetal status)
– If an abdominal delivery is required, a vertical skin incision rather than a
Pfannensteil incision (fewer wound disruptions → less blood loss)
– Low segment vertical uterine incision for poorly developed uterine
segment (usually <32 weeks) and abnormal presentations
 ROUTE OF DELIVERY

• Short course of antibiotics (24-48hrs) given if blood products are

administered
– Higher infectious morbidity in mothers who received transfusions
compared with HELLP syndrome mothers who were not given blood
products
• Due to high risk of subfascial and wound hematoma in these
women, some surgeons place a subfascial frain at caesarean
delivery and leave the incision open for the first 48 post-op hours
 ANESTHESIA

• Epidural anesthesia can be administered safely in patients

without adverse hemorrhagic and neurologic sequelae if the
maternal platelet count is >100,000/µL
– Even if the platelet is >100,000/µL, patient must be carefully assessed
due to the altered platelet function in HELLP syndrome
• General anesthesia has potential complciations in HELLP
syndrome patients with impaired liver function and an altered
ability to metabolize anesthetic agents
– However, is still the anesthetic of choice in Class 1 and 2 disease
 ANESTHESIA

• Maternal anesthesia can be provided by intermittent infusion of

butorphanol or meperidine with promethazine
• Carefully controlled and skilfully executed nonoperative vaginal
delivery is recommended if possible with locally infiltrated 1%
xylocaine as needed without pudendal block
 POSTPARTUM COURSE

• Laboratory values may initially worsen following delivery

– Decreasing platelet counts continue until 24-48 hours after delivery
– Serum LDH concentration peak 24-48 hours postpartum
– Platelet count of >100,000cells/µL achieved spontaneously by the 6th
postpartum day
• Laboratory anomalies return to normal within a short time of
delivery
• In severe cases (i.e. DIC), platelet count <20,000cells/µL, renal
dysfunction or ascites, recovery can be delayed, and are at risk
of developing pulmonary edema and renal failure
 SUBSEQUENT PREGNANCIES

• Recurrence in 7% of subsequent pregnancies

• 18% developed preeclampsia
• 18% developed hypertension
• Relatively low incidence of recurrence, so subsequent pregnancy
is generally not discouraged