Diagnostic criteria of pre – eclampsia : 

1. Hypertension
2. Oedema
3. Proteinuria

Classify type of pre – eclampsia : 

Clinical types of pre – eclampsia : Proteinuria is more significant than BP to predict fetal outcome.

A) Non – severe pre- eclampsia : Mild pre – eclampsia includes sustained rise of BP> 140/90 mm Hg but <160/110 mm Hg without significant proteinuria.

B) Severe pre – eclampsia :  Features of severe pre – eclampsia are as follows : 

1. A persistent SBP of >_ 160 mm Hg or DBP of >_ 110 mm Hg.
2. Persistent severe epigastric pain.
3. Cerebral or visual disturbances.
4. Oliguria 
5. Protein excretion of > 5 g / 24 hours.
6. Platelet count < 1,00,000 /mm3
7. HELLP syndrome.
8. Retinal hemorrhage, exudates or papilloedema.
9. Intra – uterine growth restriction of the fetus.
10. Pulmonary oedema.

Risk factor of pre eclampsia : 

1. Primigravida : young or elderly.
2. Family history : (hypertension or pre – eclampsia).
3. Placental abnormalities : Hyperplacentosis, placental ischaemia.
4. Obesity : BMI > 35 kg/ m2, insulin resistance.
5. Pre – existing vascular disease.
6. New paternity, pregnancy following ART.
7. Thrombophilias.

Objectives of management of pre – eclampsia / principles of management of pre – eclampsia :

As the exact aetiology of pre – eclampsia remains obscure, the treatment is mostly empirical and symptomatic with the following principles : 

1. To stabilize hypertension and to prevent its progression to severe pre – eclampsia.
2. To prevent the complications.
3. To prevent eclampsia.
4. Delivery of a healthy baby in optimal time with minimal maternal mortality.
5. Restoration of the health of the mother in puerperium.

Clinical featuresof pre – eclampsia : 

A) History :  H/O of other obstetric comorbidity may be present, e.g. multiple pregnancy, polyhydramnios, pre – existing HTN & GDM.

B) Onset : Clinical manifestations appear usually after the 20 th week.

C) Symptoms of pre  eclampsia : 

a) MIld symptoms : 

• slight swelling over the ankles
• Gradually the swelling may extend to the face, abdominal wall, vulva or even the whole body.

b) Alarming symptoms : 

• Headache
• DIsturbed sleep
• Diminished urinary output
• Eye symptoms
• Epigastric pain

D) SIgn of pre  eclampsia : 

1. Abnormal wight gain
2. Rise of blood pressure
3. Oedema
4. Sign of chronic placental insufficiency  : eg. scanty liquor or IUGR may be present.
5. Pulmonary oedema (may  be present)
6. Absence of pre – existing chronic cardio – vascular or renal pathology.

Investigations of pre – eclampsia : 

A) Urine examination : 

1. Heat coagulation test to detect proteinuria
2. Urine R/M/E
3. 24 hours urine collection for protein measurement.

B) Blood examination : 

1. Seurm uric acid level : A serum uric acid level is the biochemical marker of the pre – eclampsia. Raised serum uric acid level (>4.5 mg / dl) indicates  pre – eclampsia.
2. S. creatinine : May be >1 mg /dI.
3. Thrombocytopenia or abnormal coagulation profile of varying degree  may be present. 
4. Hepatic enzymes.
5. Blood urea may be normal or slightly raised.

C) Ultrasonography.

Treatment of pre eclampsia : 

A) General treatment  :

1. Urgent hospitalization
2. Adequate rest.
3. Diet : Diet should contain adequate protein  and fluid intake is restricted.

B) Specific treatment : 

1.  Anti – hypertensive therapy : Anti hypertensives has limited value in controlling BP in pre – eclampsia.

Drug used : 

• Oral drug : alpha methyl dopa, Nifedipine, Labetolol, Hydralazine.
• Parenteral : Labetolol, Hydralazine, Nitroglycerine, and Na- Nitroprusside.

2.  Sedatives : To cut down emotional factor mild sedative may be given orally  : such as Diazepam 5 mg or phenobarbitone 60 mg at bed time orally.

3.  Maintaining a progress chart : 

• Blood pressure  :  4 times a day.
• Fluid intake – output chart along with state of oedema and daily weight.
• Daily urine examination for proteinuria and if present estimation of total amount of protein in 24 hours urine.
• Investigation : Haematocrit, Platelet count, uric acid, S. creatinine, LFT (weekly).
• Ophthalmic examination.
• Fetal wellbeing assessment.

C) Obstetric treatment :

Obstetric management is depends upon the following features : 

• Severity of pr – eclampsia
• Duration of pregnancy
• Response of treatment

1) If the maternal condition and response to the treatment is satisfactory :  Pregnancy may be continued up to term & after term the termination of pregnancy will be done accordingly.

2) If maternal condition and response to the treatment is not satisfactory : The choice of treatment is immediate termination of pregnancy irrespective of fetal outcome. THe termination of pregnancy is done by – 

• Induction of labour (medical or surgical)
• Caesarean section.

D) Care of the patient during puerperium :

1. Close observation of the patient for at least 48hrs.
2. Anti – hypertensive drugs should be continued if DBP>_ 100 mm Hg.
3. Patient should be kept in the hospital till the BP is brought down to a safe level & proteinuria disappears.

Prevent of convulsion in pre – eclampsia : 

Prophylactic MGSO4, therapy is used to prevent convulsion (Dose is same as eclampsia).

Complications of Pre – eclampsia : 

Immediate : 

A) Maternal complications : 

a) During pregnancy : 

1. Eclampsia (2%).
2. Antepartum hemorrhage (placental abruption).
3. Oliguria and anuria (Acute renal failure).
4. Cardiac failure.
5. HELLP syndrome.
6. Dimness of vision and even blindness.
7. Premature labour.

b) During labour :
1. Eclampsia

2. PPH & shock

C) Puerperium :

1. Eclampsia (within 48 hours).
2. Puerperal sepsis and septic shock.

B) Fetal complications : 

• Intrauterine death (IUD)
  Intrauterine growth retardation (IUGR).
• Birth asphyxia.
• Prematurity.

Remote complications : 

1. Residual hypertension
2. Recurrent pre – eclampsia.

How can you prevent pre – eclampsia : 

1. Regular ANC : For rapid weight gain / high BP / S. uric acid level (in selective cases).
2. Balanced diet : 

• HIgh protein & low salt diet
•  Fish oil.
• Ca ++ (2 g/day), Mg & Zn supplement.

3. Anti – oxidant : Vitamin A,C & E supplement from 20 weeks of pregnancy.

4. Anti – thrombotic agent : Low – dose Aspirin 60 mg daily.

5. Heparin or LMWH : Is useful in women with thrombophillia & with high risk pregnancy.