GESTATIONAL CONDITIONS

HYPEREMESIS GRAVIDARUM
- Also known as pernicious vomiting
- Persistent nausea and vomiting of pregnancy that is prolonged after the first trimester or is so
severe that dehydration, nutritional deficiencies, acidosis and significant weight loss occur within
the 1st trimester.

Incidence:
-2% in pregnant women
-peak incidence occurs between 8-12 weeks AOG usually resolving in the 16 th.

Causes:
- The exact pathology is not clearly understood
- Elevated HCG that disrupts normal activity of GIT by causing reverse peristalsis
- Thyroid dysfunction\psychological stress – depression, anxiety and interpersonal problems.

Assessment:
1. Excessive vomiting not relieved by ordinary medications persisting beyond 12 weeks AOG.
2. Signs of DHN – thirst, dry skin, increased pulse rate, weight loss, concentrated urine and elevated
hematocrit in CBC
3. fluid and electrolyte imbalance
4. ketonuria

Management:
1. differential diagnosis – rule out other possible disorders associated with hyperemesis by tests like
liver and thyroid functions, urinalysis and CBC (monitor blood chemistries).
2. monitor I&O
3. Diet:
a. NPO for the 1st 24 hours – IVF with added B vitamin
b. After 24 hours – clear fluid then small quantities of dry toast, crackers, or cereal every 2 or 3
hours, then gradually advances to a soft diet, then to DAT
c. At home: take dry crackers, frequent feedings and sips of water to avoid gastric provocation
and distention, avoid hot and very cold food and beverages
4. Complementary therapy – i.e. use of ginger to expel flatus and aroma relieves nausea
5. administer anti-emetic drugs as ordered
6. avoid noxious stimuli that may precipitate nausea (tight clothing, iron supplement, spicy foods,
strong odors, loud noises and bright lights)
7. enough relaxation and rest
8. enteral or total parenteral nutrition
9. hospitalization when severe DHN and F and E imbalance.
 IV fluids (LRS)
 Vitamin supplements
 NPO for 24-48 hours until nausea subsides
 Oral intake is started after patient is properly hydrated and nausea subsides
 Give anti-emetics before meals
 Gradual feeding
 Small frequent feedings
 Do not force to eat
Fetal/Neonatal Risks
1. Intrauterine Growth Restriction (IUGR)
2. Low-birthweight
3. Preterm birth

ECTOPIC PREGNANCY
- Implantation of fertilized ovum in a site other than the endometrial lining of the uterus (outside
the uterus)
- 7.7% to 20% of cases will suffer a repeat ectopic pregnancy
- Sites at which ectopic pregnancy may occur
a. fallopian tube
b. ovary
c. cervix
d. intestine

Risk Factors:
1. Obstruction
a. chronic salphingitis and pelvic inflammatory disease (PID), STD’s
b. congenital malformations
c. previous tubal surgery
d. uterine tumor pressing on the proximal end of the tube
2. Others:
a. use of IUDs for contraception
b. smoking
c. history of ectopic pregnancy
Causes:
1. mechanical factors – conditions that delay the passage of ovum in the oviducts and prevent
it from reaching the uterus in time for implantation. (obstruction)
- Salphingitis
- Peritubal adhesions, kinking and narrowing
- Diverticula formation
- Previous ectopic pregnancy
- Previous tubal operations
- Tubal tumors
 - Past induced abortions
2. Functional factors
- External migrations of the ovum
- Menstrual reflux
- Altered tubal motility associated with use of IUD, progestin only contraceptives,
morning-after pill
3. Assisted reproduction
- Ovulation induction associated with fertility drugs such as Clomid
- Gamete intrafallopian transfer
- In vitro fertilization
- Ovum transfer
4. Failed contraception
- IUD
- Oral contraceptives
- Condom and diaphragm
- Tubal ligation
- Hysterectomy
Types:

a. Tubal: more than 95% occur in the fallopian tube

- Ampulla is the most common site of implantation. 55%, ruptures at 8-12 weeks
- Isthmic-25%, usually ruptures early at 6 weeks
- Fimbrial- 17%
- Interstitial-2%
- Bilateral- very rare
b. Ovarian-0.5%
c. Abdominal- 1/15,000 pregnancies
- Primary – original implantation outside the tube
- Secondary- implantation is in tube or ovary then implanted on the abdomen after
rupture
- Pregnancy terminates depending on site of implantation, some carry till term and
fetus dies, it may become mummified and calcified (lithopedion) or an adipocere
(fatty replacement)
d. Cervical

Assessment:
1. Normal symptoms of pregnancy
2. Vaginal bleeding -painless in cervical implantation
3. One-sided lower abdominal pain – sudden knife like pain
4. Referred shoulder pain
5. Aries-Stella reaction – uterus will not enlarge as in normal pregnancy
6. Adnexal Mass or tenderness
7. Cullen’s sign - bluish discoloration around the umbilicus due to
internal bleeding
8. Hard board like abdomen
9. Shock signs – cyanosis, pallor, cold clammy skin, tachycardia,
hypotension and oliguria

Diagnosis:
1. Transvaginal UTZ
 2. Serial HCG determination - in ectopic, HCG is lower than expected for gestational time and
does not double normally. (HCG doubles every 48-72 hours)
3. Culdocentesis aspiration of bloody fluid from cul-de-sac of douglas
4. Serum progesterone levels – a result of greater than 25 nanogram/ml is usually associated
with normal viable pregnancy. A serum level of less than 5 ng/ml is associated with abortion
or ectopic.
5. Uterine curettage – to distinguish non viable pregnancy or ectopic pregnancy
, if not chorionic villi is obtained from the uterus, ectopic pregnancy is suspected.
6. Colpotomy- direct visualization of oviducts and ovaries
7. Laparascopy – visualization of pelvis using a fiber optic glass
8. CBC rate of falling hematocrit can discriminate slow internal bleeding or sudden hemorrhage
of a ruptured tube
9. Elevations in WBC and rule out appendicitis or PID.

Management
1. For unruptured pregnancy – therapeutic abortion by Methotrexate (chemo drug) IV or IM
2. Saphingectomy – removal of tube
3. Oopherectomy
4. Hysterectomy
5. Products of conception should be completely removed to prevent new growth of
trophoblastic tissue

GESTATIONAL TROPHOBLASTIC DISEASE (H-MOLE)

- Abnormal proliferation followed by the degeneration of the trophoblastic villi

- Two Distinct types

a. Complete molar pregnancy
- Have only placental parts, forms
when a sperm fertilizes an empty egg
- The chromosome are either 46XX or
46XY but are contributed by only one
parent and the chromosome material is
duplicated.
- It usually leads to carcinoma

b. Partial Mole
- It has 69 chromosome in which there are
three chromosomes for every pair
instead of two. 23 from the mother and 2
sets from the father. This could occur
when two cells fertilize one egg.
- It rarely leads to carcinoma

Assessment:
Risk factors:
1. Higher occurrence in asian
2. Women below 18 and above 40 years old
3. Women with low socioeconomic status who have low protein intake
4. History of molar pregnancy
 Signs and Symptoms:
1. Uterus larger than expected for the duration of the pregnancy
2. Abdominal cramping from uterine distention
3. Vaginal Bleeding
4. Vaginal discharge of clear, fluid –filled vesicles
5. S/Sx of preeclampsia before 20 weeks’ gestation
6. Severe nausea and vomiting
7. HCG serum levels are abnormally high
8. Ultrasound reveals characteristic appearance of molar growth
9. Absence of FHR
10. s/Sx of anemia

Management:
1. Suction Curettage or dilatation and curettage to remove mole
2. Serum hCG monitoring – HCG should be monitored for 1 year and
should be negative 2-8 weeks after removal of mole. It is monitored every 2 weeks until
normal then monthly for 6 months then every 2 months for the next 6 months.
3. Chest x ray may also be done every 3 months for 6 months because
H- mole cancer cells can metastasize to lungs.
4. Oral Contraceptive use for 1 year- the woman is advised not to get
pregnant yet and pills should not contain estrogen
e. Methotrexate – anti cancer drug for one year to prevent development of malignancy
f. Hysterectomy

Complications:
Gestational trophoblastic tumors
- Choriocarcinoma – chorionic villi becomes cancer cells, can be transferred to different
parts of body by circulation and ymphatic drainage
- Invasive mole – excessive formation of trophoblastic villin that penetrates
myometrium
- Placental site trophoblastic tumor – cancer cells arising form the placental site

INCOMPETENT CERVIX
- Characterized by a painless dilation of the cervical os without contractions of the
uterus, dilation of cervix prematurely (more than 3 cm), chief cause of habitual
abortion due to mechanical defect that occurs in the 2 nd to early 3rd trimester followed
by prolapsed of membranes into the vagina, rupturation of membranes and expulsion
of products of conception.
- 20-25% of all second trimester losses.
Etiology:
A. Congenital Factors
B. Acquired Factors
 Infection
 Inflammation
 Subclinical uterine activity
 Cervical trauma
 Cone biopsy or Late second trimester elective abortion
 Multiple gestation
 C. Biochemical/Hormonal Factors
1. Increased relaxin levels

Assessment:
1. Associated findings:
a. History of cervical trauma
b. History of repeated, spontaneous, second trimester terminations.
c. Possibly spontaneous rupture of membranes

2. A common clinical manifestation is appreciable cervical dilatation with prolapsed of the

membranes through the cervix without contractions.

Diagnosis:
1. Manually by pelvic examination/internal examination to assess dilatation and effacement
degree
2. Ultrasonography to view cervical os and canal. Diagnosis is made if dilatation is greater than
2.5 cm or length of cervix is shortened to 20 mm. sometimes funneling is also seen where the
internal portion of internal os has begun to efface.
Signs and symptoms:
1. Painless vaginal bleeding/pinkish show accompanied by cervical dilatation
2. Rupture of membranes and passage of amniotic fluid

Management:
1. bed rest
2. avoidance of heavy lifting
3. abstinence to sexual activity
4. cervical cerclage – suturing of cervix at around 14 weeks AOG to prevent dilatation
(requisites: cervix has not dilated beyond 3 cm, membranes are intact, and no vaginal
bleeding and uterine clamping)
a. Mcdonald- temporary and stitches are removed by 38-39 weeks AOG to allow vaginal
delivery, it is necessary to remove sutures before labor begins to prevent lacerations
b. Shirodkar – permanent, fetus is delivered by CS
c. After suturing:
1. Bedrest for 24 hours to several days
2. Observe for bleeding, uterine contractions, and rupture of BOW
3. Report passage of fluid or signs of ruptured BOW, sutures then are removed to
prevent infection
4. If contractions occur, Ritodrine is given to stop it
5. Restrict activities for 2 weeks after procedure (sex)

SPONTANEOUS ABORTION
- Most common bleeding disorder in early pregnancy
- The expulsion of the fetus and other products of conception from the uterus before
the fetus is viable (viability) that is before 20 weeks AOG from LMP or before the
fetus weighs 500 grams.
- Spontaneous abortion occurs in 15-20% of recognized pregnancy.
Early abortion - Before 12 weeks AOG
Late abortion – 12-20 weeks AOG, where bleeding is more likely since definitive placenta and
blood supply has begun to form
 Abortus - fetus that is aborted weighing less than 500 grams
Occult pregnancy – zygote aborted before pregnancy is diagnosed/recognized
Blighted ovum – small macerated fetus, sometimes there is no fetus surrounded by fluid inside an
open sac
Lithopedion – calcified fetus/embryo
Premature infant – infant delivered having birthweight of 500-1000 grams

Etiology:
a. Fetal causes
1. Developmental anomalies – 60% of cases
2. Chromosomal abnormalities
3. Implantation abnormalities

b. Maternal factors
1. Age – risk increases with increasing age
 Below 35 years old – 15%
 Between 35-39 years old – 20-25%
 Between 40-42 years old – 35%
 Above 42 years old - > 50%
2. Structural abnormalities of reproductive tract
 Congenital uterine defects
 Cervical incompetencies
3. Inadequate progesterone production
4. Systemic infection – rubella virus, cytomegalovirus, toxoplasmosis
5. Chronic maternal diseases
 Polycystic ovary syndrome
 Uncontrolled DM
 Renal disease
 Systemic Lupus Erythromatosus
 Untreated thyroid disease
 Severe HPN
6. Ingestion of teratogenic drugs (prohibited or prescribed)
7. Chronic smoking
8. Ingestion of alcohol
9. Exposure to radiation and high doses of caffeine

Complications:
1. Hemorrhage
2. Infection/septic abortion
3. Disseminated intravascular coagulation (DIC) if missed abortion is retained beyond 1 month,
common in late abortion
Types:
1. Threatened abortion – characterized by cramping and vaginal bleeding in early pregnancy with no
cervical dilatation. There is a possible loss of the products of conception. 25-20 of all pregnancies have
some bleeding but only less than a half proceed to complete miscarriage. It may subside or an
incomplete abortion may follow.
Signs and symptoms: light vaginal bleeding, no or mild uterine cramping
Management:
1. Ask LMP as if it is more than 20 weeks AOG, it may be due to placenta previa and not
abortion, do not do internal examination
2. Instruct mother to save all pads consumed for examination of passed materials
 3. Assess pain – usually in the suprapubic area that radiate in the lower back, buttocks,
genitalia and perineum, if occurring in only one side, consider ectopic pregnancy or
ruptured ovarian cyst. When the pain subsides, it may suggest completion of the
abortion
4. Bedrest until 3 days after bleeding has stopped, if bleeding and pain persist , advise to
go to hospital
5. No coitus up to 2 weeks after bleeding stopped

2. Imminent or inevitable abortion – characterized by bleeding, cramping and cervical dilation and the
termination can not be prevented.
Signs and symptoms: moderate to profuse bleeding, moderate to severe uterine cramping,
dilatation of cervix, rupture of membranes, no tissue has passed yet
Management: hospitalization, dilatation and curettage, oxytocin after D and C, emotional
support

3. Incomplete abortion – Characterized by expulsion of only a part of the products of conception

(usually the fetus) and bleeding occurs with cervical dilation.
Signs and symptoms: heavy vaginal bleeding, severe uterine cramping, open cervix, pasaage of
tissue, UTZ shows that some products of pregnancy are still inside uterus

Management: D and C and uterus must remain contracted after, flat position and massage the
uterus, monitor for shoulder pain and abdominal pain that may suggest perforation of uterus,
monitor vital signs for shock, monitor blood loss, monitor I and O and blood studies

4. Complete abortion – characterized by complete expulsion of all the products of conception.

Signs and symptoms: light vaginal bleeding, abdominal pain and passage of tissue then no pain
and tenderness after the passage, no or mild cramping, closed cervix and in UTZ, empty uterus

Management: usually needs no further medical or surgical treatment but monitor still for
continuous bleeding or signs of infection – these are indicators that not all tissue were expelled,
rest and no intercourse and douching for upto 2 weeks, RhoGAM administration, advise to seek
consultation if with profuse bleeding, severe pelvic pain, and high grade fever

5. Missed abortion – characterized by early fetal intrauterine death without expulsion of the products of
conception. The cervix is closed and the client may report dark brown vaginal discharge.
Signs and symptoms: absence of FHT, cessation of s/s of pregnancy (uterine enlargement, no HCG
level doubling)
Management: insertion of 20 mg dinoprostone (prostaglandin) suppository in the vagina every 3-
4 hours as necessary to produce contractions to expel products of pregnancy, D and C may be
needed to remove fragments of placenta

6. Recurrent or habitual abortion – is spontaneous abortion of three or more consecutive pregnancies.

Management: cervical cerclage, fertility drugs to improve estrogen and progesterone production for
better uterine nourishment (Clomiphene, Pergonal), Aspirin or mini-heparin to prevent of fibrinogen
clot formation within small blood vessels, if cause is due to uterine polyps, tumors and adhesions
correction of these conditions before pregnancy is again attempted, treatment of medical illness as
DM, SLE, thyroid diseases, STD’s before attempting pregnancy

7. Septic Abortion – due to dissemination of bacteria or toxins in maternal circulation often associated
with induced abortion by untrained persons by non sterile technique.
 Signs and symptoms: foul smelling vaginal discharge, uterine cramping, fever, chills, peritonitis,
leukocytosis, septic shock
Management: treat abortion, high dose IV antibiotic therapy (penicillin, clindamycin and
tobramycin), D and C if incomplete abortion

PLACENTA PREVIA
- The placenta implants in the lower uterine segment, near or over the cervical os. The
degree to which it covers the os leads to three different classifications:
- When the placenta implanted low, the size and the margin are affected by changes in
the lower uterine segment especially in the 3 rd trimester when it begins to stretch and
shorten in preparation for labor causing tear or breakage in placental attachment.
- The lower uterine segment is not as muscular as the upper portion making it unable
to efficiently contract should a bleeding occurs due to this breakage.
Types:
a. Total placenta previa – occurs when the placenta completely covers the internal os.
b. Partial placenta previa – occurs when the placenta partially covers the internal os.
c. Low lying or low implantation placenta previa – occurs when the placental border reaches
the border of the internal os

Predisposing factors:
1. Conditions that may make implantation in upper segment undesirable due to decreased blood
supply/scarring:
a. Multiparity
b. Previous molar pregnancy
c. Endometritis
d. Previous CS
e. Abortion
f. D and C
2. Multiple pregnancy due to adjustment for 2 placentas
3. Advanced maternal age, over 35 years of age because and older uterus is not as vascular as
younger uterus
4. Decreased blood supply to uterine wall by smoking, PIH, drug abuse and diabetes
5. Short umbilical cord for this will sometimes slide the placenta to implant in lower segment
due to weight of fetus
6. Abnormal placentas – increta and accreta
7. Large placenta
Complications:
 1. Disseminated Intravascular Coagulation
2. Infection
3. Abnormal adhesion of placenta
4. Renal failure secondary to hemorrhage and DIC
5. Anemia
6. Postpartum hemorrhage
7. More laceration
8. Fetal effects: death, prematurity, hemorrhage, anemia, small for gestational age, brain
damage

Signs and symptoms:

1. Sudden/Abrupt, Bright red, painless vaginal bleeding-begins 24 to 30 weeks AOG, bright
bleeding may be intermittent or in gushes rarely continuous
2. Fetus may assume transverse lie for sometimes the low implanted placenta prevents fetal
head to enter the true pelvis properly
3. Decreased urine output due to hemorrhage
4. Confirmed and diagnosed by UTZ

Management:
1. Bed rest with bathroom privileges
2. Vaginal exams are contraindicated or may be done in double set –up
(done in the OR)
3. Monitoring of blood loss, pain and uterine contractility
4. Evaluation of FHR
5. Monitor maternal V/s
6. Complete laboratory evaluation
7. Administration of IV Fluids
8. Possible blood transfusion
9. Evaluation of fetal maturity by amniocentesis to enable schedule of
delivery
10. Administration of betamethasone to speed up lung maturity
11. If woman is in active labor, tocolytics like ritodrine or magnesium
sulfate is given to stop contractions, if inevitable, delivery is done
12. CS is more preferred especially in total placenta previa
13. If vaginal delivery is possible (marginal and low) – position is semi
fowler so fetal head can serve as tamponade for bleeding, however trendelenburg in left
lateral recumbent position for (total/partial) because pressure on the placenta by fetal head
aggravates bleeding
14. Postpartum care: monitor for bleeding and keep uterus contracted,
infection and anemia and treat/ manage as appropriately

ABRUPTION PLACENTA
- The premature separation of a normally implanted placenta after the 20 th week of
pregnancy, typically with severe hemorrhage.

Types:
a. Central
b. Marginal
c. Complete
According to S/S:
1. Grade 0 – no symptoms, diagnosed after delivery when placenta is examined
and found to have retroplacental clot
2. Grade 1 – some external bleeding, uterine tetany, tenderness may or may not
be noted, absence of fetal distress and shock
3. Grade 2 – external bleeding,uterine tetany, uterine tenderness, fetal distress
4. Grade 3 – internal and external bleeding (more than 1000 cc), uterine tetany,
maternal shock, probably fetal death and DIC
Accoeding to extent of separation:
1. Mild: less than 1/6 of placenta is separated bleeding may or
may not be present (<250 cc), some uterine irritability with
no fetal distress, there may or may not be vaginal bleeding,
vague backache
2. Moderate: 1/6-2/3 separation. Dark vaginal bleeding (<1000
mL), with fetal distress, uterine tenderness
3. Severe: more than 2/3 is separated, uterine tenderness,
rigidity, dark vaginal bleeding (>1000 mL) however it may be
absent externally, fetal distress and fetal death, if separated
entirely- maternal shock and fetal death, severe pain, DIC
Etiology:
1. The cause is unknown
2. Risk factors may include:
a. Uterine anomalies
b. Multiparity
c. Preeclampsia - Maternal HPN
d. Previous caesarian birth
e. Renal and vascular disease
f. Trauma to the abdomen
g. Previous third trimester bleeding
h. Abnormally large placenta
i. Short umbilical cord
j. Sudden release of AF
3. Behavioral factors:
a. cigarette smoking, methamphetamine, cocaine abuse
b. maternal alcohol consumption (14 or more drinks per week)

Assessment:
1. Sharp, stabbing pain high in the uterine fundus
 2. Heavy vaginal bleeding if separation begins at placental edges
3. Concealed bleeding if the center of the placenta separates first
4. Uterus firm to board-like, tense or rigid
5. s/sx of anemia
6. s/sx of hypovolemic shock

Management:
1. hospitalization
2. FHR monitoring
3. Maternal V/S monitoring, I and O monitoring, abdominal
circumference and fundic height- sudden increase may indicate internal bleeding, uterine
contractions secondary to release of prostaglandins by placental separation
4. Proper positioning – bedrest at sidelying position
5. IV Fluid administration – LR is usually given at 125 cc per hour
6. Blood typing and cross matching
7. Oxygen administration
8. No pelvic, abdominal or vaginal examination
9. Administer prescribed medications: bethametasone, tocolytic therapy
(terbutaline (ritodrine), MgSO4) for mild abruption placenta but contraindicated in moderate to
severe cases for it may conceal s/s of proper diagnosis and evaluation.
10. Caesarean birth Is preferred
11. Vaginal delivery is possible if fetus is already dead, there is minimal
bleeding and mother is stable

PREMATURE RUPTURE OF MEMBRANES

- Spontaneous rupture of the chorion and amnion before the onset of labor. It is
believed that fetal membranes rupture due to pressure of uterine contractions and
the physiologic weakening when the cervix dilates
- Occurs between 36-40 weeks AOG just before true labor begins
- Preterm PROM: Responsible for 30-40% of all preterm deliveries
- Prolonged ROM: when rupture occurs more than 24 hours before the birth of the
baby

Etiology:
a. incompetent cervix
b. cervicitis – most common cause is infection
c. UTI
d. Amniocentesis
e. Placenta previa
f. Abruption placenta
g. Hydramnios /overdistention of uterine wall
h. Trauma
i. Multiple gestation
j. Maternal genital tract anomalies
k. Cigarette smoking
l. Cerclage application

Maternal Risks:
a. Chorioamnionitis
b. endometritis
c. abruption placenta
Fetal/Neonatal Risks:
a. Prematurity
b. Neonatal infection/sepsis
c. Fetal hypoxia due to cord compression
d. Fetal pulmonary hypoplasia
e. Facial anomalies
f. Limb position defects
g. Fetal growth restriction

Assessment:
1. Fluid leaking in the vagina
2. Nitrazine paper test result of blue-green or blue
3. high alpha-fetoprotein (AFP) level in the vagina
4. may complain constant wetness in the underwear
5. cervical dilatation
6. uterine cramping
7. pelvic pressure
8. ferning pattern in microscopic test of dried AF

Management:
1. hospitalization
2. Bed rest to prevent cord prolapsed- if with cord prolapsed have mother positioned in knee
chest or modified trendelenburg.
3. Monitoring of maternal V/S every 2-4 hours under normal conditions, more frequently if with
s/s of infection, monitor FHT every hour, vaginal discharge (smell, color, amount) and uterine
contractions (duration, intensity, frequency, interval)
4. Regular laboratory evaluation
5. “Pelvic Rest”
6. Prophylactic antibiotics or if with infection, to treat it
7. Betamethasone administration
8. Proper perineal care
PREGNANCY INDUCED HYPERTENSION
Hypertension – a blood pressure reading in two occasions of at least 140/90 or a rise of 30 mmHg systolic
and 15 mmHg diastolic. Blood pressure should be taken in 2 occasions 4-6 hours apart.
Gestational HPN- BP 140/90 mmHg develops for the first time during pregnancy, but there is no
proteinuria and within 12 weeks postpartum the BP is normal
Pregnancy Induced HPN- HPN that develops after the 20 th week of gestation to a previously normotensive
woman. PIH include preeclampsia, eclampsia and gestational HPN.
Preeclampsia – is a hypertensive disorder of pregnancy developing after 20 weeks’ gestation and
characterized by edema, hypertension and proteinuria (300mg/24 hours).

Eclampsia – is an extension of preeclampsia and is characterized by onset of seizure activity.

Contributory Factors:
a. Multiple pregnancy
b. Primiparity <20 years old or >40 y/o
c. Pre existing diseases- Diabetes mellitus, collagen vascular disease, chronic HPN, chronic renal
dse.
d. Low socioeconomic status – inadequate prenatal care
e. Poor nutrition
f. Pregnancy complications – H-mole, gestational DM, Rh incompatibility
g. Hereditary
h. Black race
Causes:
1. No definite cause
2. Genetic predisposition
3. Autoimmune reaction
4. Protein deficiency and poor nutrition
5. Endothelin theory- vasoconstrictors

Assessment (according to type):

1. Mild pre-eclampsia
a. BP of 140/90 mmHg or higher
b. Proteinuria (+1 to +2 by dispticks, 300 mg/24 hours urine collection)
c. Weight gain – 2 lb/week
d. Mild edema in upper extremities or face – digital, dependent edema
e. Liver enzymes slightly elevated
f. No IUGR
g. Urine output is not less than 400 mL/24 hours
h. Occasional headaches
i. DTR – normal to +3
j. No epigastric pain

2. Severe pre-eclampsia
a. BP of 160/110 mmHg
b. Proteinuria (+2 to +4, 5 g/24 hours urine collection)
c. Oliguria
d. Cerebral disturbances
e. Cardiopulmonary involvement due to pulmonary edema
f. Extensive peripheral edema – pitting edema +4, generalized edema
 g. Hepatic dysfunction – liver enzymes markedly elevated
h. More rapid weight gain
i. Epigastric pain
j. Hyperreflexia (+4)
k. Photophobia and visual disturbances
l. Severe headache
m. Nausea and vomiting
n. Oliguria

3. Eclampsia
- S/Sx of pre-eclampsia to include:
a. Seizure
b. coma

Effects of Preeclampsia and Eclampsia:

1. Cardiovascular Changes
- decreased cardiac output due to vasospasm
- failure of blood volume to expand which normally occurs in pregnancy
- increased levels of clotting factors due to damage to endothelium of blood vessels secondary
to vasospasm
- abnormal formation of RBC with short lifespan
2. endocrine and metabolic changes
a. increased levels of renin, angiotensin II (elevates BP), aldosterone (Na reabsorption
and fluid retention), anti-diuretic hormone, HCG
b. edema
3. Renal changes
- Reduced renal perfusion and filtration
- Elevated creatinine, uric acid and urea (due to inability of kidney to efficiently filter waste
products)
- Decreased urine output
- Proteinuria (due to damage to renal structures secondary to poor perfusion)
Complications:
1. Abruption placenta
2. Cerebral hemorrhage and ischemia
3. Hepatic failure
4. Acute renal failure
5. Prematurity
6. Perinatal death
7. Maternal death

Management:
1. Screening and early diagnosis
- Roll over test
- Tolerance Hyperbaric test – helpful for early detection before clinical signs could appear. The
pregnant woman wears a portable BP cuff and monitors and records intermittent BP readings
over a 48 hour period.
2. Initial hospitalization
- CBC, BUN crea and uric acid levels
- Liver function tests
- 24- hour urine protein and creatinine clearance determination
- Daily weight
 - UTZ
- DTR assessment
a. 0 – no response
b. 1+ diminished
c. 2+ normal
d. 3+ brisker than average, possibly developing disease
e. 4+ hyperactive, associated with clonus, developing disease
- To assess clonus at the ankle joint, dorsiflex the foot and observe for movement when it is
released. Rhythmic jerking is present. If absent clonus, foot returns to plantar position
without jerking.

3. Ambulatory management

- Home management is allowed only if BP is 140/90 or below, there is low proteinurua, no

IUGR and well fetal well being
- Bed rest
- Left lateral position when lying down
- Regular check up – every 2 weeks
- Diet high in CHON and CHO – CHON at least 1.5 g/kg of body weight/day, moderate Na
restriction of less than 2 g/day, calcium 1200 mg/day, avoid salty food, high eat high fiber, 8-
10 glasses of water
- Take weight daily and monitor and record intake and output, BP monitoring 2x a day, count
fetal movements (3/hr)
- Must report to the hospital if – increasing BP, epigastric pain, visual disturbances, severe
headache, N/V, weight gain more than 1 lb/week, abnormal fetal movements

4. Hospital Management
- The only cure for preeclampsia is delivery
- Determination of fetal maturity (bexamethasone may be given to speed up lung maturity)
- Fluid therapy of crystalloids (LRS and NSS 100 to 125 mL/ hour)
- Medications:
a. MgSO4 (drug of choice) to treat convulsions by reducing release of acetylcholine at
myoneural junctions, reduce edema, reduce BP
b. Loading dose of 4 g infused over 20 minutes followed by continuous infusion of 2-3
g/ hour
c. Check ff before adm.: respiration should be above 14 BPM, UO should be at least
100 mL/4 hour, DTR are present (loss/absence of DTR is a sign of toxicity to MgSO4)
d. Serum Mg levels are monitored periodically: 7-8 mg/dL is therapeutic. Greater than
is toxicity
e. If toxicity develops (absent DTR, depressed RR, UO less than 25 mL/hr) – give
antidote 1 g (10 mL) 10% calcium gluconate IV over 2 minutes and notify physician.
f. MgSO4 is given upto 24 hours after delivery or from the last convulsion if it occurs
during postpartum.
g. If given postpartum, monitor for atony that can lead to hemorrhage’
h. Side effects: mother: CNS depression, hyporeflexia, flushing, confusion,
Fetus: tachycardia, hypoglycemia, hypocalcemia, hypomagnesemia
i. Hydralazine (apresoline) – Antihypertensive, initial bolus of 5 mg IV followed by 5-
10 mg every 20 minutes if diastolic pressure is 110 mmHg or more.
- Bed rest
- Monitor patient closely – V/S, I and O, fetal well-being, s/s of convulsions
- Safety measures:
 a. Goal – maintain patent airway and prevent injury
b. raise padded side rails, put bed at lowest position, have emergency equipments
available – suction apparatus, MgSO4, Ca gluconate, oxygen, after sizure position
patient in sidelying to drain oral secretions

- Preferred delivery is vaginal but CS for seriously ill

- In postpartum – monitor BP, convulsions, I and O and uterine atony, liver enzymes and CBC,
ergot products are contraindicated because they are hypertensive
5. 2 years should lapse before pregnancy is again attempted