Toxemia of pregnancy: Definition,risk factors,Clinical features,management of pre-eclampsia. Nursing students will understand toxemia of pregnancy .Jasleen Kaur

3. DEFINITION
 Pre eclampsia is a multi system disorder
of unknown etiology characterised by
development of hypertension to the
extent of 140/90 mm Hg or more with
proteinuria after 20th week in a
previously normotensive &
nonproteinuric patient .

4. Contd..
 MILD–
 This includes
cases of
sustained rise
of blood
pressure of
more than
140/90 mm Hg
but less than
160 systolic or
110 diastolic
without
proteinuria

5. SEVERE-
This includes
1. Persistant systolic BP of > 160 mm Hg or
diastolic of >110 mm Hg .
2. Persistant severe epigastric pain.
3. Cerebral or visual disturbances .
4. Oliguria ( <400ml /24 hr).
5. Protein excretion of > 5 gm /day .
6. Platelet count <100,000/mm3.
7. HELLP syndrome.
8. IUGR , Pulmonary edema.

7. Path physiology
The path physiological changes that
distinguish pre-eclampsia from normal
pregnancy are:
Intense
vasospasm
Plasma
volume
contraction
Intravascular
coagulation

8. Intense vasospasm
In pregnancies complicated
by pre-eclampsia, the blood
vessels constrict, leading
to vasospasm and a
reduction in blood flow
leading to maternal organ
damage.

9. Intravasular coagulation
Platelets are used to repair
the damaged vessel wall
caused by vasospasm
resulting in platelet
consumption which led's to
intravascular coagulation.

10. Plasma volume contraction
In normal pregnancy, plasma volume increases
dramatically resulting in a 50% increase in
total blood volume.
Women with pre-eclampsia have a slight or
unchanged total extracellular fluid volume,
plasma volume is reduced leading to
haemoconcentration

11.  The net result of vasospasm,
intravascular coagulation and plasma
contraction is decreased blood flow
resulting in organ hypo perfusion.
 Organ hypo perfusion is detrimental not
only to the mother, but to the fetus if
the placenta is similarly affected

14.  Primigravida ( young & elderly).
 Family history.
 Genetic disorder
 New paternity .
 Pre existing vascular or renal disease .
 Thrombophilias – antiphospholipid syndrome
, protein c , s deficiency .
 Placental abnormalities.( poor placentation ,
hyperplacentosis – multiple pregnancy , Rh
incompatibility , diabetes , placental ischaemia
).

16. Signs
Oligohydr
omnios

17. MILD SYMPTOMS –
Slight swelling over
ankles . This swelling
may extend to the
face , abdominal wall ,
vulva & even whole
body .
Symptoms
mild severe

18. SEVERE SYMPTOMS –
1. Headache ( occipital or frontal ).
2. Disturbed sleep .
3. Diminished urinary output .
4. Epigastric pain .
5. Eye symptoms ( blurring or dimness of
vision ).vision is usually regained in 4-6
weeks after delivery .

19.  Urine for presence of protein.
 Opthalmoscopic examination for retinal
oedema and constriction of arterioles.
 Blood values
-Serum uric acid level more than 4.5mg/dl
-Serum creatinine level more than 1 mg/dl.
-Thromobocytopenia and abnormal
coagulation
profile.
 Antenatal fetal monitoring.
Investigations

20. Complications
Immediate
Maternal Fetal
Remote

21. During pregnancy During labour Puerperium
Eclampsia Eclampsia Eclampsia
Accidental
haemorrhage
Postpartum
haemorrhage
Shock
Oliguria & anuria Sepsis
Dimness of vision &
even blindness.
Preterm labour
HELLP syndrome
1).Maternal

22.  Intrauterine death .
 Intrauterine growth
restriction ( due to chronic
placental insufficiency).
 Asphyxia .
 Prematurity ( either due to
spontaneous preterm onset
of labour or induction
2). Fetal

23.  Residual hypertension .
In this hypertension may persist even after 6
months following delivery in about 50 % cases.
 Recurrent pre eclampsia
25% chance of preeclampsia to reccur in
subsequent pregnancies.
 Chronic renal disease
High incidence of glomerulonephritis in women
with pre eclampsia
3).Remote

24. PREVENTION
 Reduce dietary salt intake
 Supplementation 1g of calcium a day
 Supplementation antioxidants: such as
vitamin C, vitamin E
 Nutritional supplementation with Mg , Zn,
fish oil , high protein .
 Regular antenatal check up .
 Antithrombotic agents.

25. Objectives –
1. To correct / stabilize the
altered physiology .
2. Prevention of
complications
3. Prevention of eclampsia.
4. Delivery of healthy baby
with minimal maternal
morbidity .
Management

26. TREATMENT MODALITIES
Rest
Diet
Drugs

27. Contd..
Rest
While in bed patient
should be in left lateral
position . It increases the
1. Increases the renal
blood flow >diuresis.
2. Increases the
uterine blood flow >
improves the
placental perfusion .
3. Reduces the blood
pressure
Diet
Diet should contain
adequate amount of
proteins (about
100gms),
with no restriction
over
salt n fluids

28. DRUGS
 SEDATIVE
Mild sedative like phenobarbitone 60 mg or diazepam
5mg orally at bedtime.
 DIURETICS
Compelling reasons to use it are-
 Cardiac failure
 Pulmonary oedema
 Massive oedema not relieved by rest
 Along with antihypertensive drug therapy to treat
fluid retention.
Mostly frusedamide 40mg given for 5 days in a week.

29. ANTI HYPERTENSIVES
Labetalol Hydralazine Nitroprusside Nitroglycerine
Adrenoreptor
antagonist
Vascular smooth
muscle relaxant
Calcium channel
blocker
Calcium channel
blocker
200 mg in 200
ml NS at the
rate of 20 mg
/hr to be
doubled every
30 mins
5 mg iv bolus to
be followed by
infusion 25 mg in
200 ml NS , the
rate being 2.5mg
to be doubled
every 30 mins
0.25-5
micrograms/kg/mi
n
5
micrograms/mins

30. PROGRESS CHART
 The effect of treatment should be
evaluated by maintaining a chart which
records the following –
1. Blood pressure – at least 4 times a day.
2. State of edema & daily weight.
3. Fluid intake n urinary output

31. Contd..
4. Urine examination – for
proteins daily.
5. Blood for- cbc, platelet
count,uric acid ,creatinine &
LFT .
6. Opthalmoscopic examination.
7. Fetal well being assessment .

32. SCHEME OF MANGMENT
Rest
BP checking
4 hourly
•Plt count
•RFT
•LFT
•24 hour
urine
opthalmosc
opy
Fetal
assessment

33. Antihypertensive if
DBP>110mm Hg
Complete
control
BP
persistently
high
Increased
BP inspite
use of
antihyperte
nsive
Addition of
omnious
symptoms
Couple
counselling
preter
m
Term
To continue
pregnancy till
37 completed
discharge
Stay in
hospital
Termination

34. Termination
Induction
•PGE2 gel
•ARM
•Oxytocin
C.S.

35. METHODS OF TERMINATION
Induction
of labour
Caesarean
section

36. 1. Aggravation of pre eclamptic features inspite of
medical treatment & / appearance of newer
symptoms such as epigastric pain.
2. If hypertension persists inspite of medical
treatment.
3. Tendency of pregnancy to overrun the expected
date.
4. Acute fulminating preeclampsia irrespective
of period of gestation.
Indications for IOL

37.  If the cervix is ripe , surgical induction by low
rupture of membranes is the method choice .Oxytocin
infusion may be added to accelerate the process.
 If the cervix is unripe & termination is not the urgent
one , than prostaglandin (PGE2)gel 500microgm
intracervical or 1-2 mg in posterior fornix to make
cervix ripe. In severe preeclampsia , antihypertensive
should be used.
METHODS

38. CAESAREAN SECTION
 When urgent termination is indicated & the cervix is
unfavorable .
 Severe preeclampsia with tendency to prolong the
induction –delivery interval.
 Associated complicating factors such as elderly
primigravida , contracted pelvis malpresentation.