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PREECLAMPSIA Reinaldo Figueroa, MD Winthrop-University Hospital PREECLAMPSIA Hypertensive disorder specific to pregnancy affects nearly 6% of all pregnancies a major cause of maternal and neonatal mortality and morbidity 15 to 20 % of maternal mortality in developed countries PREECLAMPSIA Severity ranges from: a mild disorder (transient hypertension in the later part of the pregnancy) to a life-threatening disorder with seizures, HELLP syndrome, fetal hypoxia, and growth retardation more severe disease: 0.56 per 1000 deliveries PREECLAMPSIA Predisposes women to other serious complications: placental abruption acute renal failure cerebral hemorrhage disseminated intravascular coagulation circulatory collapse PREECLAMPSIA The etiology is unknown believed to be involved: immune maladaptation placental ischemia oxidative stress genetic susceptibility PREECLAMPSIA Classification of hypertension in pregnancy Gestational hypertension Preeclampsia / eclampsia Chronic hypertension Preeclampsia superimposed on chronic hypertension PREECLAMPSIA Definition of hypertension a systolic blood pressure of 140 mmHg or above, or a diastolic blood pressure of 90mmHg or above, on two occasions 6 hours apart Abnormal proteinuria the excretion of 300 mg or more of protein in 24 hours PREECLAMPSIA Criteria for severe preeclampsia Blood pressure: 160 mmHg systolic or 110 mm Hg diastolic Proteinuria: 5 g in 24 hours Persistent and severe cerebral or visual disturbances (headache, scotoma, blurred vision) Persistent and severe epigastric pain or right upper quadrant pain PREECLAMPSIA Criteria for severe preeclampsia Pulmonary edema or cyanosis Oliguria ( 40 weeks gestation delivery, magnesium sulfate 37 - 39 weeks gestation inducible cervix: delivery, magnesium sulfate cervix not inducible: inpatient or outpatient management PREECLAMPSIA Severe preeclampsia - expectant management gestational age: not recommended for 34 weeks gestation hospitalization: tertiary care center antenatal testing: daily PREECLAMPSIA Severe preeclampsia - guidelines for expedient delivery maternal indications eclampsia, thrombocytopenia, pulmonary edema, acute renal failure persistent severe headache or visual changes elevated liver enzymes with persistent severe epigastric pain or right upper quadrant tenderness labor or rupture of membranes vaginal bleeding, abruptio placenta PREECLAMPSIA Severe preeclampsia - guidelines for expedient delivery fetal indications repetitive severe variables or late decelerations biophysical profile 34 weeks gestation PREECLAMPSIA Severe preeclampsia - management protocol admission to labor and delivery for 24 hours magnesium sulfate IV for 24 hours antihypertensives if diastolic blood pressure 110 mmHg meet guidelines for expedited delivery? yes? delivery PREECLAMPSIA Severe preeclampsia - management protocol Expedited delivery? no? 600 U/L elevated liver enzymes serum aspartate aminotransferase 70 U/L lactate dehydrogenase 600 U/L low platelets platelet count 34 weeks gestation, deliver if 34 weeks gestation, administer corticosteroids, then deliver in 48 hours PREECLAMPSIA HELLP syndrome - management for cesarean birth use general anesthesia if platelet count is 75,000 / mm3 transfuse 5 to 10 units of platelets before surgery if platelet count is 50,000 / mm3 leave vesicouterine peritoneum open install subfascial drain PREECLAMPSIA HELLP syndrome - management for cesarean birth schedule secondary closure of skin incision or subcutaneous drain administer postoperative transfusions as needed perform intensive monitoring for at least 48 hours postpartum consider dexamethasone (10 mg IV every 12 hours) until postpartum resolution of disease occurs PREECLAMPSIA HELLP syndrome - management of women with a subcapsular liver hematoma general considerations - blood bank aware for potential need of many units of blood general or vascular surgeon consultation avoid direct and indirect manipulation of liver closely monitor hemodynamic status management of hematoma depends on whether it is ruptured or not PREECLAMPSIA Eclampsia occurrence of convulsions or coma unrelated to other associated conditions all new onset seizures during pregnancy - eclampsia until proven otherwise incidence: 1 in 500 pregnancies 3% in multiple gestations PREECLAMPSIA Eclampsia precise cause unknown theories vasospasm ischemia edema multisystem organ failure PREECLAMPSIA Eclampsia seizures usually occur without aura hypertension not severe in 20% edema absent in 30% proteinuria absent in 20% hyperreflexia is not predictive of seizure headache or visual changes - most common precipitating event PREECLAMPSIA Eclampsia 80% of convulsions occur before or during the delivery 1/3 of cases may be not preventable atypical less than 20 weeks gestation more than 48 hours postpartum PREECLAMPSIA Eclampsia - risk factors low socioeconomic status extremes in childbearing age African-American no prenatal care substance abuse PREECLAMPSIA Eclampsia - management control convulsions correction of hypoxia and acidosis blood pressure control delivery after maternal stabilization PREECLAMPSIA Eclampsia - anticonvulsant therapy magnesium sulfate mechanism of action - smooth muscle relaxation by displacement of calcium dosage - 4-6 g intravenous loading dose, followed by 2 g per hour may be given intramuscularly PREECLAMPSIA Eclampsia - magnesium sulfate side effects: maternal hypotonia respiratory depression cardiac arrest neonatal depression contraindicated in myasthenia gravis use with caution in renal insufficiency PREECLAMPSIA Eclampsia - anticonvulsant therapy phenytoin used extensively in Europe may be used in myasthenia gravis mechanism of action - may increase gamma aminobutyric acid-mediated chloride conduction in postsynaptic membranes may inhibit neurotransmitter inhibitory systems PREECLAMPSIA Eclampsia - phenytoin dosage - 1 g loading dose over 1 hour cardiac monitoring during administration side effects arrhythmias with rapid administration hepatitis Steven-Johnson syndrome PREECLAMPSIA Eclampsia - anticonvulsant therapy diazepam useful for status seizures mechanism of action - facilitate the binding of GABA to its receptor benzodiazepine receptors dosage - 10 mg at a rate of 5 mg per min may be repeated at 10 to 15 minute intervals PREECLAMPSIA Eclampsia - diazepam side effects - loss of consciousness, hypotension, respiratory depression caution - may increase risk of aspiration causes prolonged depression of the neonate sodium thiopentotal long acting barbiturate used when sedation, paralysis and intubation needed PREECLAMPSIA Eclampsia - which anticonvulsant to use? magnesium is associated with decreased recurrence risks of seizures when compared with diazepam or phenytoin diazepam is associated with increased need for mechanical ventilation PREECLAMPSIA Eclampsia - management of fetus fetal bradycardia during seizure 5 minutes after the onset of the seizure may be associated with rebound tachycardia recovery phase may show late decelerations monitor for uterine hypertonicity allow for fetal recovery monitor for signs of abruption PREECLAMPSIA Eclampsia delivery is indicated regardless of gestational age immediate cesarean delivery is not necessary PREECLAMPSIA Eclampsia - radiographic evaluation should be reserved for women with neurological deficit, recurrent seizures, or atypical presentation abnormal CT findings - 50% edema, hemorrhage, infarction cerebral angiography has limited use 90% of EEG evaluations may be abnormal PREECLAMPSIA Eclampsia - management allow patient to have seizure use bite block as needed to prevent maternal injury establish airway administer magnesium sulfate as soon as possible obtain arterial blood gases monitor urine o