Preeclampsia and eclampsia

CME presentation of Pre-eclampsia and eclampsia management

1. PREECLAMPSIA AND ECLAMPSIA Chavulimu Mbiti Edwin Diploma clinical medicine and surgery.

2. Objectives 1. Definition pre-eclampsia and eclampsia 2. Risk factors 3. Classification 4. Diagnosis 5. Management

3. Definitions Preeclampsia is a disorder of widespread vascular endothelial malfunction and vasospasm that occurs after 20 weeks' gestation and can present as late as 4-6 weeks postpartum. It is clinically defined by hypertension and proteinuria, with or without edema. Eclampsia :It is characterized by convulsions -fits (in the absence of other medical conditions predisposing to convulsions) in a pt with pre-eclampsia.

4. Preeclampsia in essential Hypertension Preeclampsia in a pt with pre-existing essential hypertension is diagnosed if systolic BP has ↑ by 30 mm Hg or if diastolic BP has increased by 15 mm Hg Proteinuria of ≥ 300 mg of protein in a 24-hour urine sample. A urine dipstick value of 1+ or more (30 mg/dL).

5. Risk factors- pregnancy associated include: Chromosomal abnormalities Hydatidiform mole Multiple pregnancy: Incidence is ↑ in twin gestations. Oocyte donation or donor insemination Urinary tract infection

6. Maternal-specific risk factors Extremes of age (maternal age <20 and>35 yrs) Black race more common. Family history of preeclampsia Nulliparity (more common in primigravidae) Preeclampsia in a previous pregnancy Change of male partner Diabetes

7. Maternal-specific risk factors contin' Obesity: Body weight is strongly correlated with progressively increased risk, BMI >35 kg/ ㎡ . Chronic htn Renal disease Collagen vascular disease Antiphospholipid syndrome Periodontal disease Vit D deficiency:may ↑ the risk of preeclampsia &IUFGR

8. Essential for diagnosis of Pre-Eclampsia Hypertension : Hypertension (BP) of 140/90 mmHg or 2≥ occasions apart OR A diastolic BP of ≥ 110 mmHg on a single occasion Proteinuria : Is a protein concentration of 300mg in 24 hour urine collection or Urine dipstick of ‘ trace’ , or ‘ ≥ 1+’ Normally protein is not supposed to be present in urine. ------------------------------------------------------------------------------- E dema : Gradual or sudden swelling of the face, hands and legs

9. CRITERIA FOR SEVERE PREECLAMPSIA Severe HTN sy BP≥160 mmHg / D BP ≥110mmHg at rest on 2 occasions at least 4hrs apart* • Renal insufficiency (serum Cr >1.1 mg/dL or double baseline values) Cerebral or visual disturbances Pulmonary edema Epigastric or right upper quadrant pain Elevated liver enzymes (AST or ALT at least two times normal level) Thrombocytopenia (platelet count <100,000/µL)

10. Impending Eclampsia Severe headache Drowsiness Mental confusion Visual disturbance (e.g. blurred vision, flashes of flight) Epigastric pain Nausea / vomiting A sharp rise in blood pressure Decreased urinary output Increased proteinuria Hyper-reflexia

11. Eclampsia It is characterized by convulsions -fits (in the absence of other medical conditions predisposing to convulsions) in a woman with pre-eclampsia

12. Characteristics of Eclamptic fits: Convulsions may occur regardless of the severity of HTN, are difficult to predict & typically occur in the absence of hyper-reflexia, headache or visual changes. Convulsions are tonic-clonic and resemble grand-mal seizures of epilepsy Seizures may recur in rapid sequence as in status epilepticus, and end in death. Convulsion may be followed by coma that lasts minutes or hours, depending on the frequency of seizures. 25% of eclamptic fits occur after delivery of the baby.

13. Stages of eclamptic fit A) Premonitory stage lasts 10-20 seconds, during which: The eyes roll or stare The face and hand muscle may twitch There is a loss of consciousness B) Tonic stage lasts 10-20 seconds, during which: The muscles go stiff or rigid The colour of the skin becomes blue or dusky (cyanosis) The back may be arched The teeth are clenched The eyes bulge

14. Clonic Stage This stage lasts 1- 2 minutes and is marked by: Violet contraction and relaxation of the muscles Increased saliva causes "foaming" at the mouth Deep noisy breathing Inhalation of mucous or saliva The face looks congested (filled with blood) and swollen Tongue may be bitten by violent action of the jaws

15. Coma stage This may last minutes or hours. During this time There is a deep state of unconsciousness Breathing is noisy and rapid Cyanosis fades, but the face remains congested and swollen Further fits may occur before the woman regains consciousness

16. Differential diagnosis of Eclampsia Epilepsy, Cerebral malaria Meningitis Head injury Cerebrovascular accident Intoxication Alcohol, drugs, and poisons Drug withdrawal metabolic disorders water intoxication encephalitis hypertensive encephalopathy hysteria.

17. SIGNS/Symptoms Headache Visual disturbances - Blurred, scintillating scotomata Altered mental status Blindness - May be cortical or retinal Dyspnea Edema: This exists in many pregnant women but sudden increase in edema or facial edema Epigastric or right upper quadrant (RUQ) abdominal pain: Weakness or malaise

18. LABS/Radiology laboratory investigations CBC- platelet count UECs serum -BUN creatinine & uric acid LFTs-AST , ALT & bilirubin. Urinalysis- protein/creatinine ratio coagulation profile. Obstetric U/S BPP - AFI,EFW ,fetal cardiac activity & placentation

19. Management of patients with pre-eclampsia /eclampsia. BP control - The goal is to ↓ BP to prevent cerebrovascular and cardiac complications while maintaining uteroplacental blood flow 1st line medications labetalol, nifedipine-long acting Methyldopa hydralazine IV. Atenolol, ACE inhibitors, ARBs, and diuretics should be avoided.

20. Control of seizures The basic principles of airway, breathing, circulation (the ABCs) Active seizures-IV mgSo4 1st-line agent Diazepam & phenytoin 2nd-line agents. LOADING DOSE MgS04 20% Solution, 4g IV over 15-20 mins. Follow promptly with IM 10g of 50% mgSo4 solution, 5g in each buttock as deep IM injection with 1mL of 2% lignocaine in the same syringe Warn the woman that a feeling of warmth will be felt when magnesium sulphate is given. If convulsions occur after 15 minutes, give 2g magnesium sulphate (50% solution) IV over 5 minutes Maintenance Dose Give 5g magnesium sulphate (50% solution) + 1 mL lignocaine 2% IM every 4 hours into alternate buttocks. CT treatment with MgSo4 for 24 hours after delivery or the last convulsion, whichever occurs last. If 50% solution is not available, give 1g of 20% magnesium sulphate solution IV every hour by continuous infusion

21. CLOSELY MONITOR THE WOMAN FOR SIGNS OF TOXICITY Before repeat administration, ensure that: Respiratory rate is at least 16 per minute Patellar reflexes are present Urinary output is at least 30 ml/hr over preceding 4 hour WITHHOLD OR DELAY DRUG IF: Respiratory rate falls below 16/min Patellar reflexes are absent Urinary output ↓ ˂ 30ml/hr over the preceding 4 hours

22. In case of respiratory arrest: Assist ventilation (mask and bag, anaesthesia apparatus, intubation) Give Calcium gluconate 1g (10mL of 10% solution) IV slowly until calcium gluconate begins to antagonise the effects of magnesium sulphate and respiration begins

23. Delivery Delivery is the only cure for pre-eclampsia and eclampsia As soon as pts condition has been stabilized, within 6-8 hours from first convulsion; or within 12 hrs of admission Vaginal delivery is recommended:- If the cervix is favourable (soft, dilated, effaced), rupture the membranes & induce labour using oxytocin

24. C-section If vaginal delivery is not anticipated within 8 hours (for eclampsia) or 24 hours (for severe preeclampsia) Foetal heart rate abnormalities (< 100 or > 180 beats / minute) cervix is unfavourable (firm, thick, closed) and the foetus is alive.

25. Fluid management Despite the peripheral edema, pts with preeclampsia are intravascularly volume depleted with ↑ peripheral vascular resistance. Diuretics should be avoided. Aggressive volume resuscitation may → to pulmonary edema, occurs often 48-72 hours postpartum, probably due to mobilization of extravascular fluid. Because volume expansion has no demonstrated benefit, patients should be fluid restricted when possible, at least until the period of postpartum diuresis. Total fluids should generally be limited to 80 mL/h or 1 mL/kg/h. Careful measurement of fluid input and output . Many patients will have a brief (up to 6 h) period of oliguria following delivery; this should be anticipated & not overcorrected. If fluids are required, preferably use Ringer’s Lactate or Normal saline at a rate of 80 mls/ hr or 1ml/kg/hr. Avoid using Dextrose or Dextrose- Saline infusion

26. Complications of preeclampsia /eclampsia Abruptio placentae with DIC Renal insufficiency or failure Haemolysis, elevated liver enzyme levels, and low platelet count (or HELLP syndrome) Cerebral haemorrhage Maternal death and/or foetal demise

27. Sequelae and Outcomes Women with a hx of severe preterm preeclampsia are at ↑risk for recurrent preeclampsia (up to 40%) in a subsequent pregnancy and are the ones most likely to benefit from prepregnancy lifestyle interventions or antepartum use of low-dose aspirin. There is increasing evidence that a history of preeclampsia raises a woman’s risk for cardiovascular disease in later life as compared with women who do not experience preeclampsia. 

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