Preeclampsia – Eclampsia

Preeclampsia

• Preeclampsia is defined as the presence of newly elevated blood pressure and proteinuria during pregnancy.
• Blood pressure of 140 mm Hg or higher systolic or 90 mm Hg or higher diastolic after 20 weeks of gestation.
• Proteinuria of 0.3 g or more in 24 hours.
• Historically, the presence of three elements was required for the diagnosis of Pre - eclampsia: hypertension, proteinuria, and edema.

Preeclampsia with severe features

• Blood pressure of 160 mm Hg or higher systolic or 110 mm Hg or higher diastolic
• Progressive kidney injury.
• Thrombocytopenia.
• Hemolysis, elevated liver enzymes, low platelets (HELP).
• Pulmonary edema.
• Vision changes or headache.
• When hypertension is present with severe features of preeclampsia, seizure prophylaxis could be beneficial.

Eclampsia

Eclampsia is diagnosed when seizures develop in a patient with evidence of preeclampsia.

Treatment: A) Preeclampsia

• Tab - Ascard (aspirin) 81mg, 1 tablet PO x OD (initiated between 12 weeks ' and 28 weeks ' gestation for women at increased risk for preeclampsia; risk factors include a history of preeclampsia, multifetal gestation, chronic hypertension, diabetes mellitus, kidney disease, or autoimmune diseases such as systemic lupus erythematosus or antiphospholipid syndrome).
• Clinicians may also consider low-dose aspirin (81mg orally daily). If more than one of the following moderate risk factors are presents: Nulliparity, obesity, family history of preeclampsia, African-American race, age greater than 35 years and personal history factors
• The only cure is delivery of the fetus at a time as favorable as possible for its survival.

Inj- Betnesol (betamethasone) 12mg, IM x OD for two days

• The critical factors are the gestational age of the fetus, fetal pulmonary maturity, and the severity of maternal disease.
• Preeclampsia - eclampsia at term is managed by delivery. Prior to term, severe preeclampsia eclampsia requires delivery with very few exceptions.
• Epigastric pain, seizures, severe range blood pressures, thrombocytopenia, and visual disturbances are strong indications for delivery of the fetus.
• Marked proteinuria alone can be managed more conservatively.

1. Home management - Home management may be attempted for patients with preeclampsia without severe features and a stable home situation. This requires assistance at home, rapid access to the hospital, a reliable patient, and the ability to obtain frequent blood pressure readings. A home health nurse can often provide frequent home visits and assessments.
2. Hospital care - Hospitalization is required for women with preeclampsia with severe features or those with unreliable home situations.

• Regular assessments of blood pressure, urine protein, and fetal heart tones and activity are required.
• A CBC with platelet count, electrolyte panel, and liver enzymes should be checked regularly, with frequency dependent on severity.
• A 24 - hour urine collection for total protein and creatinine clearance should be obtained on admission and repeated as indicated.
• Magnesium sulfate is not used until the diagnosis of severe preeclampsia is made and delivery planned (see Eclampsia, below).
• Fetal evaluation should be obtained as part of the workup.
• If the patient is being admitted to the hospital, fetal testing should be performed on the same day to assess fetal wellbeing. This may be done by fetal heart rate testing with nonstress testing or by biophysical profile.
• A regular schedule of fetal surveillance must then be followed.
• Daily fetal kick counts can be recorded by the patient herself. ' OR '
• If the fetus is less than 34 weeks ' gestation, corticosteroids can be administered to the mother.

Inj- Decadron (dexamethasone) 6mg, IM x BD for two days

However, when a woman clearly has unstable severe preeclampsia, delivery should not be delayed for fetal lung maturation or administration of corticosteroids.

• In women with gestational hypertension or preeclampsia without severe features at or beyond 37 weeks ' gestation, delivery rather than expectant management upon diagnosis is recommended. The method of delivery is determined by the maternal and fetal status.
• A vaginal delivery is preferred because it has less blood loss than a cesarean section and requires less coagulation factors.
• Cesarean section is reserved for the usual fetal indications. For mild preeclampsia, delivery should take place at term.

B. ECLAMPSIA: 1. Emergency care

• If the patient is convulsing, she is turned on her side to prevent aspiration and to improve blood flow to the placenta.
• Inj- Lorazepam 2-4mg IV x slow (over 4 minutes or until the seizure stops) OR Inj- Valium (diazepam) 10mg, IV x stat (diluted) ' OR ' Inj - Magnesium sulfate 4-6gm (diluted) IV over 15-20 minutes.
• A continuous intravenous infusion of magnesium sulfate is then started at a rate of 2-3 gm / hr unless the patient is known to have significantly reduced kidney function.
• Magnesium blood levels are then checked every 4-6 hours and the infusion rate adjusted to maintain a therapeutic blood level (4-7 mEq / L).
• Urinary output is checked hourly and the patient assessed for signs of possible magnesium toxicity such as loss of deep tendon reflexes or decrease in respiratory rate and depth, which can be reversed with calcium gluconate, 1 g intravenously over 2 minutes.

2. GENERAL CARE

• In patients who have preeclampsia with severe features, magnesium sulfate should be given intravenously, 4 - to 6 - gm load over 15-20 minutes followed by 2-3 gm / hr maintenance, for seizure prophylaxis.
• The occurrence of eclampsia necessitates delivery once the patient is stabilized. It is important, however, that assessment of the status of the patient and fetus take place first.
• Continuous fetal monitoring must be performed and maternal blood typed and cross - matched quickly.
• A urinary catheter is inserted to monitor urinary output, and a CBC with platelets, electrolytes, creatinine, and liver enzymes are obtained.
• If hypertension is present with systolic values of 160 mm Hg or higher or diastolic values 110 mm Hg or higher, antihypertensive medications should be administered to reduce the blood pressure to 140-150 / 90-100 mm Hg. Lower blood pressures than this may induce placental insufficiency through reduced perfusion.
• Antihypertensive most often used are

Inj - Hydralazine, 5-10mg IV every 20 minutes ' OR '

Inj - Labetalol, 10-20 mg IV every 20 minutes as needed

• The 2017 ACOG guidelines for treatment of emergency hypertension include the use of immediate - release oral nifedipine (not sublingual), particularly for patients who do not have intravenous access.

3. DELIVERY

• Delivery is mandated once eclampsia has occurred. Vaginal delivery is preferred.
• The rapidity with which delivery must be achieved depends on the fetal and maternal status following the seizure and the availability of laboratory data on the patient.
• Oxytocin, given intravenously and titrated to a dose that results in adequate contractions, may be used to induce or augment labor.
• Oxytocin should only be administered by a clinician specifically trained in its use
• Regional analgesia or general anesthesia is acceptable.
• Cesarean section is used for the usual obstetric indications.

4. POSTPARTUM

• Magnesium sulfate infusion (2-3 gm / hr) should be continued for 24 hours postpartum
• Late - onset preeclampsia - eclampsia can occur during the postpartum period. It is usually manifested by either hypertension or seizures.
• Treatment is the same as prior to delivery - i.e., with hydralazine and magnesium sulfate.

When To Refer

New onset of hypertension and proteinuria in a pregnant patient more than 20 weeks ' gestation. New onset of seizure activity in a pregnant patient.

When to Refer

Symptoms of preeclampsia with severe features in a pregnant patient with elevated blood pressure above baseline. Evaluation for preeclampsia when severe features of the disease are suspected. Evaluation for preeclampsia in a patient with an unstable home environment. Evidence of eclampsia.