Management of Pre-eclampsia

and eclampsiaCase Discussions

BACKGROUND: Ten percent of all pregnancies are complicated by hypertension (HTN).Eclampsia and

preeclampsia account for about half of these cases worldwide.

DEFINITION: Eclampsia is defined as the clinical presentation of an unexplained seizure, convulsion, or altered mental status in the setting of the signs and symptoms of preeclampsia. It is considered a complication of severe preeclampsia.

A woman with preeclampsia develops:--- high blood pressure (>140 mmHg systolic or >90 mmHg diastolic)--- protein in the urine--- swelling (edema) of the legs, hands, face or entire body.

A 25-year old 2nd gravida with a pregnancy of 28 weeks of gestation comes for antenatal visit and on routine check up, she is found to be having blood pressure of 150/100 mm of Hg.

What is the diagnosis?

Repeat blood pressure measurement should be performed after 6 hours for the diagnosis of hypertension in pregnancy.4 Urine should be checked for presence or absence of proteinuria, diagnosis of the patient will depend on the presence or absence of the proteinuria.If blood pressure is found to be same or > 140/ 90 mm of Hg on two occasions, 6 hours apart

without proteinuria it is gestational hypertension

If proteinuria (defined as the urinary excretion of 300 mg/L or more of protein in a 24 hour urine collection or > 30 mg/dl or 1+ by qualitative assessment using reagent strips) is present, it is preeclampsia, therefore proteinuria should be ruled out by testing for urine albumin.

If patient gives history of pre-pregnancy high blood pressure, or has history of high blood pressure before 20 weeks of gestation during this pregnancy, the diagnosis is chronic hypertension.

If blood pressure comes to normal 6 hours later by rest, patient should be observed carefully as there is high possibility of developing gestational hypertension later on in pregnancy.

Elaborate the points in the history of hypertensive patients in pregnancy which would help in the diagnosis and management

1.Age and parity: Preeclampsia often affects young and nulliparous women; whereas older women >35 years of age are at greater risk for chronic hypertension with superimposed preeclampsia.

2.History of hypertension in family, in earlier pregnancy or prepregnancy high blood pressure: If there is history of gestational hypertension in earlier pregnancy, there are more chances of developing hypertension in this pregnancy, the incidence being 70%. The risk of developing preeclampsia is 20-40% for daughters of preeclamptic mothers; 11-37% for sisters of preeclamptic women; and 22-47% in twin sisters.

3.Race and ethinicity: Africans are more susceptible than caucasians

4.History of diabetes, thyroid disorder, anemia: These are related disorders. Both hypo- thyroidism and hyperthyroidism are associated with hypertension.

5.History of twins, hydramnios, H.mole: would cause earlier hypertension in this pregnancy.6.Smoking reduces the risk of preeclampsia.

What are the important points in examination

Besides vital parameters like pulse, blood pressure, respiratory rate, temperature, urine output, pallor, pedal edema, other important points in examination are:• Height, weight and BMI of the patient: obesity is more commonly

associated with preeclampsia. The relationship between maternal weight and the risk of preeclampsia is progressive.

• Thyroid swelling: Any obvious fullness is to be noted and investigated.• Cardiovascular system: signs of congestive cardiac failure like basal

crepitations, raised JVP, dyspnea and tachypnea have to be ruled out.

Obstetric examination: Fundal height should correspond to the period of gestation.

Fundal height more than period of gestation suggests twins, hydramnios, molar pregnancy and these conditions are more commonly associated with hypertension in pregnancy.

Fundal height less than period of gestation is suggestive of fetal growth retardation and also may be associated with hypertension or antihypertensive therapy, particularly atenolol

. How will you manage the above patientFirst we will like to confirm the diagnosis of gestational hypertension . To rule out severe hypertension hospitalization is advisable at least initially for 48 hours. During this period 4 hourly blood pressure measurements with other investigations are performed. They are as follows:

• Complete blood count including platelet count• Urine albumin • Liver function test • Lactate dehydrogenase (LDH) for the diagnosis of HELLP syndrome• PT and PTTK-Only if platelet count is abnormal• Fundus examination to rule out severity of the

Urine albumin should be done daily by dipstick method. If the patient is confirmed to be mild hypertensive after investigation without any organ dysfunction, she may be allowed to go home

All investigations are repeated once a week or fortnightly depending on the severity except urine albumin and blood pressure measurement which should be done daily.

In addition to maternal investigations, fetal monitoring is also required. Fetal assessment includes daily fetal movement count by the patient which should be more than 10 in 24 hours or more

than 3 in one hour three times a day,

non-stress test (NST), biophysical profile, umbilical artery and cerebral artery Doppler. These investigations are performed between 28-30 weeks of gestation initially and the biophysical profile/NST is repeated at least once a week till patient delivers. The frequency may increase if hypertension becomes of a severe variety or Doppler shows changes suggestive of fetal growth restriction.

What is the role of elective cesarean delivery?

Patients with mild disease are generally allowed vaginal delivery unless there are obstetric indications for cesarean sections. Once severe preeclampsia is diagnosed, labor induction and vaginal delivery have been considered ideal. Temporization with an immature fetus is considered subsequently. Several concerns, including an unfavorable cervix, a perceived sense of urgency because of severity of preeclampsia, and the need to coordinate neonatal intensive care, have led some obstetricians to advocate cesarean delivery.

What is the role of antihypertensive drugs?Most obstetricians would like to start antihypertensive drugs after blood pressure reaches 150/100 mm of Hg thinking that these will prevent the progression of mild disease into severe disease and also prevent the complication like severe hypertension, abruptio placentae, IUD, cardiac failure, pulmonary edema, cerebral hemorrhage.

Methyldopa (aldomet) has been the most widely used antihypertensive drug during pregnancy and longest followed up. It is found to be safe from the point of view of development of children later on in life, whose mothers were administered this drug during pregnancy. It has been submitted to many

controlled trials during pregnancy and has been shown to have beneficial effects.7 The usual starting dose is 250 mg of methyldopa three times a day. This amount may be increased up to a total of 2 gm /day according to the patient’s response. The common side effects are postural hypotension, excessive sedation and depression. Positive Coombs’ test and abnormal liver test are also reported. Calcium channel blocker like nifedipine is also being used Labetalol is also being used but associated with intrauterine growth retardation of the fetus

Case 2 A 32-years old multiparous woman with 32weeks of

period of gestation has come to the casualty with blood pressure of 160/110 mm of Hg and complains of headache and urine albumin on dipstix is 2 +.

What is the diagnosis? The diagnosis of this patient is more likely of severe preeclampsia with impending

eclampsia. The diagnosis may also be that of severe pre- eclampsia superimposed on chronic hypertension if the patient gives history of chronic hypertension in the interval between pregnancy or before 20 weeks of the pregnancy.

What are the additional points in the history and examination to be looked for?

history of excessive weight gain history of headache/visual disturbances like blurring of vision, bright

or black spots: suggestive of impending eclampsia history of epigastric pain/ right upper quadrant pain history of decreased urinary output any history of convulsion any history of intake of antihypertensive drugs any history of breathlessness/chest pain/ ghabrahat etc: suggestive of

impending cardiac failure/pulmonary edema any history of renal disease

In addition to examination points discussed inthe case1 of mild hypertension mentioned earlier, following points to be noted:1.Reflexes: Brisk deep tendon reflexes are also common and result from central nervous

system irritability. It is unusual for preeclamptic patients to have seizures without first showing signs of nervous system irritability.

2.Fundus examination: Most common findings on fundus in severe preeclampsia are: (1) increase in a vein to artery ratio and segmental vasospasm (2) The presence of hemorrhage,exudates or extensive arteriolar changes suggest chronic hypertension.

(3) Papilledema is not a common finding in preeclampsia. it suggests the possibility of a brain tumor,

Q.10. What are the main objectives of the management?

The basic management objectives for any pregnancy complicated by preeclampsia are:

1.Termination of pregnancy with the least possible trauma to mother and fetus. As of now only cure for preeclampsia is the termination of pregnancy. At best, it may be controlled only when it is of mild variety. It is dangerous to continue pregnancy in severe preeclampsia for more than 1-2 weeks.

2.Birth of an infant who subsequently thrives3.Complete restoration of health to the mother

Q.11. What are the points of severity of the disease?

What is the immediate management of this patient?

Our aims for the immediate management of this patient are: To bring down the blood pressure to safe levels (from severe variety

to moderate variety) Assess general condition for presence of immediate risk factors

for convulsions (headache, altered sensorium, drowsiness,agitation, Assessment of the fetal wellbeing and reasonable maturity

1. Use of antihypertensive drugs, importantly intravenous labetalol or oral nifedipine. Intravenous labetalol is used in the doses of 20 mg→40 mg→80 mg→80 mg repeated every 10-20 minutes till a maximum dose of 220 mg. Oral nifedipine in the doses of 10 mg→20 mg→20 mg→20 mg→20 mg may also be used upto a maximum

dose of 90 mg,with blood pressure monitoring every 10-20 minutes.8 Once the blood pressure control is achieved ( blood pressure < 160/ 110 mm of Hg) maintenance dose in the form of oral labetalol 100 mg twice a day (maximum up to 1200 mg) or methyldopa 250 mg thrice a day (maximum up to 2000 mg/day) or nifedipine 10 mg twice to thrice a day (maximum up to 80 mg) may be started. The dose of oral drug can be titrated according to the blood pressure levels.

Use of magnesium sulphate: It is the most commonly used drug for the prevention and treatment of eclampsia.

Magnesium sulphate is used as 4 gm (20% solution) of loading dose intra- venously followed by 5 gm of 50% solution intramuscularly in each buttock. Maintenance dose is 5 gm in alternate buttock 4 hourly till 24 hours after delivery

What is the expectant management in the case of severe preeclampsia?

Most obstetricians would like to terminate the pregnancy if reasonable maturity of fetus is present ( >32 weeks or >1 kg). Patient has to be treated only in a tertiary care center where facility of expert neonatologists, anaesthesiologists, senior obstetricians, O.T facility,and blood bank facility are available. In a rare case, when period of gestation is less than 28 weeks, to gain 1 or 2 weeks more, patient would be observed by extremely close monitoring that is done every 2 hourly blood pressure, urine output, general conditions (tachypnea, dyspnea, crepts in chest) monitoring and if necessary, everyday monitoring by investigations like hemogram with platelet count, Liver function test, kidney function test, PT and PTTK

Patient in dangers

1.Patients throwing convulsions2.HELLP syndrome ( 40% mortality)3.Unannounced abruption and IUD4.DIC5.Cardiac complications like pulmonary edema6.Fetal complications like intrauterine growth retardation, absent or reversed

umbilical artery Doppler, intrauterine death, neonatal death. However, neonatal death may occur even after termination of the pregnancy.

How do we manage a patient with eclampsia?

Check vitals Place patient in lateral decubitus position to prevent aspiration. The bed rails should be elevated

to prevent maternal injury. Padded tongue blade should be inserted between teeth to avoid injury to the tongue.

Quick history and examination. Keep airway clean and patent by frequent oral suctioning. Give oxygen by mask at 8-10 litres/minute, if convulsion occurs or pulse oximetry shows hypoxia Prevent convulsions further by keeping silence,dim lights, and minimal noise Give loading dose of magnesium sulphate, 4 gm of 20% solution intravenously slowly over 5

minutes and 5 gm of 50% solution intra- muscularly in each buttock followed by a maintenance dose of 5 gms IM in alternate buttocks every 4 hourly till 24 hours after delivery.

Intravenous labetalol or oral nifedipine to bring down the blood pressure to moderate level.

Pulse oximetry: There is possibility of help from anesthetists if patient is not maintaining oxygen saturation on pulse oximeter

10.After the patient is stabilized, do per vaginum examination and decide termination, preferably vaginal delivery by instilling dinoprostone gel if cervix is too unfavorable or oxytocin augmentation in higher concentration to prevent fluid overload (for primi patients 5 units in 500 ml of Ringer lactate

It should be noted that cesarean section in eclampsia has higher morbidity and mortality than vaginal delivery. However, indications of cesarean in eclampsia sometimes can be, though rarely

(1) obstetric indication like transverse lie, malpresentation, placenta previa, cephalo pelvic disproportion

(2) uncontrolled fits not responding to the anticonvulsants treatment and for termination of pregnancy if there is no immediate prospect of vaginal delivery inspite of induction of labor.

What are the causes of death in eclampsia• Intracranial hemorrhage, cerebrovascular accidents• Pulmonary edema• Status eclampticus• Congestive cardiac failure• Acute renal failure/hepatic failure• Hypertensive encephalopathy• Acute tubular necrosis or cortical necrosis• Disseminated intravascular coagulation (DIC)• Hyperpyrexia due to pontine hemorrhage• ARDS• Aspiration pneumonitis

• All above conditions either singly or in combination.

What is the prognosis of the disease?

The seizure characteristics of eclampsia are acute and transient and long-term neurologic deficits are rare in patients adequately treated. However, 35% of patients who develop eclampsia will have preeclampsia in a subsequent pregnancy. However, recurrence of eclampsia is 1.4%.

• In women with preeclampsia in first pregnancy, the probability of recurrence in second pregnancy is about 30% and is in inverse relation to the gestational age at which the patient developed the disease.

• The incidence of chronic hypertension was significantly increased.

What are the complications expected in this patient: Maternal complications are:

• Super imposed preeclampsia (incidence being 25%)• Development of severe hypertension.Placental abruption Fetal complications are:

• Fetal growth restriction• Preterm delivery and perinatal mortality

• Prone to developmental anomalies due to exposure to fetotoxic drugs like ACE inhibitors in early pregnancy.