Pre-eclampsia and Eclampsia

DEFINITIONS

  • multisystem disorder of pregnancy characterised by hypertension and organ system derangement.
  • defective trophoblast invasion of the spiral arteries and abnormal trophoblast differentiation.

Pre-eclampsia – hypertension occurring after 20 weeks gestation and resolving within 3 months of delivery with the following specific features:

  • SBP > 140mmHg or DBP > 90mmHg

+ one or more of

  • proteinuria (>0.3g/24hrs)
  • renal impairment – proteinuria, high Cr
  • liver disease – epigastric pain, liver tenderness, elevated transaminases
  • neurological problems – seizures, visual disturbance, papilloedema, clonus
  • haematological disturbance – thrombocytopaenia, haemolysis, DIC
  • fetal growth restriction – non reassuring CTG, reverse flow on Doppler, IUGR
  • severe if SBP >160 or DBP >110 or severe organ dysfunction

Gestational Hypertension – occurs during pregnancy but not associated with other signs of PET

Pre-existing Hypertension – HT that existed before pregnancy

Eclampsia – a seizure in a patient with PET

HISTORY

  • asymptomatic
  • headaches
  • RUQ pain
  • cortical blindness
  • transient scotomata
  • SOB

RISK FACTORS

  • PET during another pregnancy
  • advanced maternal age
  • multiple pregnancy
  • high BMI
  • conception before age 20
  • connective tissue disorders
  • protein C and S deficiencies
  • factor V leiden mutation
  • hyperhomocysteinemia

EXAMINATION

  • BP >140/90
  • hyperreflexic
  • agitated
  • epigastric or RUQ pain
  • pulmonary oedema
  • oliguria

INVESTIGATIONS

  • proteinuria > 2g in 24 hrs
  • elevated creatinine
  • transaminitis
  • elevated bilirubin
  • thrombocytopaenia
  • deranged coagulation
  • haemolysis
  • high urate
  • hypocalaemia
  • PT and APTT normal (unless has abruption or severe hepatic involvement)

MANAGEMENT

Aims

1. management of HT
2. delivery of baby and placenta
3. prevention of eclampsia

  • position patient in left lateral tilt
  • intermittent -> continuous monitoring of baby
  • MDT input (obstetrician, neonatologist, midwife)
  • reduce BP to <140/90 – aggressively treat if >160/110 (decrease by 10-20mmHg every 20min)
  • antihypertensives;
    1. methyldopa PO 0.5-3g/day
    2. labetalol IV 5-10mg injected slowly
    3. nifedipine PO 10-20mg or IV 100-200mg over 2 min
    4. beta-blockers (metoprolol, pindolol, propanolol, esmolol)
    5. hydralazine IV 10-20mg slowly
    6. GTN IV 0.1-0.8mcg/kg/min
    7. SNP IV 1-4mcg/kg/min
  • load with MgSO4 (5g over 5min -> 1g/hr, monitor for toxicity – drowsiness, loss of patella reflexes, respiratory depression, loss of consciousness -> treatment = stop infusion and 10mL calcium gluconate 10%)
  • cautious IV fluids (high risk of APO)
  • platelet count needs coagulation screen
  • epidurals good if no contraindications
  • if decision to move to C/S standard care

Intraoperative/labour Management

  • single shot spinal, CSE and epidural have all been employed
  • hypotension less common
  • GA; abate hypertensive response to intubation (1mg alfentanil), monitor for APO @ emergence
  • use arterial line
  • avoid syntometrine and ergometrine -> acute hypertension

Postoperative/delivery Management

  • continue antihypertensives
  • continue MgSO4
  • NSAIDs if not contraindicated
  • thromboprophylaxis
  • manage APO in standard manner (LMNOP)

CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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