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Severe Preeclampsia/ Eclampsia
LTC Shad Deering, MD FACOG
Assistant Dean for Simulation Education
Uniformed Services University of the Health Sciences
Disclaimer
The remarks made today are not representative of
the official views of the US Army or US Government
No financial disclosures
Learning Objectives
Understand the risk factors for severe
preeclampsia and eclampsia
Describe the key treatments for control of
severe preeclampsia
Be familiar with current recommendations for
treatment and monitoring after eclampsia
Definition - Preeclampsia
SBP ≥ 160 / DBP ≥ 110 on two occasions at least
4hrs apart
Thrombocytopenia (< 100,000)
Impaired liver function (ALT/AST > 2x normal range)
Severe persistent RUQ/Epigastric pain unresponsive to
medication and not accounted for by alternative Dx
Progressive renal insufficiency to > 1.1 or a doubling
of serum creatinine in the absence of other renal
disease
Pulmonary edema
New onset cerebral edema or visual disturbances
Seizures / generalized convulsions and/or
coma in the setting of preeclampsia and
absence of other neurologic conditions
Definition - Eclampsia
Key Points
Many recent changes in the diagnostic
criteria for severe preeclampsia
“New onset hypertension can fulfill the
diagnosis of preeclampsia even in the
absence of proteinuria”
HTN workgroup 2013
Incidence
Severe preeclampsia
Approximately 1% of all pregnancies
Eclampsia
0 – 0.6% of women with mild preeclampsia
2-3% of women with severe preeclampsia (without seizure
prophylaxis)
1.6-10 cases per 10,000 deliveries in developed countries
6-157 cases per 10,000 deliveries in developing countries
Norwitz, 2013
Risk Factors
Previous history of pre-
eclampsia (RR 7.19)
Antiphospholipid
antibodies (RR 9.72)
Pre-existing diabetes (RR
3.56)
Twin pregnancy
(RR 2.93)
Nulliparity (RR 2.91)
Family history of
preeclampsia (RR
2.90)
Obesity (RR 2.47)
Maternal age ≥ 40
(RR 1.96)
Chronic hypertension
(RR 1.38)
Duckitt, 2005
Complications
Preterm delivery / Issues related
to prematurity
Placental abruption
Maternal stroke
Acute renal failure
Maternal/Fetal death
Key Points
If delivery can safely be delayed for the
administration of steroids, then expectant
management for at least 48 hours may be considered
Inpatient management required
Seizure prophylaxis with magnesium sulfate until delivery
decision made
Up to 40% of patients with severe preeclampsia at
less than 34wks gestation may be candidates for
expectant management
Eclampsia is a contraindication to expectant
management, regardless of gestational age
Magee 2009
Expectant Management
Maternal hemodynamic
instability
Non-reassuring fetal testing
(abnormal
dopplers/oligohydramnios)
Severe hypertension
unresponsive to medical Rx
Severe headache/Visual
disturbances
Eclampsia
Pulmonary edema
Renal failure
Placental abruption
HELLP
PPROM
Diagnosis prior to
viability
Gestational age
>34+0 weeks
Contraindications
Hospitalize until delivery
May discontinue Magnesium Sulfate after 48
hours and steroid course complete
Monitor blood pressure every 4 hours
Monitor & record fluid intake/output
Frequently assess maternal symptoms
HA/visual changes/epigastric pain
Expectant Management
Preeclampsia labs at least 2x/week
CBC/AST/ALT/Creatinine/Electrolytes
Fetal assessment
Daily NST
AFI 2x/week
Dopplers at least weekly if IUGR
Consult neonatology/ anesthesiology
Expectant Management
Delivery
Induction is reasonable if
Favorable cervix (regardless of GA)
Gestational age of at least 32 weeks
(Seal, 2012)
Delivery must be accomplished, but is NOT
emergent after eclamptic seizure unless:
non-reassuring fetal status after recovery from
seizure
other concerns, such as abruption
Delay Delivery for 48 hours At 33+6 weeks or less, administer corticosteroids and DELAY
DELIVERY for 48 hours if mother/fetus stable and any of the
following present:
PPROM
Preterm labor
Low platelet count (< 100k)
Persistently elevated hepatic enzymes >2x normal
Fetal growth restriction < 5%
Severe oligohydramnios (AFI < 5)
Reversed end-diastolic flow of umbilical arteries
New onset renal dysfunction
HTN workgroup – 2013
Quality of evidence : Moderate
Strength of recommendation: Qualified
Immediate Delivery At 33+6 weeks or less, administer corticosteroids but
DO NOT DELAY delivery if any of the following present
Uncontrollable severe hypertension
Eclampsia
Pulmonary edema
Placental abruption
Disseminated intravascular coagulation
Non-reassuring fetal status
Intrapartum fetal demise
HTN workgroup – 2013
Quality of evidence : Moderate
Strength of recommendation: Strong
Eclampsia Checklist Clearly communicate diagnosis to team members
Position patient
Left lateral decubitus
Raise bed rails/keep patient in safe position
Call for additional assistance
Physician/Nursing/Anesthesia/Pediatrics
Maternal Care
Provide O2 by facemask
Obtain IV access
Treat severe hypertension (> 160/110) with IV medication
Fetal Care
Continuous toco/FHRT (expect decels)
Magnesium Sulfate
6 grams IV over 15-20 minutes OR 10 grams IM (5 gram in each buttock)
Timing of Eclampsia
Antepartum (38-55%)
Intrapartum (36%)
Postpartum
< 48 hours = 5-39%
> 48 hours = 5-17%
Norwitz, 2013
Eclampsia - Notes
The seizure may last up to 4 minutes
The FHRT will demonstrate significant decelerations
Continue to monitor and consider urgent delivery if
no resolution approximately 10 minutes AFTER the
seizure
Treatment with magnesium sulfate afterwards prevents
recurrent seizures and decreases maternal mortality
Treat hypertension aggressively as 15-20% of death
from eclampsia related to strokes
Norwitz 2013
Intrapartum/Postpartum Magnesium sulfate seizure prophylaxis after
diagnosis and for at least 24 hours after
delivery
Continue intraoperative administration if
cesarean section performed
Continue to monitor blood pressure and treat
severe range hypertension
Monitor laboratory abnormalities
Ensure diuresis and watch for evidence
magnesium toxicity
Urgent treatment for
Severe systolic (>= 160mmHg) or diastolic (>=
110 mmHg)
Untreated severe HTN places patient at
significant risk for
Cerebral hemorrhage
Maternal death
IV Labetalol or Hydralazine are first line
treatment
ACOG Committee Opinion #514
Anti-hypertensive Therapy
Anti-hypertensive Therapy
LABETALOL
20mg IV over 2 minutes
10 minutes (BP √)
40mg IV over 2 minutes
10 minutes (BP √)
80mg IV over 2 minutes
10 minutes (BP √)
Switch to Hydralazine if still >
160/110
HYDRALAZINE
5-10mg IV over 2 minutes
20 minutes (BP √)
10mg IV over 2 minutes
20 minutes (BP √)
Change to Labetalol if still >
160/110
Summary
Severe preeclampsia affects multiple symptoms and
is a progressive disease
Eclampsia is an uncommon but serious obstetric
emergency that requires prompt intervention to
ensure optimal outcomes
New guidelines for evaluation and treatment of
hypertension in pregnancy are important to
understand and put into practice
Diagnosis of severe preeclampsia no longer requires
evidence of proteinuria
Summary
Pay attention to severe range hypertension
and treat early
Monitor closely for development of
magnesium toxicity, especially in the
presence of renal insufficiency
Prompt treatment of hypertension is critical
Remember severe preeclampsia/eclampsia
can also occur after delivery
Evidence Hypertension in Pregnancy: Report of the American College of Obstetricians
and Gynecologists’ Task Force on Hypertension in Pregnancy. Obstet
Gynecol, Nov 2013; 122(5):1122-1131. (Levels of evidence vary, noted in
slides)
Magnesium Sulfate Use in Obstetrics. ACOG Committee Opinion #573, Sept
2013.
Emergent Therapy for Acute-Onset, Severe Hypertension with Preeclampsia or
Eclampsia. ACOG Committee Opinion #514, Dec 2011. (Level III)
Repke JT. What is new in preeclampsia? Best articles from the past year.
Sibai BM. Etiology and treatment of postpartum hypertension-preeclampsia.
AJOG, June 2012, 470-475. (Level III)
Seal SL, Ghosh D, Kamilya G, et al. Does rout of delivery affect maternal
and perinatal outcome in women with eclampsia? A randomized controlled
pilot study. Am J Obstet Gynecol 2012; 206:484.e1. (Level I – though
limited by sample size)
Evidence Zhang J, Meikle S, Trumble A. Severe maternal morbidity associated with
hypertensive disorders in pregnancy in the United States. Hypertension
Pregnancy 2003; 22:203.
Norwitz ER. Eclampsia. UpToDate, Aug 29, 2013.
Magee LA, Yong PJ, Espinosa V, et al. Expectant management of severe
preeclampsia remote from term: a structured systematic review. Hypertens
Preg 2009; 28:213.
Sibai B. Etiology and management of postpartum hypertension -
preeclampsia. AJOG 2012; 206(6):470-475.
Publications Committee, SMFM, Sibai BM. Evaluation and management of
severe preeclampsia before 34 weeks’ gestation. Am J Obstet Gynecol
2001; 205:191-198. (Levels I, II, and III)
Duckitt K, Harrnington D. Risk factors for pre-eclampsia at antenatal
booking: systematic review of controlled studies. BMJ 2005;330:565.
Thank You for Your Attention!
Planning Committee
Mike Foley, Director Shad Deering, co-Director
Helen Feltovich, co-Director Bill Goodnight, co-Director
Loralei Thornburg, Content co-Chair Deirdre Lyell, Content co-Chair
Suneet Chauhan, Testing Chair Mary d’Alton
Daniel O’Keeffe Andrew Satin
Barbara Shaw