Critical Care in

Obstetrics:

An Innovative and Integrated Model for Learning the Essentials

Severe Preeclampsia / Eclampsia

COL Shad Deering, MD FACOG

Chair, Department of OB/GYN 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

Outline

§  Learning Objectives

§  Background

§ Management

§  Treatment of Hypertension

§  Summary

§  References

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

Background

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

Hypertension in Pregnancy

§ Preeclampsia / Eclampsia

§ Chronic hypertension (any cause)

§ Chronic hypertension with superimposed preeclampsia

§ Gestational hypertension

Definition – SEVERE 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

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

§  A 40 year-old African American G2P1001 presents to labor and delivery at 34+1 weeks with nausea and right upper quadrant abdominal pain. She denies any vaginal bleeding, rupture of membranes, or contractions. Her prenatal course is complicated by a history of preeclampsia in her previous pregnancy which resulted in induction of labor at 37wks. On physical exam she appears moderately uncomfortable. Her blood pressure is 155/100.

§  Which of the following risk factors has the highest relative risk for the development of preeclampsia?

§  Advanced maternal age

§  Previous history of preeclampsia

§  Chronic hypertension

Case Question

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

§  Preeclampsia & Delivery < 34wks §  H/O Preeclampsia in 2 or more pregnancies

§  Low dose (60-80mg) ASA in first trimester

§  No indication for vitamin C / E

§  Bedrest not indicated

Prevention

US Preventive Services Task Force Recommendations

Management

§  Preterm diagnosis §  Daily movement counts

§  2x/wk blood pressure monitoring

§  Weekly labs

§  Serial US for growth

§  Delivery at 37wks unless indicated earlier

§  Inpatient or Outpatient management?

Mild Preeclampsia

§  The patient continues to complain of RUQ pain accompanied by nausea and a new onset headache. Her blood pressures increase to 170/110 and you treat her with a single dose of 20mg Labetalol IV. Her laboratory evaluation returns and results are:

§  Hgb 11.2 / Hct 33 /Plt 90k,

§  AST 97, ALT 110 / Cr 1.0,

§  Urine protein/creatinine ratio 0.2

§  Based on the laboratory evaluation and symptoms, which of the following is TRUE?

§  The patient does not have preeclampsia as there is not evidence of significant proteinuria

§  The most likely diagnosis for this patient is gestational thrombocytopenia

§  The patient has severe preeclampsia and should be delivered

Case Question

§  Administer Steroids and Expectant Management

§  Administer Steroids and then move to delivery in 48 hours

§  Immediate Delivery

Treatment Options

Key Points – Severe Preeclampsia

§  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

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

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

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

§  Monitor BP for at least 72hrs after delivery and then again 7-10 days postpartum

Delivery Recommendations

ACOG Committee Opinion # 560

§  After you have counseled the patient for delivery, you go back to the work station to write a note.

§  Five minutes later, you are called emergently to the bedside as the patient started having tonic-clonic seizure activity associated with worsening hypertension. There is evidence of recurrent late decelerations on the FHR monitor.

§  What is the most appropriate initial intervention?

§  Administer 6 grams of magnesium sulfate IV over 2 minutes

§  Proceed with emergent cesarean delivery

§  Administer 6 grams of magnesium sulfate IV over 15-20 minutes

§  Administer 5mg diazepam IV

Case Question

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

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)

Treatment of Hypertension

§  During her eclamptic seizure, the patient's blood pressure reading is 180/110.

§  Which is the most appropriate next step to address her severe hypertension?

§  Do not treat for this blood pressure and wait 15 minutes to repeat and determine if medications are necessary

§  Administer 80mg Labetalol IV

§  Administer 10mg Furosemide IV

§  Administer 10mg Hydralazine IV

Case Question

§  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

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

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.

§  Hendersen et al. Low-Dose Aspirin for Prevention of Morbidity and Mortality From Preeclampsia: A Systematic Evidence Review for the U.S. Preventive Services Task Force. Ann Intern Med, 2014;160:695-703.

 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