XIII. Ulusal Perinatoloji Kongresi 13-16 Nisan 2011, ‹stanbul Perinatoloji Dergisi 2011;19(Suppl 1): S63-S70 e-Adres: http://www.perinataldergi.com/20110191122 Eclampsia Management: Our Experience Dr Girija Wagh, MD FICOG Dip in Endoscopy Professor and Head, OBGYN, Bharati Vidyapeeth University Medical College, Pune, India Introduction are complicated by PIH and therefore we need to have a high index of suspicion. As a country the biggest challenge faced today by us obstetricians is the maternal mortality and mor- • By definition Eclampsia is defined as the occur- bidity. Also what we encounter as the most challeng- rence of one or more convulsions superim- ing disorder is preeclampsia and eclampsia. As said posed on pre-eclampsia. when we do not know the makers of PIH what can • Preeclampsia is pregnancy-induced hyperten- we know about the markers? Truly we donot know sion in association with proteinuria (> 0.3 g in why PIH occurs and lifetimes have gone by in burst- 24 hours) ± edema and virtually any organ sys- ing this mystery. tem may be affected Preeclampsia and eclampsia are obstetric dis- We also know that there are four major types of eases, and obstetricians are the group best equipped hypertensive disorders during pregnancy. And we to diagnose, evaluate and manage them. Today as a need to classify them.It is important that we do so as clinician however we need to tackle what we have that helps in better prognostication and treatment from the experiences gathered and try to deliver the planning. best to our patients.We should not falter there and 1. Chronic hypertension should try to deliver the best.From making the diag- 2. Preeclampsia eclampsia syndrome nosis to treating atypical eclampsia, management of preeclampsia involves serious, often unpredictable 3. Superimposed preeclampsia challenges. In this article, we highlight several chal- 4. Gestational hypertension lenges that obstetricians face when managing Attempts should be made to establish these diag- preeclampsia and eclampsia, and offer useful strate- noses antenatally, intranatally, postnatally and in sub- gies to help minimize morbidity and mortality in sequent pregnancy both mother and infant. Although severe preeclampsia represents only a Optimum Antenatal Care is a Must fraction of those amounts, and eclampsia an even Early and adequate prenatal care cannot me more lower percentage, they are potentially catastrophic emphasized ! Although the diagnostic criteria for complications of pregnancy and one of the leading preeclampsia have been widely established – persis- causes of maternal death. They also are responsible tent BP elevation above 140/90mmHg and protein- for a large percentage of infants born prematurely as uria exceeding 300mg over a 24hr collection period- a result of a worsening maternal or fetal condition. the condition does not always play by the rules. With The National Eclampsia Registry interim statistics close monitoring of weight, urine protein, and BP, reveals that the incidence of hypertensive diseases the clinician can identify and follow the patient and during pregnancy to be quite high with quite a sub- detect a condition much early stantial incidence of eclampsia. These are actually Risk Factors for Preeclampsia: cases reported by the FOGSI members. There can be • Chronic hypertension quite some more which are being treated by periph- eral health workers and the incidence can actually be • Chronic renal disease higher.What we know for sure is 1in 10 pregnancies • Connective tissue disease 64 Wagh G, Eclampsia Management: Our Experience • Current foetal growth restriction fulfilled, along with one or more of the findings list- • Gestational hypertension in the current preg- ed below: nancy • Persistent blood pressure above 160/110 • History of prior preeclampsia mmHg • Insulin dependent diabetes • Proteinuria • Refractory oliguria (<500cc over 24 hours) • Multiple gestation • Renal failure (minimal criterion would be a rise • Nulliparity in serum creatinine of 1mg/dl above baseline) • Obesity • Persistent right upper quadrant or epigastric • Thrombophilia. pain or both It is important to diagnose it early: • Persistent headache Early identification of preeclampsia may allow • Scotomata/blurred vision for interventions, including delivery, that will lessen • Shortness of breath with reduced oxygen satu- the risk of progression to severe preeclampsia and ration or pulmonary edema eclampsia and reduce foetal and maternal morbidity • Thrombocytopenia (platelets <100,000 / and mortality. It is, therefore, essential for the clini- cu.mm) cian to ask specifically about signs and symptoms of • Hemolysis (based on peripheral smear analysis preeclampsia and to listen carefully to the answers. or increased Bilirubin) Signs and symptoms may sometimes be typical: • Impaired liver function of unclear etiology • Eclampsia • Weight gain • Estimated foetal weight below 5th percentile • Increasing edema for gestational age • Persistent headache • Blurred vision Prediction • Malaise Attempts to predict preeclampsia have met with poor results. Measurement of the ratio of uterine • Nausea artery systolic to diastolic flow has not been informa- • Epigastric discomfort tive in the general healthy population of pregnant • Right upper quadrant discomfort. women. Nor has uric acid determination been useful; Although a number of tests have been proposed it generally has very poor predictive value and to predict who may be at greatest risk for preeclamp- should be interpreted with caution. sia, none have risen to the level that they can be rec- ommended for general population screening. When to Hospitalize? Mild preeclampsia can be managed expectantly Diagnostic Criteria until foetal maturity or 37weeks of gestation.But hos- The diagnosis of preeclampsia is based on persis- pitalization can be offered in the Indian context. This tent BP elevation above 140/90 mmHg and protein- offers an opportunity to investigate the patient prop- uria exceeding 300 mg over a 24-hour collection peri- erly,monitor the urine output, BP and the fetal con- od. Other criteria have been applied, such as rise in dition through USG and Doppler if necessary.Also systolic or diastolic BP above baseline and urine dip- the patient can be offered dietary advice and the cor- stick criteria for proteinuria, but BP above rect categorization after her BP has been monitored 140/90mmHg and proteinuria above 300mg are round the clock.But any serious presentations such most frequently used in medical centres Gestational as severe edema, ascites, high BP, severe proteinuria, hypertension and chronic hypertension do some- headache, pain, sever IUGR,convulsions etc demand times coexist with superimposed preeclampsia, but a hospital care. should not be confused with preeclampsia or lead to Assessment: management decisions that should apply only to patients with preeclampsia. Initial evaluation consists of: Before severe preeclampsia can be diagnosed, • Foetal non stress testing the initial criteria for preeclampsia should have been • Amniotic fluid index Perinatoloji Dergisi 2011;19(Suppl 1): S63-S70 65 • Serial BP determination cated and should be administered in a timely fashion. • 24-hour urine collection( if dipstick proteinuria Labetalol, nifedipine have been used effectively is negative ) in such acute settings, when administered parenter- • Initial laboratory evaluation comprising of a ally (except nifedipine, which can be given orally complete blood count with platelets and aspar- and should never be given sublingually) and when tate amino transferase (AST), alanine amino given in proper dosage. transferase (ALT), and creatinine levels and Pharmacotherapy of acute hypertension: LDH levels The tests should be directed to assess the mater- Table 1. Pharmacotherapy of acute hypertension. nal conditions as Preeclampsia is a multisystemic dis- order. Constant vigilance should be undertaken to Drug Dosage Directions prevent eclampsia as far as is possible and to diag- nose HELLP early. There is a tendency to prolong the Labetalol 10-20 mgIV push Repeat every 10-20mins, doubling pregnancy as much as possible to be able to achieve the dosage each time until a salvagibility in the fetus.But one needs to weigh the maximum total cumulative dosage risk to the mothers system such a prolongation could of 300mg has been given. cause. Also LDH levels above 600 have proved to be Nifedipine 10 mg Repeat in 20mins for four doses a better parameter to guide a clinician regarding the (maximum 40mg); then give presence of hemolysis. This can help one guide 10-20 mg orally (never sublingually) regarding the intervention and rising LDH levels every 4-6h to achieve a stable BP of would help this decision.While interpreting renal 140-150/90-100 mmHg. parameters in Pregnancy one should muster care as these parameters are already reduced in a normal pregnancy due to increased GFR and hemodilution Preventing Seizures Additional tests may be ordered as indicated but Magnesium sulfate is the drug of choice to pre- are of limited value in making management deci- vent both initial and recurrent eclamptic seizures. sions. If foetal and maternal evaluations are reassur- Two large clinical trials ended any doubts about its ing, and if the patient has remained stable, then out- efficacy, demonstrating its superiority over both patient management may be considered. In general, phenytoin and diazepam in the settings of if proteinuria exceeds one gram in 24 hours, in-hos- preeclampsia and eclampsia. pital management is