PREECLAMPSIA / ECLAMPSIA

Question 1

Considerations for the Critically Unstable Pre-Eclampsia

Answer 1

Maternal Resuscitation takes precedence

Place patient in LATERAL TILT POSITION or manually displace the uterus to the left

If systolic BP ≥160 mm Hg or diastolic BP ≥110 mm Hg:
Labetalol 20 mg IV
or
Hydralazine 5-10 mg IV or
Immediate-release nifedipine 10-20 mg PO
AND
Start magnesium sulfate for seizure prophylaxis:
4-6 g IV given over 10-20 minutes followed by continuous infusion of 2 g/h.
If the patient seizes, give an additional 2 g IV bolus
Assess Fetal Heart Rate

Immediately notify Obstetrics or Neonatology / Pediatrics

Definitive Treatment for the unstable patient is Delivery

Question 2

Clinical Features / Diagnostic Criteria of Preeclampsia

Answer 2

Diagnostic Criteria:

BP ≥140 mm Hg or diastolic BP ≥90 mm Hg on at least 2 occasions at least 4 hours apart after 20 weeks GA with a previously normal blood pressurewarrants further investigation in the ED

SBP ≥160 or DBP ≥110 mm Hg must be controlled quickly to reduce the risk of stroke

AND

Proteinuria:

≥300 mg/24-h urine specimen
Protein:creatinine ratio of 0.3 mg/dL
Dipstick reading of ≥2+ (used only if other methods of detecting proteinuria unavailable)

OR

Signs / Symptoms of end-organ dysfunction:

Thrombocytopenia (platelet count <100,000/mm3)

Renal insufficiency (serum creatinine >1.1 mg/dL or a doubling of serum creatinine in the absence of other renal disease)

Impaired liver function
(serum transaminase 2 times normal) not explained by alternative diagnoses

Pulmonary edema

New-onset headache (not improved with acetaminphen)

Visual disturbances

Persistent right upper quadrant/epigastric pain not controlled by medications*

Can occur before, during or after labour and up to 6 weeks post partum

Question 3

Clinical Features of Eclampsia

Answer 3

Pre-eclampsia + seizures

Question 4

Investigations

Answer 4

CBC: evaluate thrombocytopenia

Serum Creatinine: evaluate renal dysfunction

LFT’s (LDH, AST, ALT): evaluate liver dysfunction

Urine Protein or protein:creatinine Ratio

Question 5

Management

Answer 5

BLOOD PRESSURE CONTROL:
If systolic BP ≥160 mm Hg or diastolic BP ≥110 mm Hg:
Labetalol 20 mg IV
or
Hydralazine 5-10 mg IV or
Immediate-release nifedipine 10-20 mg PO

IF ADDITIONAL DOSES NEEDED:
Labetalol: 10-20 mg IV, then 20-80 mg every 10-30 minutes. Max Cumulative dose 300 mg;
Infusion of 1-2 mg/min IV.
Avoid in asthma, heart disease, heart block, and bradycardia.

Hydralazine: 5 mg IV or IM, then 5-10 mg IV every 20-40 minutes with maximum cumulative dose of 20 mg;
Infusion of 0.5-10 mg/h.
Nifedipine (immediate release): 10-20 mg orally, repeat in 20 minutes if needed, followed by 10-20 mg every 2-6 hours; Maximum dose in 24 h is 180 mg.
Aim to stabilize BP ≤160/90 mm Hg

SEIZURE PROPHYLAXIS:
magnesium sulfate
4-6 g IV given over 10-20 minutes
THEN
continuous infusion of 2 g/h.

If the patient seizes, give an additional 2 g IV bolus

Mild Renal Insufficiency or oliguria (<30 ml / hr over 4 hrs): 4-6 g IV over 10-20 min
THEN
maintenance dose of 1 g/h.

Monitor for Magnesium Toxicity

Consults Obstetrics

Consult Pediatrics

definitive treatment is delivery.

Question 6

Monitoring for Magnesium Complications & Antidote

Answer 6

Loss of patellar reflexes

Calcium gluconate 10% 1.5-3 g (1.5-30 mL) IV is the treatment of symptomatic hypermagnesemia

Respirations <12/min
Urine output <100 mL over 4 hours

Respiratory Depression:
calcium gluconate 10% solution, 10 mL IV over 3 minutes, along with furosemide to increase excretion.