UBP 6.1 (Short Form): Obstetrics – Preeclampsia/Eclampsia

Question 1

Pre-operative Management:

Are you concerned about her right upper quadrant pain?

(A 26-year-old, 5’6” tall, 280 pound, G1P0 female presents to the obstetric floor in preterm labor with breech twins and complaining of right upper quadrant pain. She is at 35 weeks gestation and the obstetrician wants to perform a cesarean section. VS: HR = 94; R = 18; BP = 168/97 mmHg; T = 37 C.)

Answer 1

I am concerned, because this patient’s blood pressure is consistent with preeclampsia and her right upper quadrant pain may indicate hepatic involvement, a complication associated with severe preeclampsia and HELLP syndrome.

HELLP is as serious condition that may lead to impaired hepatic function, hepatic hematomas, and even hepatic rupture with massive blood loss.

Question 2

Pre-operative Management:

What is HELLP syndrome?

(A 26-year-old, 5’6” tall, 280 pound, G1P0 female presents to the obstetric floor in preterm labor with breech twins and complaining of right upper quadrant pain. She is at 35 weeks gestation and the obstetrician wants to perform a cesarean section. VS: HR = 94; R = 18; BP = 168/97 mmHg; T = 37 C.)

Answer 2

HELLP is a syndrome that may represent a variant of severe preeclampsia and consists of

Hemolysis (microangiopathic hemolytic anemia,

Elevated Liver enzymes (i.e. AST or LDH), and

Low Platelets (<100,000/uL).

HELLP usually presents prior to delivery (70% of the time), but may develop postpartum.

The syndrome is associated with an increased risk of –

• preterm delivery, DIC, acute renal failure, ascites, cerebral edema, placental abruption, pulmonary edema, hepatic bleeding, hepatic failure, retinal detachment, sepsis, stroke, acute respiratory distress syndrome, and maternal and/or fetal death.

Signs and symptoms consistent with HELLP syndrome include:

1. right upper quadrant or epigastric pain,
2. hypertension,
3. headache,
4. nausea and vomiting, and
5. proteinuria (keep in mind that hypertension and proteinuria are not always present).

Clinical management includes:

1. providing magnesium for seizure prophylaxis,
2. administering antihypertensive medications for blood pressure control (i.e. SBP < 160 mmHg; DBP < 105 mmHg),
3. correcting any coagulopathy, and, when time permits,
4. administering corticosteroids to accelerate fetal lung maturity.
5. Definitive treatment, however, requires Delivery of the baby.

Clinical Note:

• For babies at 24-32 weeks gestational age magnesium sulfate is often administered for neuroprotection (reduced rate of cerebral palsy).

Question 3

Pre-operative Management:

The nurse asks you about a preoperative fluid bolus. What will you tell her?

(A 26-year-old, 5’6” tall, 280 pound, G1P0 female presents to the obstetric floor in preterm labor with breech twins and complaining of right upper quadrant pain. She is at 35 weeks gestation and the obstetrician wants to perform a cesarean section. VS: HR = 94; R = 18; BP = 168/97 mmHg; T = 37 C.)

Answer 3

I would tell her that is reasonable to provide a judicial fluid bolus prior to initiating a regional or general anesthetic.

Patients with preeclampsia tend to be hypovolemic with increased SVR, decreased colloid oncotic pressure, and increased vascular permeability.

Decreased colloid oncotic pressure and increased vascular permeability place the patient at risk for cerebral and pulmonary edema especially with overaggressive fluid administration.

However, since preeclampsia is associated with decreased uteroplacental and organ perfusion, the avoidance of hypotension is important.

Question 4

Pre-operative Management:

You determine that she is receiving magnesium sulfate. Why would that be?

(A 26-year-old, 5’6” tall, 280 pound, G1P0 female presents to the obstetric floor in preterm labor with breech twins and complaining of right upper quadrant pain. She is at 35 weeks gestation and the obstetrician wants to perform a cesarean section. VS: HR = 94; R = 18; BP = 168/97 mmHg; T = 37 C.)

Answer 4

Magnesium is utilized in the treatment of preeclampsia primarily for seizure prophylaxis.

However, there may be some beneficial maternal hemodynamic effects such as decreased SVR and increased uteroplacental perfusion.

Despite a high therapeutic index, there are some potential complications associated with magnesium toxicity such as muscle weakness and respiratory and cardiovascular depression.

These complications can be avoided by careful monitoring of the patient for signs of toxicity such as loss of patellar reflexes, visual changes, muscle weakness, and somnolence.