Critical Care in

Obstetrics:

An Innovative and Integrated Model for

Learning the Essentials

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

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

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

Management

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

Treatment of

Hypertension

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.

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