​Kembara Xtra - Medicine - Preeclampsia and Eclampsia

​Kembara Xtra - Medicine - Preeclampsia and Eclampsia 
Preeclampsia is a pregnancy disease that appears after 20 weeks of gestation and is characterized by new-onset proteinuria, hypertension (HTN), and reduced organ function. Reversible by delivery; may go from being minor to life-threatening in hours or days.
Eclampsia: A recent start of grand mal seizures without a history of an underlying neurologic condition Preeclampsia and eclampsia after childbirth often develop within 48 hours of delivery but can develop up to 4 weeks later.
cardiovascular, renal, reproductive, fetoplacental, CNS, hepatic, and pulmonary system(s) impacted Synonym(s): pregnancy toxemia

Prevention Incidence
Every pregnancy has a 5-8% chance of having preeclampsia.
Prevalence
 Predominant age - Younger, primiparous women seem to be more prevalent
- Patients with preeclampsia who are older (>40 years) than patients in their 20s had a 4 times higher incidence of seizures.
Eclampsia happens in between 1.6 and 10 out of every 10,000 deliveries in wealthy nations and between 6 and 157 out of every 10,000 in poor nations.
Eclampsia is a major cause of perinatal mortality and morbidity (2-8% of all pregnancies), with 40% of eclamptic seizures occurring before birth and 16% occurring more than 48 hours after delivery.


Pathophysiology and Etiology 
Preeclampsia's root causes are becoming more apparent.
- Inimplantation of the placenta abnormally - Angiogenic factors
- Genetic propensity
- Immunologic occurrences
Damage to the vascular endothelium and oxidative stress Among the systemic abnormalities in eclampsia are the following: - Vasomotor: widespread vasospasm
- Hematologic: hemoconcentration, coagulopathy, increased blood viscosity, and decreased plasma volume Reduced glomerular filtration rate in the kidneys
- Hepatic: subcapsular hematoma, periportal necrosis, and hepatocellular damage - CNS: cerebral edema, cerebral hemorrhage, and cerebral vasospasm
Genetics
pregnant women at a 2–4 times greater risk of developing preeclampsia

Risk factors include: multifetal pregnancy, systemic lupus erythematosus, nulliparity, age > 40 years, family history of preeclampsia, high body mass index, diabetes, chronic high blood pressure, chronic kidney illness, and in vitro fertilization.
GENERAL PREVENTION Good control of preexisting HTN. Adequate prenatal care. Inadequate prenatal care results in a 7-fold increase in death.
Aspirin (ASA) at low doses (60–80 mg):
- ASA administered early (after 12 weeks' gestational age [GA]) may reduce the risk of preeclampsia, the rate of preterm birth, and the newborn mortality rate in patients at moderate to high risk (1)[B] (see "Risk Factors" previously mentioned).
Some data suggests vitamin C (1,000 mg/day) and vitamin E (400 IU/day) may reduce the risk for preeclampsia, however recent guidelines advise against its usage. Low-dose calcium supplementation has been proven to lessen the risk and severity of preeclampsia in calcium-deficient populations.

Accompanying Conditions 
Preterm delivery, fetal death, premature placentae, placental insufficiency, fetal growth limitation, maternal seizures (eclampsia), maternal pulmonary edema, maternal liver failure, or maternal death

Preeclampsia is diagnosed as follows:
- Heart rate:
 New-onset high blood pressure (BP): systolic blood pressure (SBP) greater than 140 mm Hg or diastolic blood pressure (DBP) less than 90 mm Hg (on two occasions at least 4 hours apart), or greater than 160/110 mm Hg after 20 weeks of pregnancy (within a shorter time period), and either - Proteinuria
Spot protein: creatinine 0.3 - Or, if none of these symptoms have recently appeared and there is no proteinuria: Platelets below 100,000 per liter and liver transaminase levels over normal
 Pulmonary edema Creatinine >1.1 mg/dL or doubling of blood creatinine values
 Visual or cerebral symptoms
- Severe signs of preeclampsia
Platelets 100,000/L, severe, ongoing right upper quadrant (RUQ) or epigastric discomfort, or both, serum creatinine levels that have doubled, or >1.1 mg/dL, and visual problems
 A brand-new headache
Thoracic edema
Eclampsia is diagnosed by the following criteria: - New-onset tonic-clonic, focal, or multifocal seizures - No prior neurological conditions.
HISTORY
Possibly asymptomatic. Rapid excessive weight gain (>5 lb/week; >2.3 kg/week) has been observed in certain cases; more severe cases are accompanied by headache, altered mental status, and visual disruption. A seizure is frequently preceded by headache, visual disruption, and epigastric or RUQ pain.
Seizures can happen once or repeatedly.


clinical assessment 

Preeclampsia without severe symptoms is defined as raised blood pressure of less than 140/90 mm Hg. Severe symptoms are defined as elevated blood pressure of more than 160 mm Hg systolic or 110 mm Hg diastolic.
Eclampsia: tonic-clonic seizure activity (focal or generalized); normal blood pressure, even in response to therapy; does not rule out the possibility of seizures

Multiple Diagnoses 

Chronic HTN: High BP before the 20th week of pregnancy; Chronic HTN with preeclampsia superimposed; Gestational HTN: Increased BP initially noticed after the 20th week, frequently near to term, with no proteinuria and no indication of organ damage. BP must return to normal within 12 weeks after delivery, otherwise it will be classed as chronic HTN.
 Meningitis/encephalitis, epilepsy, brain tumors, burst cerebral aneurysm, and seizures during pregnancy.
However, all pregnant women who experience convulsions should be diagnosed with eclampsia until alternative reasons can be excluded.


Initial test results from the laboratory and imaging
Spot urine testing or urinalyses for protein should be performed routinely in all hypertension patients at every prenatal appointment, but they are not recommended for low-risk, non-hypertensive pregnant women.
 A complete blood count (CBC) that includes platelets, creatinine, serum transaminase levels, and uric acid as a baseline for hypertensive individuals and if preeclampsia is suspected or likely Coagulation profiles: Anomalies point to serious illness.
 Daily fetal movement monitoring by the mother ("kick counts"), or 24-hour urine or spot protein/creatinine ratio if urine protein sinks 1+ on many occasions or if preeclampsia is being considered  US imaging is used to track growth and cord blood flow; proceed as advised based on test results and clinical stability.
Nonstress test (NST) at diagnosis and every two weeks after that until delivery; Biophysical profile (BPP) if NST is nonreactive; US imaging for growth progress every three weeks; amniotic fluid volume at least once weekly; With seizures, CT scan and MRI should be taken into consideration if focal findings persist or if uncharacteristic signs/symptoms are present.

Tests in the Future & Special Considerations

Preeclampsia brought on by HELLP syndrome may be complicated by thrombocytopenia, hepatic dysfunction, renal failure, and disseminated intravascular coagulation.
Interpretation of Tests
CNS: hemorrhage, cerebral edema, hyperemia, localized anemia, and thrombosis. 40% of eclamptic deaths are caused by cerebral abnormalities.

Management 

Preeclampsia without serious symptoms Outpatient treatment
- Maternal: weekly labs (CBC, creatinine, and liver function test [LFT]); daily weights; and daily blood pressure monitoring - Fetal:
Patients are monitored using daily "kick counts"
NST, BPP, and US37-week delivery (labor induction) (2) [C]
 Steroids for a 37-week gestation
 Preeclampsia with serious symptoms: Daily labs; inpatient care; maternal
IV magnesium sulfate (MgSO4) for the prevention of seizures
 Antihypertensive therapy should be dosed appropriately to maintain SBP 160 mm Hg and DBP 110 mm Hg (other sources advise 150/100 mm Hg postpartum). Fetal: Daily US with BPP and continuous heart monitoring
 Monitor fetal development and amniotic fluid levels.
- GA (2) is necessary for definitive management (delivery)[C].
- <23 weeks:
 Make a pregnancy termination offer.
- From weeks 23 through 34:
 Hypertensive drugs
 Assess the condition of the mother and fetus.
Enhancing fetal lung maturity with steroids
Plan to deliver at 34 weeks while receiving prophylactic magnesium sulfate.
Proceed with delivery if there is HELLP syndrome (full or partial), severe oligohydramnios, considerable renal dysfunction, lingering symptoms, fetal growth restriction, the start of labor, or PROM.
- Magnesium sulfate, steroids, and delivery are started at approximately 34 weeks; steroids are advised up to 37 weeks.

Caution In cases of maternal hypertensive crisis, abruptio placentae, uterine rupture, or fetal distress, emergency delivery is advised regardless of GA.
 Seizures: procedures to start delivery as soon as convulsions are under control, correction of hypoxia and acidosis, lowering of blood pressure Betamethasone 12 mg IM daily, divided into two doses, or dexamethasone 6 mg every 12 hours, divided into four doses, if delivery is probable at 37 weeks.

First Line of Mediation
Women with severe preeclampsia should receive seizure prophylaxis.
- Magnesium sulfate: maintenance dose 1 to 2 g/hr IV continuous infusion; loading dose 4 g IV in 200 mL normal saline over 20 to 30 minutes (Recent guidelines imply that it should not always be given for seizure prophylaxis to prevent eclampsia, but the strength of the suggestion is limited by the low quality of the data.)  BP management: Antihypertensives should not be used for modestly increased blood pressure (without severe symptoms).
- Labetalol (IV): 20 mg over 2 minutes, then doses of 20 to 80 mg spaced 20 to 30 minutes apart, titrated to maintain blood pressure of 160/110 mm Hg, with a maximum of 300 mg per 24 hours (contraindicated in asthma, heart disease, congestive heart failure) Hydralazine (IV): 5 to 10 mg over 2 minutes, then 5 to 10 mg IV boluses at 20-minute intervals; titrated to maintain BP 160/110 mm Hg; maximum of 25 mg/24 hr If necessary for a severe range, take 10 mg orally followed by 20 mg in 20 minutes.
Sustained release (PO): 30 to 120 mg/day (used in the postpartum; use with caution because it contains magnesium sulfate, which can cause hypotension and neuromuscular blockade).
Eclampsia and seizures
- 4 to 6 g IV over 15 to 20 minutes, followed by a 1 to 2 g/hr infusion of magnesium sulfate for seizures For recurrent convulsions, more magnesium boluses may be administered; the dosage will depend on the results of the neurologic examination and the patellar reflexes.
Myasthenia gravis, renal insufficiency, and pulmonary edema are contraindications. - Levels between 6 and 8 mEq/mL are regarded as therapeutic, however keep an eye on the clinical condition of:
There are patellar reflexes.
No depression exists in respirations.
There is a 25 mL/hr urine production.
Fluid therapy - Ringer lactated solution with 5% dextrose at 60 to 120 mL/hr, with careful attention to fluid volume status - Calcium gluconate or chloride (1 g, administered slowly IV) may reverse magnesium-induced respiratory depression. - May be given safely, even in the presence of renal insufficiency.


Next Line
Magnesium sulfate has been shown in randomized trials to be more effective and safe than diazepam in the treatment and prevention of eclampsia.
Levetiracetam 500 mg IV or oral may be repeated in 12 hours (dose needs to be adjusted in renal impairment) or Phenobarbital 20 mg/kg infused at 50 mg/min; may repeat with additional 5 to 10 mg/kg after 15 minutes. Diazepam 2 mg/min until resolution or 20 mg given. Lorazepam 1 to 2 mg/min up to total of 10 mg given. Phenytoin 15 to 20 mg/kg at a maximum rate of 50 mg/

Women having a history of preeclampsia should disclose this to the doctors who will be caring for them in later life. Follow-up Without severe features: restricted activity and close monitoring; with severe features: restricted activity, in hospital. It is a strong risk factor for cardiovascular disease.

Diet 
In patients who frequently have intravascular hypovolemia, salt restriction is not advised, and calcium supplements may be suggested for those who consume less than 600 mg of calcium per day.

Preeclampsia may return in up to 40% of subsequent pregnancies in nulliparous women who develop the condition before 30 weeks of pregnancy.
Preeclamptic, multiparous women may be at higher risk for subsequent essential HTN; they also have higher mortality during subsequent pregnancies than do primiparous women. 25% of eclamptic women will have HTN during subsequent pregnancies, but only 5% of these will be severe and only 2% will be eclamptic again.

Complications 
Although many women may experience temporary neurologic impairments, the majority of eclamptic women may not experience long-term consequences.
Preeclampsia history is comparable to conventional cardiovascular disease risk factors. Obesity and smoking should be strictly discouraged for women who have a history of preeclampsia. The presence of additional metabolic syndrome symptoms should also be properly watched.
Death of the mother or the fetus (maternal and/or fetal death)

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