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ECLAMPSIA

Preeclampsia
 Preeclampsia is a more severe
disease of pregnancy that includes a
triad of hypertension, edema, and
proteinuria. It includes a syndrome
of underperfused organs secondary
to vasospasm and endothelial
activation and is most common in
primigravidas. Preeclampsia occurs
in up to 5% of pregnancies.

Preeclampsia/eclampsia
affects women of all ages, but the
frequency is increased in
nulliparous women younger than
20 years. Women older than 40
years with preeclampsia have 4
times the incidence of seizures
compared to women in their third
decade of life.

Preeclampsia/eclampsia
creates a functional derangement
of multiple organ systems, such
as the central nervous system and
the hematologic, hepatic, renal,
and cardiovascular systems.

Symptoms include
 epigastric or right upper quadrant
pain. This pain may be secondary to
hepatic ischemia and edema leading to
stretching of the Glisson capsule.
 Proteinuria is an important sign and is
defined as greater than 300 mg of
protein in a 24-hour urine collection
 Additional laboratory data:
thrombocytopenia, likely secondary to
platelet activation and aggregation in
the microvasculature.
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Symptoms include
anemia may be present in more severe
disease, thus indicating microangiopathic
hemolytic anemia.
With regard to the kidneys, a decrease in
the GFR occurs secondary to intrarenal
vasospasm. Acute renal failure (ARF) may
develop, and acute tubular necrosis (ATN)
may ensue if this hypoperfusion persists.
HELLP syndrome (Hemolysis, ELevated
liver enzymes, and Low Platelets) is
observed when severe preeclampsia or
eclampsia is accompanied by significant
liver involvement.
 risk factors are associated with
the development of
preeclampsia:
 Age older than 35 years
 Age less than 16 years
 First pregnancy
 Multiple pregnancies
 History of chronic hypertension
 Obesity
 African American race

Eclampsia is defined as seizure
activity or coma unrelated to other
cerebral conditions in an obstetrical
patient with preeclampsia. While
most cases present in the third
trimester of pregnancy or within the
first 48 hours following delivery, rare
cases have been reported prior to 20
weeks' gestation or as late as 23 days
postpartum. Eclampsia has also been
described without prior development
of preeclampsia.

Pathophysiology:

Placenta and fetal membranes play a role in
the development of preeclampsia because
of the prompt resolution of the disease
following delivery. A common pathway
thought to be associated with the
development of preeclampsia is uteroplacental ischemia. Uteroplacental ischemia
is postulated to predispose to the
production and release of biochemical
mediators that enter the maternal
circulation, causing widespread endothelial
dysfunction and generalized arteriolar
constriction and vasospasm.
Signs and symptoms:
tonic-clonic seizure activity (focal or
generalized).
Headache (82.5%)
Hyperactive reflexes (80%)
Marked proteinuria (52%)
Generalized edema (49%)
Visual disturbances (44.4%)
Right upper quadrant pain or
epigastric pain (19%)
Physical:
Eclamptic seizure
The patient may have 1 or more
seizures.
Seizures generally last 60-75 seconds.
The patient's face initially may become
distorted, with protrusion of the eyes.
The patient may begin foaming at the
mouth.
Respiration ceases for the duration of
the seizure.
The seizure may be divided
into 2 phases:

Phase 1 lasts 15-20 seconds and begins
with facial twitching. The body becomes
rigid, leading to generalized muscular
contractions.
Phase 2 lasts approximately 60 seconds.
It starts in the jaw, moves to the
muscles of the face and eyelids, and
then spreads throughout the body. The
muscles begin alternating between
contracting and relaxing in rapid
sequence.

A coma or a period of
unconsciousness follows phase 2.
Unconsciousness lasts for a
variable period.
Following the coma phase, the
patient may regain some
consciousness.
The patient may become
combative and very agitated.
The patient has no recollection of
the seizure.

A period of hyperventilation
occurs after the tonic-clonic
seizure. This compensates for
the respiratory and lactic
acidosis that develops during
the apneic phase.
Seizure-induced complications
may include tongue biting,
head trauma, broken bones, or
aspiration.

Lab Studies:
Complete blood cell count
Platelet count
Twenty-four–hour urine for
protein/creatinine
GFR
Electrolytes
Liver function tests
Uric acid
Serum glucose
 The most common hematologic
abnormality in obstetric disorders is
thrombocytopenia, occurring in 17%
of patients with eclampsia.
Disseminated intravascular
coagulation (DIC) appears to be
uncommon in patients with eclampsia.
Decreased glomerular filtration rate
Decreased renal plasma flow
Decreased uric acid clearance

Imaging Studies:
CT scan of the head:cerebral
edema,hemorrhage, infarction
Magnetic resonance imaging
Angiography
EEG and cerebral spinal fluid
studies rarely are useful
Medical care:
Diet:
Patients with eclampsia should have nothing
by mouth until medically stabilized.
During a seizure, maintaining the patient's
airway and being careful to help avoid
aspiration of stomach contents is important.
Activity:
Strict bedrest
Left lateral hip roll to help improve uterine
blood flow to the fetus
Medical care:
Initial management: As with any seizure, the
initial management is to clear the airway and
administer adequate oxygenation.
Control of the seizure: A syringe containing 24 g of magnesium sulfate intramuscularly or
intravenously should be the only
anticonvulsant at the bedside.
Hypertension control: Record blood pressure
every 10 minutes. Control blood pressure
(diastolic 90-100 mm Hg) with administration
of antihypertensive medications (ie,
hydralazine, labetalol).
Medical care:
Monitoring: Carefully monitor the neurologic
status, urine output, respirations, and fetal
status for all patients. An indwelling Foley
catheter should be placed in the bladder to
help collect and record urine output.
Invasive monitoring: Pulmonary artery
pressure monitoring may be necessary for
accurate fluid management in eclamptic
patients. This is particularly important in
patients who have evidence of pulmonary
edema or oliguria/anuria.
Induction of labor may be initiated when the
patient is stable.
NEPHROTIC CRISIS
Hypovolemia occurs when
hypoalbuminemia decreases
the plasma oncotic pressure,
resulting in a loss of plasma
water into the interstitium
and causing a decrease in
circulating blood volume.
Hypovolemia is generally
observed only when the
patient's serum albumin level
is less than 1.5 g/dL.
Symptoms include
 vomiting
 abdominal pain
 diarrhea.
The signs include
cold hands and feet
delayed capillary filling
oliguria
tachycardia
нypotension is a late feature