Eclampsia

Pregnancy-induced hypertension; Pre-eclampsia; Eclampsia - Acute
Rahul Soman, M. Pharm

 

 

Definition  

Increased blood pressure during pregnancy

 

Medical History  

* Past medical history of Hypertension

* Diabetes mellitus

* Past medical history of Multiparous

* Family history of Gestational hypertension

* High altitude illness [High altitude illness - Acute]

* Thrombophilia

* Smoker

* Obesity

* Asthma [Asthma - Acute]

 

Findings  

* Headache

* Acquired blindness

* Altered mental status

* Blurred vision

* Petechiae

* Retina finding

* Seizure

* Visual field scotoma

* Hypertension

* Nausea and vomiting - Acute

* Abdominal pain - Acute

* Anxiety

* Dyspnea - Acute

* Edema - Acute

* Epigastric pain

* Excessive weight gain

* Oliguria

* Respiratory crackles

* Facial edema

 

Tests  

 

Suspected or known preeclampsia  

* Protein measurement, urine, quantitative 24 hour: Proteinuria greater than or equal to 300 mg/24 hours in the presence of hypertension after 20 weeks of gestation is diagnostic for preeclampsia .

 

Suspected and known preeclampsia  

* Platelet count: A platelet count less than 100,000/mm3 alone or with evidence of microangiopathic hemolytic anemia increases the certainty of a diagnosis of preeclampsia .

* Hepatic function panel: The finding of elevated hepatic enzymes increases the certainty of a preeclampsia diagnosis.

* Bleeding time: Bleeding times are significantly prolonged in women with preeclampsia. This may occur even in the presence of a normal platelet count .

* Creatinine measurement, serum: The finding of an elevated serum creatinine level (>1.2 mg/dL) increases the certainty of a preeclampsia diagnosis .

* Fibrinogen measurement: Fibrinogen level is obtained in preeclampsia when there is a low platelet count or high LDH level or evidence of coagulopathy .

 

Suspected pre-eclampsia  

* Urine dipstick for protein: Urine dipstick for protein should not be utilized as the sole screening tool in the diagnosis of pre-eclampsia .

 

Pre-eclampsia  

* Hematocrit determination: An abnormal hematocrit level supports the diagnosis of preeclampsia and is a marker of disease severity.

 

Suspected pregnancy-induced hypertension  

* Serum uric acid measurement: Uric acid level is a marker of disease severity in pregnancy-induced hypertension and fetal outcome .

 

Suspected preeclampsia  

* D-dimer assay: D-dimer assay is an early screen for coagulation abnormalities in women with a preeclamptic coagulopathy .

 

Patients with preeclampsia or eclampsia and focal neurologic findings or alteration in mental status  

* CT of head: CT is used to rule out intracranial hemorrhage in patients with eclampsia or preeclampsia and focal neurologic signs or an alteration in mental status .

 

Differential Diagnosis  

* Hypertension - Chronic

* Pre-eclampsia

* Eclampsia

* Pre-eclampsia added to pre-existing hypertension

* Gestational hypertension

* HELLP syndrome

* Pancreatitis, acute

* Viral hepatitis

* Hyperemesis gravidarum - Acute

* Necrosis of liver of pregnancy

* Cholecystitis - Acute

* Appendicitis - Acute

* Thrombotic thrombocytopenic purpura - Acute

* Seizure - Acute

* Kidney disease

 

Treatment  

 

Drug Therapy  

 

 

Mild chronic hypertension in pregnancy  

 

METHYLDOPA (Related toxicological information in METHYLDOPA)  

Adults: 250 mg orally 2 to 3 times daily for 48 hours; increase or decrease at intervals of not less than 2 days until desired therapeutic response is achieved; usual maintenance dose 500 to 2 g daily in 2 to 4 divided doses maximum 3 g/day

 

 

Moderate gestational hypertension or mild gestational hypertension with signs of end organ damage  

 

LABETALOL HYDROCHLORIDE  

Adults: 100 mg orally twice daily; increase every 2 to 3 days to a maximum dose of 400 mg twice daily

 

 

Prevention and treatment of seizures in women with severe preeclampsia or eclampsia  

 

MAGNESIUM SULFATE  

Adults: 4 to 6 g magnesium sulfate IV loading dose diluted in 100 mL fluid administered over 15 to 20 minutes, followed by 2 g/hour as a continuous IV infusion

 

 

Severe acute hypertension in pregnancy  

 

LABETALOL HYDROCHLORIDE  

Adults: Initial bolus not to exceed 20 mg IV; if ineffective, incremental repeat doses (40, 80, 80, and 80 mg) every 15 minutes; maximum cumulative dose, 300 mg OR continuous infusion 1 mg/kg

 

HYDRALAZINE HYDROCHLORIDE  

Adults: 5 to 10 mg IV every 15 to 20 minutes to a maximum dose of 30 mg

 

SODIUM NITROPRUSSIDE (Related toxicological information in NITROPRUSSIDE, SODIUM)  

Adults: Initial infusion rate of 0.20 microgram/kg/minute, increased by the same amount every 5 minutes, to a maximum of 4 microgram/kg/minute; to avoid the risk of cyanide accumulation, infusion should be limited to a few hours in a pregnant woman

 

NICARDIPINE HYDROCHLORIDE  

Adults: Initial infusion rate of 5 mg/hr; increase the infusion rate by 2.5 mg/hr every 5 minutes to a maximum of 10 mg/hr or until a 15% reduction in mean arterial pressure is obtained

 

 

Reduction of neonatal complications in women with severe preeclampsia at 34 weeks' gestation or less  

 

BETAMETHASONE  

Adults: 12 mg IM every 24 hours for 2 doses

 

DEXAMETHASONE  

Adults: 6 mg IM every 12 hours for 4 doses

 

Procedural Therapy  

 

Suspected and known preeclampsia  

* Obstetric monitoring: Close fetal monitoring is needed to ascertain signs of fetal distress and to follow the pattern of labor .

 

Hypertension in pregnancy  

* Expectant management: Expectant management can diminish maternal complications, prolong the pregnancy, and improve neonatal outcomes .

 

Severe preeclampsia  

* Delivery procedure: Delivery is the only definitive treatment for preeclampsia.