Headache, Blurred Vision, Convulsions, Loss of Consciousness or Elevated Blood Pressure |
Pre-eclampsia and eclampsia are serious condition that must be promptly identified and treated.
Eclampsia can happen with normal blood pressure in 20% of women.
According to ACOG Bulletin #219, an increase in systolic blood pressure of 30 mm or increase in diastolic blood pressure of 15 mm is no longer valid because:
In one study, 74% primigravids with normotensive pregnancies had an increase diastolic blood pressure of greater than 15 mm Hg at some stage in pregnancy and 57% had an increase of more than 20 mm. This was confirmed in a second study also (Villar and Sibai 1989).
Edema is no longer included in the definition, as if it is absent, but the other two diagnostic criteria are present, we would still call the patient pre-eclamptic.
Signs/symptoms due to vasospasm and/or leaky capillaries
End-organ changes:
Central nervous system
Pulmonary
Renal
No significant different by age, nulliparity, multiple gestation, diabetes.
Only difference is by gestational age. This suggests women who develop high blood pressure early are more likely to develop pre-eclampsia.
The earlier that hypertension was diagnosed, the more likely pre-eclampsia was diagnosed. (Alternatively, the later in gestation that hypertension developed, the less likely a woman would develop pre-eclampsia than one who develop hypertension earlier). There was no significant difference between the women who developed pre-eclampsia in terms of age, parity, gestational age, diastolic blood pressure or history of diabetes.
The only significant different in the groups of women who developed pre-eclampsia and those who did not is gestational age of the baby. This mean that those women who developed hypertension early were more likely to develop pre-eclampsia.
Identifying hypertension and pre-eclampsia early and treating it can help reduce the risk of eclampsia.
However, Moutquin looked at blood pressure at all gestational ages.
From 9-28 weeks gestation, a systolic blood pressure of 130 mm Hg or a diastolic blood pressure of 80 mm Hg was not sensitive or predictive or developing pre-eclampsia later. Rising blood pressure (gestational hypertension) cannot be used to predict pre-eclampsia.
Low sensitivity and positive predictive value at all gestational ages to predict pre-eclampsia.
Blood pressure, however, is not a good predictor of pre-eclampsia. At all gestational ages, blood pressure has a low sensitivity and specificity to predict pre-eclampsia.
Many researchers have tried to predict who will get eclampsia. Only a small portion of women who do have eclamptic fits had elevated diastolic blood pressure or elevated mean arterial pressure in the second trimester of pregnancy. We cannot, therefore, predict who will get eclampsia.
When a patient seizes, it is important to ensure that the airway is clear, oxygen is being delivered to the tissues and the patient cannot harm herself.
Treatment includes antihypertensives and anticonvulsants. Antihypertensives include hydralazine, labetolol and nifedipine. The goal is to lower blood pressure, but not to drop it too much or too fast, as that can cause intracranial hemorrhage.
The anticonvulsant of choice is magnesium sulfate.
Once the woman is stabilized, prepare her for delivery. Delivery should be accomplished regardless of the fetal gestational age, in order to protect the mother’s health.
Anticonvulsants should be continued in all women requiring delivery; and should be continued until 24 hours postpartum because they still remain at risk.
Start magnesium as soon as you make the decision to deliver the patient
Continue for 24 hours postpartum or after last seizure
Eclampsia (seizures) was prevented 11 times more often with magnesium than placebo.
Magnesium sulfate reduces convulsions over placebo.
Magnesium sulfate does not increase unfavorable maternal or neonatal outcomes.
Magnesium sulfate reduced convulsions by 55% compared to diazepam.
Magnesium sulfate reduced recurrent convulsions by 70% compared to phenytoin.
Magnesium sulfate reduced pneumonia by 33% compared to phenytoin.
Magnesium sulfate reduced admission to NICU compared to phenytoin. It also reduced the duration of stay and death in the NICU.
Magnesium sulfate is also much more effective and safer than phenytoin in treating eclampsia.
Concern about tocolytic effects of magnesium
No difference in labor outcomes between magnesium and phenytoin: use of oxytocin, time on labor ward, prolonged second stage and cesarean section.
Magnesium does not negatively affect the progress or outcome of labor.
The woman should be closely monitored every hour. Do NOT leave unattended.
