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Good morning!!. Eclampsia. ─A Case Presentation & Review R2 陳世昱. www.anaesthesia.co.in anaesthesia.co.in@gmail.com. Brief History (1)- general data. Name: 簡○○ Gender: female Age: 34y/o 居住地： 台北縣樹林鎮 Pregnancy at 38 th wks. Brief History (2)- background.

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  1. Good morning!!

  2. Eclampsia ─A Case Presentation & Review R2陳世昱 www.anaesthesia.co.inanaesthesia.co.in@gmail.com

  3. Brief History (1)-general data • Name: 簡○○ • Gender: female • Age: 34y/o • 居住地：台北縣樹林鎮 • Pregnancy at 38th wks

  4. Brief History (2)-background • The G2P1 woman has a history of H/T and skin allergy to drugs, but was generally healthy before. • She was diagnosed pre-eclampsia at pre-natal exam at 34wks; however, she didn't take anti-hypertensive agents and refused Dr’s suggestion of induction.

  5. Brief History (3)-episode 1 • 2002/09/09 Sudden loss of consciousness was told by herself in the morning(though without witness), and Eclampsia was diagnosed at LMD. • She was then transferred to our ER OBS. PR:96/min, BP:155/106mmHg with clear consciousness and normal DTR, muscle power was observed then, and nor other neurological S/S was noted. Proteinuria 4+ was detected later.

  6. Brief History (4)-episode 2 • Around 11:20AM, tonic-clonic convulsion suddenly occurred and lasted about 2mins(BP:197/118 HR:72), and FHB decelerated to 70/min at least for 5 mins without returning to the baseline. • Valium 1 Amp and Apresoline ½ Amp were given, and emergent C/S was arranged immediately.

  7. Brief History (5)-arriving… • 11:28AM: arrived our OR • Con’s:unconscious, self-breathing (with a mouth bite), weak muscle power (under MgSO4 dripping) • BP:145/82mmHg, HR:NSR 125/min, SaO2:97%, BW:56/69(?)Kg • Iv line: 20G in L’t forearm and 22G over R’t forearm

  8. Brief History (6)-preparing… • A: secure airway, be prepared for ET intubation─instruments, position and drugs (Ketamine 100mg, Pentothal 150mg, Succinylcholine 100mg and Fentanyl 100μg) • B: spontaneous breathing with prior oxygenation, and ventilator monitor by side(SaO2:97%) • C: two iv lines with Lactate-Ringer sol. Infusion (BP cuff: 145/82mmHg)

  9. Brief History (7)-handling… • After positioning, disinfections and surgeons were ready, a rapid-sequence induction with cricoid pressure was performed, iv drugs were flush in at 11:35AM, and 7.0# ETT was intubated immediately, while the surgery started almost at the same time. • Airway gas: maintained with O2 1L/min, N2O 1L/min with 0.5% Isoflurane

  10. Brief History (8)-handling…(cont.) • 11:42AM:ROM; 11:43 born a male child, 2408gm, Apgar score:1-4-7 (Ped. Drs performed ETT intubation and sent him to NICU for further care). 2 amp of Pitocin was dripping after the birth, and Atracurium 10mg was given at 12:00PM when P’t moved her hand.

  11. Brief History (9)-handling…(end) • Her BP slightly decreased after born the child, though the HR remained 120/min. SaO2 and EtCO2 were all maintained WNL throughout the whole surgery. • She was then sent to ICU for further intensive care with ETT after the end of the surgery, as recorded at 12:50PM.

  12. Articles Review Eclampsia → PIH

  13. Leading Words… • Pregnancy-induced hypertension (PIH) is a subtle and insidious disease process. The signs and symptoms of PIH become apparent relatively late in the course of the disease, usually during the third trimester of pregnancy. • Eclampsia is the development of convulsions, coma, or both in a woman with signs and symptoms of preeclampsia. • In the U.S., preeclampsia and eclampsia complicate approximately 7-10% and 1/10,000-15,000 pregnancies, and contribute to 20-40% of maternal deaths and 20% of perinatal deaths.

  14. Placental trigger Failure of the invasion of trophoblast cells Maladaptation of maternal spiral arterioles Poor villous development results in placental insufficiency Secondary damage, such as fibrin deposition and thrombosis Maternal response From vascular endothelial to multisystem disorder with various forms. Strong maternal inflammatory Rs, and far broader immun-ological systemic activity. Hereditary factors Awaited to clarify Phatho-physiology:

  15. Comparison: • Normal Hemodynamic Values of pregnant and non-pregnant women: • Physiological and phatho-physiological changes of preeclampsia:

  16. Classification

  17. Clinical manifestations of PIH • Hypertension alone is diagnosed as PIH. • Hypertension(140/90mmHg) and proteinuria(0.5g/d) are the most significant indicators of preeclampsia. Edema is significant only if hypertension, proteinuria, or signs of multisystem organ involvement are present(triad). • The clinical manifestations of preeclampsia are directly related to the presence of vasospasms, which result in endothelial injury, RBC destruction, platelet aggregation, increased capillary permeability and SVR, PVR, leading to tissue hypoxia and MODS.

  18. First pregnancy or pregnancy of new genetic make-up Multifetal gestation The presence of pre-existing diabetes, collagen vascular disease, H/T, or renal disease Hydatidiform mole Fetal hydrops Maternal age(<18y or>35y) Maternal weight (<100lbs or obese) African-American race Family history of PIH Anti-phospolipid synd. Low socio-economic status Late entry or no prenatal care Risk Factors

  19. SBP160 and/or DBP110mmHg on 2 occasions at least 6 hrs apart with the p’t on the bedrest Impaired liver function demonstrated by RUQ/epigastric pain and/or other liver function tests Oliguria,<400-500ml of u/o in 24hrs Cerebral or visual disturbance Thrombocytopenia:PLT<150,000 Pulmonary or cardiac involvement ↑serum creatinine >1mg/dL Intra-uterine growth restriction Proteinuria 5g in 24hrs or 3-4+ on dipstick Criteria of Severe Preeclampsia

  20. Neurologic: Headache Visual disturbances Hyperexcitability Seizures Intracranial Hemorrhage Cerebral edema Pulmonary Upper airway edema Pulmonary edema Cardiovascular Decreased intravascular volume Increased arteriolar resistance HTN Heart failure Hepatic Impaired function Elevated enzymes Hematoma Rupture Complications:

  21. Complications (cont.): • Renal • Proteinuria • Sodium retention • Decreased glomeruler filtration • Renal failure • Hematologic • Coagulopathy • Thrombocytopenia • PLT dysfunction • Prolonged pTT • Microangiopathic hemolysis

  22. Management (1) : • Pre-eclampsia occurs only in the presence of a placenta. • The management of pre-eclampsia is complicated by the presence of the fetus. The only definitive therapy for preeclampsia is delivery. • For the woman with severe preeclampsia, HELLP syndrome or eclampsia, especially at preterm gestation, delivery may be the most appropriate management decision.

  23. If DBP is higher than 110 mmHg for maternal pharmacologic management of severe preeclampsia-HELLP synd. : If GA>34wks and any jeopardy to mother or fetus, or the labor has begun, deliver. If GA<24 wks, consider termination of pregnancy. If GA is 24-28 wks, begin maternal counseling, institute prophylactic magnesium sulfate therapy and antihypertensive therapy as indicated, and monitor maternal and fetal status daily. Deliver if there is evidence of fetal lung maturity and maternal or fetal deterioration. Management (2) :

  24. Diuretics and high concentrations colloid solutions for peripheral edema→further ↓ intra-vascular volume and increase risk of pul. edema and utero-placental insufficiency. Valium is no longer the first-line agent to stop seizure activity related to the depressant effect on the fetus and mother. A rapid bolus of valium may lead to apnea, cardiac arrest, or both; also someone who is skilled in intubation must be available. Heparin should not be administered as prophylaxis against coagulopathy because of the compromise in the maternal vascular system. Inappropriate or controversial Managements :

  25. Postpartum management: • After birth, most women will stabilize within 48 hours. However, because of the risk of eclampsia during the first 24 to 48 hours, careful monitoring of vital signs, level of consciousness, and DTRs and laboratory assessments are continued. • Most postnatal convulsions occur within the first 24hrs after delivery, so anticonvulsant therapy is generally continued for 48 h after delivery. • Postnatal visit and discussion

  26. Prognosis: • Although pre-eclampsia is associated with significant morbidity and mortality for mother and baby, it almost resolves completely postpartum. • Women with severe pre-eclampsia have an increased risk of recurrence in their next pregnancy, but the disorder is generally less severe and manifests 2-3 weeks later than in the first pregnancy.

  27. Mortality : • Maternal mortality associated with pre-eclampsia and eclampsia (in U.K.)

  28. Causes of death:

  29. Summery: • Stepwise management of pregnancy hypertension

  30. Follow/up Results (1): • ICU record (from 9/9 13:00): ETT was removed at 8pm under clear consciousness, SaO2 ~98%, HR~80/min and BP~ 145/98mmHg, Trandate and MgSO4 keep use; then transferred back to normal ward on 9/10. • 9/11 Head CT : no definite focal mass, ICH or abnormal density change was found, and ventricles are normal in size.

  31. Follow/up Results (2): • Lab datas: 9/9 9/9 9/10 9/12 • PLT 79k 54k 95k 135k • Urine protein 4+ 100.0 • BUN 28.9 26.5 25.8 30.4 • Creatinine 2.25 2.1 1.98 1.5 • GOT 538 236 230 • GPT 505 233 • Mg 2.2 2.02 • FDP 80-100 • D-dimmer 8.13

  32. Happy Ending… • The female went home on 9/16 without other physical problem, and was described for OBS OPD for further following up.

  33. Thanks for your attention~ www.anaesthesia.co.inanaesthesia.co.in@gmail.com

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