E C L A M P S I A

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.

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 utero-placental 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 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

CT scan of the head:cerebral edema,hemorrhage, infarction 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: Activity: 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 2- 4 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