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33 yr, G2 L1 (nvd), GA 35 w 3 to 4 days vomiting, diarrhea epigastric pain and
headace Bp 110/80 150/100 Emergency unite Bp 200/100 + headace and
vomiting Hb 14 and plt 187000 4 gr magnesium sulfate and cs
After cs LDH 670 972 Hb 13 Plt 172000 Ast 54 72 Alt 30 32 Cr 1.2 1.44 1.7 1.6 1.2
7 days later7 days later
Bp 180/100 190/100 Bp 180/100 190/100 Magnesium sulfate 4 gr stat and 1 gr/h INF S TNG Serum TNG captopril 25 mg stat
4 50 AM i l i i 4:50 AM, tonic-clonic seizure Magnesium sulfate 20%, 2gr Phenytoin
Lab dataLab data
Hb: 12 3 Hb: 12.3 PLT: 280000 UA: Pr (+++)( ) Cr: 1.2 1 LFT: normal UR AC: 6
Neurologic consultNeurologic consult
Brain MRI : hypoxi ischemic change Brain MRI : hypoxi ischemic change Brain MRV: normal Brain MRA: normal Suggestion : continue magnesium sulfate phenytoin Cardiology consult: Enalapril 50mg BD amlodipine daily
INTRODUCTIONINTRODUCTION
EclampsiaEclampsia
The occurrence of one or more generalized convulsions
and/or coma in the setting of preeclampsia and in the
absence of other neurologic conditions
INCIDENCE AND EPIDEMIOLOGYINCIDENCE AND EPIDEMIOLOGY
occurs in 2 to 3 percent of severely preeclamptic womennot receiving anti-seizure prophylaxis
between 0 and 0.6 percent in women with preeclampsiawithout severe features
Risk factors Risk factors NulliparityPreeclampsia in a previous pregnancyAge >40 years or <18 yearsFamily history of preeclampsiay y p pChronic hypertensionChronic renal diseaseAntiphospholipid antibody syndrome or inherited thrombophiliaVascular or connective tissue diseaseVascular or connective tissue diseaseDiabetes mellitus (pregestational and gestational)Multifetal gestationHigh body mass indexBl kBlack raceMale partner whose mother or previous partner had preeclampsiaHydrops fetalisUnexplained fetal growth restriction
Male partner whose mother or previous partner had preeclampsia
Woman herself was small for gestational ageFetal growth restriction, abruptio placentae, or fetal demise in a previous pregnancyProlonged interpregnancy intervalPartner related factors (new partner, limted sperm exposure [eg, previous use of barrier contraception])
Hydatidiform moleSusceptibility genes
Peak incidencePeak incidence
teenage years and low twenties
women over 35 years of age
Timing
A t t
Timing
Antepartum
intrapartum
postpartum
E l i i t 20 k fEclampsia prior to 20 weeks of gestation is rare
molar pregnancy molar pregnancy
ti h h li id d antiphospholipid syndrome
Timingg
Approximately one half of all cases of Approximately one-half of all cases ofeclampsia occur prior to term
Just over one-third of cases occur atterm, intrapartum or within 48 hours of, pdelivery
Late postpartum eclampsiaLate postpartum eclampsia
eclamptic seizures developing greater than 48 eclamptic seizures developing greater than 48hours, but less than four weeks postpartum
one-quarter of all postpartum cases
PATHOGENESIS OF SEIZURESPATHOGENESIS OF SEIZURES
Cerebral overregulation in response to high
systemic blood presure
vasospasm of cerebral
t iunderperfusion of the brainsystemic blood presure arteries
localized ischemia/infarction, and cytotoxic (intracellular) edemacytotoxic (intracellular) edema
PATHOGENESIS OF SEIZURESPATHOGENESIS OF SEIZURES
Loss of autoregulation
hyperperfusion, endothelial damage, and vasogenic edema
autoregulation
CLINICAL MANIFESTATIONS AND DIAGNOSIS
one or more generalized convulsions and/or coma
the absence of other neurologic conditionsthe absence of other neurologic conditions
tonic-clonic seizures
almost always self-limiting
l d i 60 75 d usual duration 60 to 75 seconds
In the hours before the seizureIn the hours before the seizure
persistent frontal or occipital headaches persistent frontal or occipital headaches thunderclap headaches visual disturbances right upper quadrant or epigastric paing pp q p g p altered mental status shortness of breath shortness of breath
Postpartum eclampsiaPostpartum eclampsia
The diagnosis may be delayed because prodromalg y y p
symptoms are nonspecific and severe signs and
symptoms, such as severe hypertension and severe
headache, may be intermittent.y
A large retrospective cohort study (2012)
152 patients with preeclampsia/eclampsiap p p pThe most common presenting symptom headache (70%) headache (70%) shortness of breath blurry vision nausea or vomiting, edemag, neurological deficit epigastric pain epigastric pain
Bilateral facial palsy is a rare entity inpregnancy that may be the first sign ofp g y y gpreeclampsia and suggests increased severityof disease, warranting close monitoring., g g
DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS
In general, women with typical eclamptic seizures
who do not have focal neurologic deficits or
l d d t i di ti l tiprolonged coma do not require diagnostic evaluation
with either electroencephalographic or cerebral
imaging studies . If cerebral imaging is performed,
magnetic resonance imaging is the optimal studymagnetic resonance imaging is the optimal study.
1-Reversible posterior leukoencephalopathyd (RPLS)syndrome (RPLS)
posterior reversible encephalopathy syndrome(PRES)
common clinical syndromey headaches, seizures, confusion, and visual
disturbances with characteristic neuroimagingfindings
resulting from a number of different causes such ashypertension eclampsia & immunosuppressivetherapy
Reversible posterior leukoencephalopathysyndrome (RPLS)y ( )
Some experts suggest that RPLS is an indicatorp gg
of eclampsia, even when features of
preeclampsia (hypertension, proteinuria) are not
presentpresent .
RPLS in eclampsia settingsRPLS in eclampsia settings
Blood pressures lower than in patients who develop Blood pressures lower than in patients who develop
RPLS in other settings
Th h d h i i ll l li d The headache is typically constant, nonlocalized,
moderate to severe, and unresponsive to analgesia
(thunderclap headache).
2- Use of illicit drugs
Cocaine intoxication presenting as preeclampsia and l ieclampsia
If a patient presents in the third trimester with hypertension andIf a patient presents in the third trimester with hypertension and
clinical symptoms of preeclampsia that rapidly improve shortly
ft d i i i i t i ti h ld b id dafter admission, cocaine intoxication should be considered as
the possible source
3-Infection4-Hypertensive disease4-Hypertensive disease .
5-Space-occupying lesions of the central nervous system
(brain tumor, abscess).
6 Metabolic disorders (hypoglycemia uremia6-Metabolic disorders (hypoglycemia, uremia,
inappropriate antidiuretic hormone secretion resulting in
water intoxication).
7-Stroke
8- Thrombotic thrombocytopenic purpura or
thrombophiliap
9-Cerebral vasculitis.
10- idiopathic epilepsy
evaluation and treatment of noneclampticseizures
seize in the first half of pregnancyseize in the first half of pregnancy focal neurologic deficitsprolonged comaatypical eclampsiayp p
General principlesGeneral principles
maintenance of airway patency
prevention of aspiration
MANAGEMENTMANAGEMENT
Prevention of maternal hypoxia and trauma
Management of severe hypertension, if presentManagement of severe hypertension, if present
Prevention of recurrent seizures
Evaluation for prompt delivery
Treatment of hypertensionTreatment of hypertension
Strokes account for 15 to 20 percent of deaths fromeclampsia
risk of stroke th d f l ti i t li d di t li the degree of elevation in systolic and diastolic pressures maternal age
Aggressive antihypertensive therapy for BP ≥160/105 to 110BP ≥160/105 to 110
treatment of hypertensive crisistreatment of hypertensive crisis
Hydralazine
L b t l lLabetalol
nifedipine nifedipine
treatment of mild hypertension is not
recommended, as neither maternal nor fetal
b fi h b d dbenefits have been demonstrated.
Treatment of convulsionsTreatment of convulsions
Approximately 10 percent of eclamptic women will have Approximately 10 percent of eclamptic women will haverepeated seizures if managed expectantly
magnesium sulfateg Phenytoin diazepam diazepam
i lf tmagnesium sulfate
t l i i l th Ph t i & di recurrent convulsions is less than Phenytoin & diazepam
less likely to be admitted to an intensive care facility
less likely to develop pneumonia
lower cost
ease of administration (eg, cardiac monitoring is not required)
less sedation
The effects of maternal magnesium sulfate treatment on newborns
Neuro protective effects Neuro protective effects
Hypotonic
lower Apgar scores at birth
Increase NICU admision Increase NICU admision
Increase risk of intubation
FDA announcementFDA announcement
More than 5 -7 days treatment in pregnant women
with magnesium sulfate lead to hypocalcema and
increased risk of osteopenia and bone fracture inincreased risk of osteopenia and bone fracture in
newborns
Management of persistent convulsionsManagement of persistent convulsions
magnesium sulfate (2 f i lf t 15 t 20 magnesium sulfate (2 grams of magnesium sulfate over 15 to 20minutes)
Diazepam (0.1 to 0.3 mg/kg over 60 seconds, maximump ( g g ,cumulative dose 20 mg)
Lorazepam (0.02 to 0.03 mg/kg IV, up to a cumulative dose of 0.1mg/kg)
Sodium amobarbital (250 mg intravenously over three tofive minutes )five minutes )
DeliveryDelivery
The definitive treatment for eclampsia is prompt The definitive treatment for eclampsia is promptdelivery
the mode of delivery
gestational age Bishop score
the mode of delivery fetal condition and
position
Cesarean deliveryCesarean delivery
it is desirable to wait 15 to 20 minutes and until the
mother and fetus show signs of recovery (control ofg y (
convulsions; mother oriented to name, time, and
l f l h i ) b f diplace; fetal heart rate reassuring) before proceeding
to surgery, if possible.
AnesthesiaAnesthesia
Magnesium Therapy in Pre-eclampsia Prolongs Analgesia
Following Spinal Anaesthesia with Fentanyl andFollowing Spinal Anaesthesia with Fentanyl and
Bupivacaine: An Observational Study.
Maternal outcome abruption placentae disseminated intravascular coagulopathydisseminated intravascular coagulopathy acute renal failure hepatocellular injury liver rupture intracerebral hemorrhage transient blindness cardiorespiratory arrest i ti iti aspiration pneumonitis acute pulmonary edema postpartum hemorrhage postpartum hemorrhage
Highest risk of maternal deathHighest risk of maternal death
women with eclampsia prior to 28 weeks of gestation women with eclampsia prior to 28 weeks of gestation
multiple seizures outside of the hospital setting
THANKSTHANKSTHANKS