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Eclampsia
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  • These categories develop during pregnancy. Multisystem syndrome.
  • These two are related to preexisting conditions. Primary pathology is elevated B/P
  • A prior poor outcome from pregnancy may have been undiagnosed preeclampsia. If the race of the father is different than the mother
  • There are many theories of cause of gestational hypertension.
  • Edema not as significant below waist because it is normal in pregnancy. Edema above the waist is more significant due to the endothelial damage in the vasculature and leaking of fluid into extravascular space.
  • -Most commonly reported after 20 weeks gestation and within the first 48 hours postpartum. Though, seizures have been reported before 20 weeks and after 48 hours delivery. -Primips and multiple gestation have an increased incidence than the general population . (Sibai, 2007)
  • Mack truck, with bolus, anti-emetic to prevent emesis

Transcript

  • 1. Gestational Hypertension / Maternal Seizure Donna Adelsperger, M.Ed., RN Alyssa Graham, BSN, RNC-OB Sandy Warner, MSN, RNC-OB
  • 2. Hypertensive Disorders of Pregnancy
    • 2 nd leading cause of maternal death
    • Contributes to stillbirths and PNM&M
    • Can result in:
      • Cerebral hemorrhage
      • Dissemininated intravascular coagulation (DIC)
      • Hepatic failure
      • Acute renal failure
      • Abruptio placenta
  • 3. Incidence and Impact
    • Most common medical complication
    • Complicates 6-10% of all Pregnancies in U.S.
      • 3-8 % of Healthy Primiparas
      • 18% of Multiparas with prior Hx
    • 3.9 per 1000 live births
    • Mortality estimated 3-5% of those with seizures
    • The Preeclampsia Foundation (2007) estimates the annual cost of Preeclampsia in the United States is $7 Billion
  • 4. Classification of Hypertensive States of Pregnancy
    • Gestational hypertension
      • development of mild HTN during pregnancy
        • Previous normal B/P, no proteinuria and labs WNL
    • Preeclampsia
      • Development of HTN and proteinuria after 20 wks pregnancy
        • Previous normal B/P
        • With molar pg, can develop before 20 wks
      • Eclampsia
        • Seizures in preeclamptic pt
  • 5. Classification
    • Chronic HTN
      • HTN occurring before pregnancy or B/P > 140/90 or greater before 20 wks on 2 occasions, 6 hrs apart
    • Preeclampsia superimposed on chronic HTN
      • Development of preeclampsia or eclampsia
        • In pt with chronic HTN
      • National High Blood Pressure Education Program Working Group (2000)
  • 6. Conditions that Predispose
    • Nulliparity
    • Multiple pregnancy
    • Hydatidiform mole
    • Chronic hypertension
    • Chronic renal disease
    • (Gilbert, 2007)
    • Diabetes mellitus
    • Hydrops foetalis
    • Malnutrition
    • Under 17 or over 35
    • Women > 40 have 8x higher incidence than those < 20
    • (Martin et al., 2009)
  • 7. Other Risk Factors
    • Obesity
    • Family history or preeclampsia in previous pregnancy
    • African American race
    • Pre-existing medical or genetic conditions
    • Thrombophilias (Anti-phospholipid/Clotting Disorders
    • Factor 5 Leiden
    • 1 st pregnancy with new partner (immune response to sperm?)
  • 8. Preeclampsia
    • Cause unknown (“Disease of Theories”)
      • Vascular
      • Placental defect
      • Genetic predisposition
    • (Sibai, 2005)
  • 9. Preeclampsia
    • Vascular theory
        • Arteriolar vasoconstriction
        • Increased peripheral vascular resistance
        • Endothelial cell damage
    • Vasospasm causes ↑ BP—restriction of blood flow associated with endothelial cell damage which stimulates platelet and fibrinogen utilization
    • Researchers are unsure if vasospasms cause vessel damage or vice versa
  • 10. Preeclampsia
    • Placental defect theory
        • Alteration in trophoblastic implantation into the spiral arteries
          • Spiral arteries not optimal and unable to constrict
          • Affects blood flow as the placenta matures
          • Under-perfusion of placenta produces chemicals that cause damage to endothelial lining of blood vessels and interferes with normal pregnancy circulation and fluid shift
  • 11. Preeclampsia
    • Genetic predisposition theory
      • More likely to have if the patient’s mother/grandmother/sisters with history
      • More likely to have if paternal grandmother of fetus with history while carrying that FOB
      • Increased familiar incidence of antiphospholipid antibodies
    • The recent completion of Human Genome Project may lead to Dx by Microarray analysis
      • Identification of angiotensin gene T 235
    • (Founds, et al. JOGNN, Mar/April, 2008)
  • 12. Symptoms - 3 Classic
    • High Blood Pressure
    • Proteinuria
    • Edema
  • 13. Other Symptoms
    • Neurological symptoms (Cerebral or Visual Disturbances):
        • Hyper-reflexia—brisk reflexes (+/- Clonus)
        • Headaches
        • Blurring of vision—double Vision
        • Scotoma – spots before eyes
    • Epigastric or RUQ pain
    • Pulmonary edema or cyanosis
    • Impaired liver function of unclear etiology
    • Thrombocytopenia
  • 14. Complications of Preeclampsia
    • Maternal
      • Eclampsia – most dangerous
      • HELLP syndrome
      • Placental abruption
      • Pulmonary edema
      • Stroke
      • Renal or hepatic failure
      • Myocardial infarction
      • DIC
      • Cerebral hemorrhage
    • Fetal
      • IUGR
      • Prematurity
      • IUGR
      • Oligohydramnios
      • Fetal Hypoxia
      • Category II or III tracing
      • Increased, absent or reverse doppler flow studies
      • Low BPP score < 6
      • Fetal death
  • 15. Management
    • Cure: DELIVERY
    • Mode of delivery is patient-specific and depends on maternal condition and fetal status
    • Control BP with medications
    • Steroids to ↑ fetal lung maturity
    • Seizure Prophylaxis:
      • Magnesium Sulfate 4-6 gm loading dose (over 15-30 minutes)
      • Maintenance—continuous infusion 1-3 gm/hour
  • 16. Warning Signs of Impending Eclampsia
    • Severe persistent headache 83%
    • Hyperreflexia 80%
    • Proteinuria 80%
    • Edema 60%
    • Clonus 46%
    • Visual disturbances 45%
    • Epigastric pain 20%
    • Normal BP (Anumba & Robson, 1999) 20%
    • (Sibai, 2007)
  • 17. Eclamptic Seizures
    • Rare
    • New onset of grand mal seizures in preeclamptic patients
    • Occur antepartum, intrapartum, and post partum (have occurred as early as 1st trimester and as late as several weeks post delivery)
    • Theories of etiology:
      • Vasospasm – especially cerebral (Gilbert, 2007)
      • Hemorrhage
      • Ischemia
      • Edema
      • Microthrombi
      • (Sibai, 2007)
  • 18. Eclampsia Rates
    • Antepartum 50%
    • Intrapartum 25%
    • Postpartum 25%
    • (Sibai, 2007)
  • 19. Management of Eclampsia Assess mother and fetus Delivery method depends on maternal, fetal, & obstetric conditions Stabilize & deliver (ACOG, 2002) Administer labetalol or hydralazine Give other antihypertensive medications per MD Control hypertension Protect mother Protect airway Activate multidisciplinary team Administer Magnesium Sulfate Control seizures MANAGEMENT GOAL
  • 20. Magnesium Sulfate
    • Drug of choice
    • “ High Risk” medication
    • Loading dose:
      • 4-6 gram bolus over 20-30 min.
    • Maintenance dose:
      • 2-4 gram/hour IVPB
    • Always run as IVPB
    • Magnesium Sulfate usually continued until 12-24 hours post partum
  • 21. Magnesium Sulfate
    • May initially lower arterial BP because of its relaxant effect on smooth muscle
    • This response is transient & BP will return to pre-infusion levels
    • Slows smooth muscle & neuromuscular contractility, depresses cardiac conduction, & decreases CNS irritability
  • 22. Magnesium Sulfate Considerations
    • Let patient know treatment effects and possible sensations: flushing, sluggish thoughts, hot flashes, muscle weakness, headache, nausea & vomiting, generalized malaise (cheap drunk)
    • Irritating to vein—use large vein
    • Metabolized in kidney, so must verify adequate urinary output (≥ 30 ml/hour)
      • Patient may need Foley Catheter
  • 23. Magnesium Sulfate
    • Assessment includes:
      • Intake & output
      • Vital signs (BP q 5 min during bolus)
      • Presence of DTR’s
      • Respiratory rate & effort
      • Auscultate breath sounds for pulmonary edema
      • Level of consciousness
  • 24. Magnesium Sulfate
    • Magnesium Sulfate toxicity is rare if renal function is normal because excreted by kidneys
      • toxic levels more likely if oliguria and/or renal disease
    • S & S of toxicity are typically result of smooth muscle weakness and include:
      • Respiratory depression
      • Decreased uterine contractility
      • Lethargy & confusion
      • Sudden decrease in FHR
      • Depression or absence of reflexes
  • 25. Magnesium Sulfate
    • Therapeutic range 4-8 mg/dL
      • Loss of DTR’s 9-12 mg/dL
      • Respiratory arrest > 15 mg/dL
      • Cardiac arrest >25-30 mg/dL
    • Calcium Gluconate is Antidote
      • 10 mL of 10% solution given IV slowly over 1-3 minutes until signs of overdose are reversed
  • 26. Other Medications
    • Magnesium Sulfate – drug of choice
    • Drug therapy dependant on physician choice, if intubation needed and if patient is pregnant
      • Lorazepam
      • Valium
      • Versed
      • Pentathol
      • Succinylcholine
  • 27.