"Strikes Like Lightning” An EMS Case Review  on Preeclampsia and Eclampsia Anne Clouatre, MHS, EMT-P EMS Regional Pro...
Disorders of Pregnancy <ul><li>Case Review and Discussion </li></ul><ul><ul><li>ante- and postpartum complications </li></...
Case Review  by EMS Personnel <ul><li>Report of call </li></ul><ul><li>Actions taken </li></ul><ul><li>Information discove...
History <ul><li>30’s female, G 3 P 3 </li></ul><ul><li>Restricted to bedrest x 2 months prior to  “healthy, normal, full-t...
ED Course <ul><li>At ED, difficult intubation </li></ul><ul><ul><li>valium, Ativan, nasal trumpet, 100 mg lidocaine </li><...
In-house Course <ul><li>Emergent CT and other medical imaging performed of head and chest </li></ul><ul><ul><li>Why? </li>...
In-house Course,  continued   <ul><li>Differential Dx </li></ul><ul><ul><li>acute intracranial bleed vs. pulmonary edema <...
Preeclampsia <ul><li>Characterized by    HTN, proteinuria and/or edema </li></ul><ul><li>May progress rapidly from mild t...
Risk Factors <ul><li>Primigravida (75-80%) </li></ul><ul><li>Chronic hypertension </li></ul><ul><li>Underlying renal disea...
Other Risk Factors <ul><li>Other specific underlying disorders: </li></ul><ul><ul><li>obesity, insulin resistance, low bir...
Additional Risk Factors <ul><li>Pregnancy-associated risk factors: </li></ul><ul><ul><li>multiple pregnancy </li></ul></ul...
More Risk Factors <ul><li>Partner-related risk factors: </li></ul><ul><ul><li>Nulliparity/primipaternity/teenage pregnancy...
Other Risk Factors <ul><li>Non-partner related risk factors: </li></ul><ul><ul><li>History of previous eclampsia </li></ul...
Antepartum vs. Postpartum <ul><li>Preeclampsia and eclampsia can develop after 20 weeks gestation and can manifest themsel...
Preeclampsia <ul><li>Study of 445 women with severe  </li></ul><ul><ul><li>preeclampsia and eclampsia: </li></ul></ul><ul>...
What does eclampsia represent? <ul><li>It MAY represent the end stage of at least two very different pathophysiological pa...
But WHY? <ul><li>It is believed that “the blueprint of this disorder is laid down early in pregnancy. It has been suggeste...
Some Multisystem Effects of Preeclampsia Porter, Littleton and Parker EMS 303-765-6EMS
Prevention <ul><li>NO single strategy has proven effective including: </li></ul><ul><ul><li>dietary sodium restriction </l...
Prevention <ul><li>Preeclampsia is a disorder of placental implantation </li></ul><ul><ul><li>Therefore, it is not entirel...
Overall Best Treatment?? <ul><li>“ The primary treatment  </li></ul><ul><li>of preeclampsia and eclampsia is delivery.” </...
Prevention and Treatment  of Eclamptic Convulsions <ul><li>Magnesium Sulfate </li></ul><ul><li>Reported  benefits : </li><...
Prevention and Treatment  of Eclamptic Convulsions <ul><li>Magnesium Sulfate </li></ul><ul><li>Reported  detrimental effec...
Prevention and Treatment  of Eclamptic Convulsions <ul><li>Magnesium sulfate </li></ul><ul><ul><li>An additional 16% of ec...
Prevention and Treatment  of Eclamptic Convulsions <ul><li>Magnesium sulfate </li></ul><ul><ul><li>“ There has never been ...
Drug of Choice? <ul><li>Magnesium sulfate continues to be the drug of choice </li></ul><ul><ul><li>loading dose followed b...
Other Meds? <ul><li>“  Magnesium sulfate  should probably remain a mainstay of the underlying treatment of eclampsia. Trad...
Could the Outcome  in This Case Have Been Altered? <ul><li>If so, how? </li></ul><ul><li>If not, why not? </li></ul><ul><u...
Questions or Comments? <ul><li>Feel free to contact me  </li></ul><ul><li>or other members of our EMS team  </li></ul><ul>...
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Preeclampsia And Eclampsia: An EMS Case Review

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An EMS case review discussing preeclampsia and eclampsia including purported etiology, risk factors, pharmacology - references are dated but core information is still helpful

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Preeclampsia And Eclampsia: An EMS Case Review

  1. 1. &quot;Strikes Like Lightning” An EMS Case Review on Preeclampsia and Eclampsia Anne Clouatre, MHS, EMT-P EMS Regional Program Director Centura Health Porter, Littleton and Parker Adventist Hospitals Emergency Medical Services 303.765.6367
  2. 2. Disorders of Pregnancy <ul><li>Case Review and Discussion </li></ul><ul><ul><li>ante- and postpartum complications </li></ul></ul><ul><li>Today’s topic: </li></ul><ul><ul><li>preeclampsia and eclampsia </li></ul></ul>Porter, Littleton and Parker EMS 303-765-6EMS
  3. 3. Case Review by EMS Personnel <ul><li>Report of call </li></ul><ul><li>Actions taken </li></ul><ul><li>Information discovered </li></ul><ul><li>Follow-up </li></ul>Porter, Littleton and Parker EMS 303-765-6EMS
  4. 4. History <ul><li>30’s female, G 3 P 3 </li></ul><ul><li>Restricted to bedrest x 2 months prior to “healthy, normal, full-term delivery” at home without report of complications per midwife and family members </li></ul><ul><li>Per family, pt. c/o headache 6 days postpartum but did not wish to seek medical care </li></ul><ul><li>Presented to urgent care center 8 days postpartum with c/o headache and new onset of shortness of breath </li></ul><ul><li>Working dx: pregnancy-induced hypertension vs. pre-existing condition vs. pulmonary embolism </li></ul><ul><ul><li>No report of protein in urine </li></ul></ul><ul><ul><li>No report of edema </li></ul></ul><ul><li>Ambulance called to clinic for transport to hospital emergency department for further evaluation and work-up </li></ul><ul><li>U/A in ambulance bay, patient c/o visual disturbances and then abruptly seized with tonic-clonic activity noted </li></ul>Porter, Littleton and Parker EMS 303-765-6EMS
  5. 5. ED Course <ul><li>At ED, difficult intubation </li></ul><ul><ul><li>valium, Ativan, nasal trumpet, 100 mg lidocaine </li></ul></ul><ul><ul><li>floppy cords (2 nd ary to edema, fat or anatomy ) , sx of pulmonary edema </li></ul></ul><ul><ul><ul><li>question about 1000 ml NS being infused PTA at clinic </li></ul></ul></ul><ul><ul><ul><ul><li>no more fluid given in ED </li></ul></ul></ul></ul><ul><li>Cardiac arrest </li></ul><ul><ul><li>subclavian line </li></ul></ul><ul><ul><li>intermittent PEA </li></ul></ul><ul><ul><li>brief perfusing rhythm with ACLS protocols initiated </li></ul></ul><ul><ul><li>BP: 190 systolic </li></ul></ul><ul><ul><li>P: low 50’s </li></ul></ul><ul><ul><li>converted into ST with hemodynamic stability </li></ul></ul>Porter, Littleton and Parker EMS 303-765-6EMS
  6. 6. In-house Course <ul><li>Emergent CT and other medical imaging performed of head and chest </li></ul><ul><ul><li>Why? </li></ul></ul><ul><ul><ul><li>To r/o IC bleed and PE </li></ul></ul></ul><ul><ul><ul><li>Pt. had been bedridden prior to delivery </li></ul></ul></ul><ul><ul><ul><ul><li>suspected possible clots, emboli, thrombi </li></ul></ul></ul></ul><ul><li>To ICU: unresponsive with a BP of 190 </li></ul><ul><li>Status: grave condition </li></ul>Porter, Littleton and Parker EMS 303-765-6EMS
  7. 7. In-house Course, continued <ul><li>Differential Dx </li></ul><ul><ul><li>acute intracranial bleed vs. pulmonary edema </li></ul></ul><ul><ul><li>vs. cardiac problem vs. fat embolism </li></ul></ul><ul><li>Outcome </li></ul><ul><ul><li>expired on HD 3 </li></ul></ul><ul><ul><li>Etiology unclear </li></ul></ul><ul><ul><ul><li>IC bleed vs. PE; neither was definitively reported </li></ul></ul></ul>Porter, Littleton and Parker EMS 303-765-6EMS
  8. 8. Preeclampsia <ul><li>Characterized by  HTN, proteinuria and/or edema </li></ul><ul><li>May progress rapidly from mild to severe </li></ul><ul><li>Leading cause of fetal and maternal M and M </li></ul><ul><li>Occurs in about 5-7% of all pregnancies </li></ul><ul><li>Incidence: 1:200-1:3000 pregnancies </li></ul>Porter, Littleton and Parker EMS 303-765-6EMS
  9. 9. Risk Factors <ul><li>Primigravida (75-80%) </li></ul><ul><li>Chronic hypertension </li></ul><ul><li>Underlying renal disease </li></ul><ul><li>Diabetes mellitus </li></ul><ul><li>History of prior preeclampsia </li></ul>Porter, Littleton and Parker EMS 303-765-6EMS
  10. 10. Other Risk Factors <ul><li>Other specific underlying disorders: </li></ul><ul><ul><li>obesity, insulin resistance, low birth weight </li></ul></ul><ul><ul><li>gestational diabetes </li></ul></ul><ul><ul><li>activated protein C resistance, protein S deficiency </li></ul></ul><ul><ul><li>antiphospholipid antibodies </li></ul></ul><ul><ul><li>hyperhomocysteinemia </li></ul></ul><ul><ul><li>sickle cell disease, sickle cell trait </li></ul></ul><ul><li>Exogenous factors </li></ul><ul><ul><li>smoking (risk reduction for eclampsia only) </li></ul></ul><ul><ul><li>stress, work-related psychosocial strain </li></ul></ul><ul><ul><li>in-utero DES exposure </li></ul></ul>Porter, Littleton and Parker EMS 303-765-6EMS
  11. 11. Additional Risk Factors <ul><li>Pregnancy-associated risk factors: </li></ul><ul><ul><li>multiple pregnancy </li></ul></ul><ul><ul><li>structural congenital abnormalities </li></ul></ul><ul><ul><li>hydrops fetalis </li></ul></ul><ul><ul><li>chromosomal anomalies (trisomy 13, triploidy) </li></ul></ul><ul><ul><li>hydatidiform moles </li></ul></ul><ul><ul><li>urinary tract infection </li></ul></ul>Porter, Littleton and Parker EMS 303-765-6EMS
  12. 12. More Risk Factors <ul><li>Partner-related risk factors: </li></ul><ul><ul><li>Nulliparity/primipaternity/teenage pregnancy </li></ul></ul><ul><ul><li>Limited sperm exposure, donor insemination, oocyte donation </li></ul></ul><ul><ul><li>Oral sex (risk reduction) </li></ul></ul><ul><ul><li>Partner who fathered a preeclamptic pregnancy in another woman </li></ul></ul>Porter, Littleton and Parker EMS 303-765-6EMS
  13. 13. Other Risk Factors <ul><li>Non-partner related risk factors: </li></ul><ul><ul><li>History of previous eclampsia </li></ul></ul><ul><ul><li>Age, interval between pregnancies </li></ul></ul><ul><ul><li>Family history </li></ul></ul>Porter, Littleton and Parker EMS 303-765-6EMS
  14. 14. Antepartum vs. Postpartum <ul><li>Preeclampsia and eclampsia can develop after 20 weeks gestation and can manifest themselves up to 7-14 days postpartum </li></ul><ul><li>One study showed that 20 out the 82 patients with eclampsia did not have seizures until AFTER delivery, yielding an overall ratio of antepartum to postpartum eclampsia of approximately 3:1 </li></ul>Porter, Littleton and Parker EMS 303-765-6EMS
  15. 15. Preeclampsia <ul><li>Study of 445 women with severe </li></ul><ul><ul><li>preeclampsia and eclampsia: </li></ul></ul><ul><ul><li>Quantitative proteinuria and degree of BP elevation are not predictive of either abruptio placentae or eclampsia as has been previously suggested. The greatest morbidity with eclampsia occurred in women with preterm gestations not receiving medical attention. </li></ul></ul>Porter, Littleton and Parker EMS 303-765-6EMS
  16. 16. What does eclampsia represent? <ul><li>It MAY represent the end stage of at least two very different pathophysiological pathways: </li></ul><ul><ul><li>one in which cerebral perfusion is low because of vasospasm (widespread vasospasm) </li></ul></ul><ul><ul><li>AND </li></ul></ul><ul><ul><li>one in which cerebral perfusion is increased because of abnormal autoregulation and a failure of the normal protective mechanisms (endothelial injury) </li></ul></ul>Porter, Littleton and Parker EMS 303-765-6EMS
  17. 17. But WHY? <ul><li>It is believed that “the blueprint of this disorder is laid down early in pregnancy. It has been suggested that the primary event for the development of preeclampsia is a failure of the second wave of trophoblast invasion from 16-20 weeks’ gestation that is responsible for destruction of the muscularis layer of the spiral arterioles. </li></ul><ul><ul><li>As pregnancy progresses and the metabolic demand of the fetoplacental unit increases, the spiral arterioles are therefore unable to accommodate the necessary increase in blood flow. This then leads to the development of ‘placental dysfunction’ which manifests clinically in the pregnant woman as preeclampsia.” </li></ul></ul><ul><ul><li>this hypothesis remains to be validated... </li></ul></ul>Porter, Littleton and Parker EMS 303-765-6EMS
  18. 18. Some Multisystem Effects of Preeclampsia Porter, Littleton and Parker EMS 303-765-6EMS
  19. 19. Prevention <ul><li>NO single strategy has proven effective including: </li></ul><ul><ul><li>dietary sodium restriction </li></ul></ul><ul><ul><li>dietary supplementation </li></ul></ul><ul><ul><ul><li>zinc, magnesium, fish oil, vitamins </li></ul></ul></ul><ul><ul><li>bed rest </li></ul></ul><ul><ul><li>diuretics </li></ul></ul><ul><ul><li>antihypertensives </li></ul></ul><ul><ul><ul><li>do not alter disease, but may prevent CVAs </li></ul></ul></ul><ul><ul><li>low-dose aspirin </li></ul></ul><ul><ul><li>calcium </li></ul></ul><ul><ul><ul><li>may help high-risk populations </li></ul></ul></ul><ul><ul><li>heparin </li></ul></ul><ul><ul><li>antiplatelet agents </li></ul></ul><ul><ul><li>nitric oxide </li></ul></ul>Porter, Littleton and Parker EMS 303-765-6EMS
  20. 20. Prevention <ul><li>Preeclampsia is a disorder of placental implantation </li></ul><ul><ul><li>Therefore, it is not entirely preventable </li></ul></ul><ul><ul><li>Earlier implementation of preventative measures may be more effective than those initiated later in pregnancy </li></ul></ul>Porter, Littleton and Parker EMS 303-765-6EMS
  21. 21. Overall Best Treatment?? <ul><li>“ The primary treatment </li></ul><ul><li>of preeclampsia and eclampsia is delivery.” </li></ul>Porter, Littleton and Parker EMS 303-765-6EMS
  22. 22. Prevention and Treatment of Eclamptic Convulsions <ul><li>Magnesium Sulfate </li></ul><ul><li>Reported benefits : </li></ul><ul><ul><li>vasodilation in vascular beds </li></ul></ul><ul><ul><li>increased uterine and renal blood flow </li></ul></ul><ul><ul><li>increased prostacyclin release by endothelial cells </li></ul></ul><ul><ul><li>decreased plasma renin activity </li></ul></ul><ul><ul><li>decreased ACE levels </li></ul></ul><ul><ul><li>attenuation of vascular response to pressor substances </li></ul></ul><ul><ul><li>bronchodilation </li></ul></ul><ul><ul><li>reduced platelet aggregation </li></ul></ul>Porter, Littleton and Parker EMS 303-765-6EMS
  23. 23. Prevention and Treatment of Eclamptic Convulsions <ul><li>Magnesium Sulfate </li></ul><ul><li>Reported detrimental effects : </li></ul><ul><ul><li>decreased uterine activity and prolonged labor </li></ul></ul><ul><ul><li>decreased fetal heart rate variability </li></ul></ul><ul><ul><li>excessive postpartum hemorrhage </li></ul></ul><ul><ul><li>neonatal neuromuscular and respiratory depression </li></ul></ul><ul><ul><li>low APGAR scores </li></ul></ul><ul><ul><li>increased pulmonary edema (3.3%) </li></ul></ul><ul><ul><li>reduced platelet aggregation </li></ul></ul><ul><ul><li>decreased functional vital capacity and FEV1 </li></ul></ul>Porter, Littleton and Parker EMS 303-765-6EMS
  24. 24. Prevention and Treatment of Eclamptic Convulsions <ul><li>Magnesium sulfate </li></ul><ul><ul><li>An additional 16% of eclamptic seizures occur more that 48 hours after delivery </li></ul></ul><ul><ul><li>Therefore, MgSO 4 seizure prophylaxis can be expected to have a potential impact only for reduction of seizures that occur during delivery and within 12-24 hours after delivery. </li></ul></ul>Porter, Littleton and Parker EMS 303-765-6EMS
  25. 25. Prevention and Treatment of Eclamptic Convulsions <ul><li>Magnesium sulfate </li></ul><ul><ul><li>“ There has never been any systematic, controlled evidence, however, </li></ul></ul><ul><ul><li>that magnesium sulfate prevents progression to eclampsia from either mild or severe eclampsia.” </li></ul></ul>Porter, Littleton and Parker EMS 303-765-6EMS
  26. 26. Drug of Choice? <ul><li>Magnesium sulfate continues to be the drug of choice </li></ul><ul><ul><li>loading dose followed by a maintenance dose </li></ul></ul><ul><ul><ul><li>6 g in 100 ml 5% dextrose in LR solution over 15 minutes, followed by maintenance dose of 2 g/hr--adjusted according to patellar reflexes and urine output in the previous 4-hour period </li></ul></ul></ul><ul><li>Nimodipine has shown some promise and has less side effects for both mom and baby </li></ul><ul><ul><li>still may have more seizure breakthroughs than MgSO 4 </li></ul></ul>Porter, Littleton and Parker EMS 303-765-6EMS
  27. 27. Other Meds? <ul><li>“ Magnesium sulfate should probably remain a mainstay of the underlying treatment of eclampsia. Traditional treatment of seizure activity should be considered in patients with secondary injury or anoxia-induced seizure activity.” </li></ul>Porter, Littleton and Parker EMS 303-765-6EMS
  28. 28. Could the Outcome in This Case Have Been Altered? <ul><li>If so, how? </li></ul><ul><li>If not, why not? </li></ul><ul><ul><li>Discussion </li></ul></ul><ul><li>Review… </li></ul><ul><ul><li>What have you learned? </li></ul></ul><ul><ul><li>What can you apply for future use? </li></ul></ul>Porter, Littleton and Parker EMS 303-765-6EMS
  29. 29. Questions or Comments? <ul><li>Feel free to contact me </li></ul><ul><li>or other members of our EMS team </li></ul><ul><li>if you have any questions </li></ul><ul><li>or comments: </li></ul><ul><li>Anne – Porter, Littleton and Parker EMS </li></ul><ul><li>303.765.6367 </li></ul>Porter, Littleton and Parker EMS 303-765-6EMS

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