Critical care management of preeclampsia and eclampsia - PowerPoint PPT Presentation

1 / 30
About This Presentation
Title:

Critical care management of preeclampsia and eclampsia

Description:

DIC often secondary to placental abruption, sepsis or fetal death ... Complications: ARF, ARDS, hemorrhage, placental abruption, rarely liver hematoma with rupture ... – PowerPoint PPT presentation

Number of Views:2956
Avg rating:3.0/5.0
Slides: 31
Provided by: gun282
Category:

less

Transcript and Presenter's Notes

Title: Critical care management of preeclampsia and eclampsia


1
Critical care management of preeclampsia and
eclampsia
  • Gunnar Dahlgren, MD, PhD
  • Department of Anesthesia and Intensive Care
  • Karolinska University Hospital
  • Stockholm

gunnar.dahlgren_at_karolinska.se

2
The obstetric ICU patient
Intensive Care Unit
Delivery room
Post Anesthesia Care Unit
Operating room
3
The cause of preeclampsia is unknown
  • Primary placental causes
  • Secondary maternal systemic illness
  • Ill-defined links between the two (maternal
    systemic inflammatory response?)


4
Primary changes in the vasculature
  • Impaired endothelial production of prostacylin,
    and possibly NO
  • Release of platelet-derived factors as
    thromboxane and serotonin
  • Release of endothelial procoagulant factors

Vasoconstriction Low grade DIC
5
Pathology
  • Placenta Spiral arteries fail to undergo
    physiological dilatation and show luminal disease
    similar to acute atherosis in non-pregnant
    patients
  • Kidney Glomerular capillary endotheliosus. Might
    progress to ATN or acute cortical necrosis
  • Placenta, kidney, brain, and liver show features
    consistent with chronic ischemia

6

Inadequate cellular oxygenation
  • Low cardiac filling pressures (CVP, PCWP),
    decreased plasma volume
  • Vasoconstriction - increased SVR
  • Low cardiac output
  • Tissue oxygen extraction impaired

Inadequate oxygen delivery and consumption
7
Hypertension in pregnancy
  • Pre-existing hypertension (3-5 of pregnancies)
  • Pregnancy-associated hypertension (12)
    (occurring de novo after the 20th week of
    pregnancy and settling within 6 weeks after
    delivery)
  • Gestational hypertension (6-7)
  • Preeclampsia (5-6)
  • Superimposed preeclampsia (25 of women with
    pre-existing hypertension)

Lancet 2000 356 1260-1265
8
Preeclampsia/eclampsia definitions
  • Preeclampsia Hypertension gt140/90 with
    proteinuria of at least 0.3g/24h
  • Severe preeclampsia Preeclampsia with
    hypertension gt160/110 or proteinuria gt5g/24h or
    multiorgan involvement
  • Eclampsia Convulsions in any woman who has, or
    then presents with, hypertension in pregnancy of
    any cause

9
Symptoms other than hypertension and proteinuria
in severe preeclampsia
  • Oliguria (lt400 ml/24h)
  • Cerebral signs (headache, blurred vision, altered
    consciousness)
  • Pulmonary edema, cyanosis
  • Epigastric or right upper quadrant pain
  • Impaired liver function
  • Hepatic rupture
  • Trombocytopenia
  • HELLP syndrome

10
Fetal complications of severe preeclampsia
  • Intrauterine growth retardation
  • Premature delivery
  • Abruptio placentae
  • Fetal distress/fetal demise

Associated maternal risks General/regional
anesthesia DIC Hemorrhage
11
Maternal complications of severe preeclampsia
  • Cardiovascular dysfunction (cardiac failure,
    hypertension)
  • Renal dysfunction (oliguria, reduced GFR,
    elevated creatinine, acute tubular necrosis,
    cortical necrosis)
  • Respiratory dysfunction (ARDS, pulmonary edema)
  • Hepatic dysfunction (elevated liver enzymes,
    subcapsular hematoma, HELLP syndrome)
  • Cerebral dysfunction (encephalopathy, ischemia,
    cortical blindness, retinal detachment,
    infarction, hemorrhage, edema, eclampsia)

12
Delivery of the fetus and placenta is the
definitive management of severe preeclampsia.
Once severe disease has been established and is
progressing, delivery of the fetus and placenta
must be accomplished to limit maternal risk.
Int Care Med 1997 23 248-255
13
Invasive hemodynamic monitoring
  • There are no data from randomized controlled
    clinical studies illustrating the usefulness of
    PA-catheters or echocardiographic techniques in
    patients with preeclampsia
  • Echocardiography shows good agreement with
    PA-catheter measurements of cardiac output
  • CVP may be misleading and needs cautious
    interpretation, particularly in patients treated
    with vasoactive agents or plasma volume
    augmentation
  • Invasive monitoring could still be considered in
    patients with persistant oliguria, pulmonary
    edema and significant blood loss in order to
    guide therapy

Best Pract Res Clin Obst Gyn 2001 15 605-622
14
Maternal complications of severe preeclampsia
  • Cardiovascular dysfunction (cardiac failure,
    hypertension)
  • Renal dysfunction (oliguria, reduced GFR,
    elevated creatinine, acute tubular necrosis,
    cortical necrosis)
  • Respiratory dysfunction (ARDS, pulmonary edema)
  • Hepatic dysfunction (elevated liver enzymes,
    subcapsular hematoma, HELLP syndrome)
  • Cerebral dysfunction (encephalopathy, ischemia,
    cortical blindness, retinal detachment,
    infarction, hemorrhage, eclampsia)

15
Cardiac failure?
  • Untreated preeclamptic women almost always have
    low filling pressures and a hyperdynamic
    circulation

16
Untreated pre-eclampsia Best Pract Res Clin Obst
Gyn 2001 15 605-622

17
Cardiac failure?
  • Untreated preeclamptic women almost always have
    low filling pressures and a hyperdynamic
    circulation
  • The situation in treated preeclamptic patients is
    more variable and unpredictable

18
Treated pre-eclampsia Best Pract Res Clin Obst
Gyn 2001 15 605-622
19
Cardiac failure?
  • Untreated preeclamptic women almost always have
    low filling pressures and a hyperdynamic
    circulation
  • The situation in treated preeclamptic patients is
    more variable and unpredictable
  • In patients with pulmonary edema a significant
    part of the women has a depressed cardiac
    performance

20
Pulmonary edema Best Pract Res Clin Obst Gyn
2001 15 605-622
21
Cardiac failure?
  • Untreated preeclamptic women almost always have
    low filling pressures and a hyperdynamic
    circulation
  • The situation in treated preeclamptic patients is
    more variable and unpredictable
  • In patients with pulmonary edema a significant
    part of the women has a depressed cardiac
    performance
  • Diastolic dysfunction, estimated with
    echocardiography, is not uncommon in preeclamptic
    patients with pulmonary edema
  • There is an association between preeclampsia and
    peripartem cardiomyopathy

22
Hypertension
  • Untreated severe hypertension increases the risk
    for cerebral hemorrhage, renal/liver dysfunction,
    pulmonary congestion, decreased placental
    perfusion, placental detachment
  • Treatment indicated in severe hypertension
  • Hydralazine less effective than nifedipine and
    equally effective as labetalol for reducing blood
    pressure
  • Side-effects (eg maternal hypotension, placental
    abruption, cesarean section) more frequent with
    hydralazine than with labetalol and nifedipine

BMJ 2003 327 955-964
23
Oliguria
  • Decreased plasma volume
  • Decreased renal perfusion and glomerular
    filtration
  • Pre-renal oliguria may develop to acute tubular
    necrosis, most often with a good prognosis
  • Acute cortical necrosis is rare poor prognosis

Diuresis lt100 ml/4h Plasma volume expansion if
CVP is lt5 mmHg Furosemide if fluid balance is
positive Echocardiography PA catheter to optimize
left ventricular preload (PCWP 12-14 mmHg) and
reduce afterload appropriately
24
Pulmonary edema
  • Incidence 6 in severe preeclampsia
  • Reduced COP (from 22 in normotensive patients at
    term to 15 mmHg in severe preeclampsia), a
    further reduction in COP after delivery.
  • A COP-PCWP difference of 4 mmHg or less is
    associated with pulmonary edema in critically ill
    non-pregnant patients (Chest 1977 72 709)
  • Increased capillary permeability
  • Possible left ventricular dysfunction (systolic
    and/or diastolic)
  • Increased risk during the first day(s) post
    partem

25
HELLP syndrome
  • Microangiopathic hemolytic anemia, consumptive
    thrombocytopenia, liver dysfunction
  • 4-12 of patients with severe preeclampsia, 30
    occur postpartum
  • DIC often secondary to placental abruption,
    sepsis or fetal death
  • Platelet count indirectly proportional to
    severity of disease
  • Differential diagnoses TTP, HUS, SLE, sepsis,
    acute fatty liver of pregnancy
  • Complications ARF, ARDS, hemorrhage, placental
    abruption, rarely liver hematoma with rupture

26
Lancet 1995 345 1455-1463
27
Lancet 2002 359 1877-1890
28
Eclampsia
  • The treatment of choice for eclampsia and
    prophylaxis against recurrent convulsions is
    magnesium sulphate (Lancet 1995 345 1456-1463)
  • Magnesium sulphate is also the drug of choice for
    seizure prophylaxis in patients with preeclampsia
    (Lancet 2002 359 1877-1890)
  • Prophylaxis in patients with preeclampsia is
    however in many departments limited to patients
    with severe preeclampsia or impending eclampsia
  • Stabilize maternal condition before vaginal or
    cesarean delivery!

29
Impending eclampsia Severe preeclampsia with
signs of cerebral affection like visual
disturbancies, headache, increased reflexes, and
clonus BJA 1996 76 133-148

30
Summary
  • Preeclampsia is a syndrome of unknown etiology
    with multiorgan involvement
  • It presents with a wide spectrum of symptoms
  • It is sometimes difficult to distinguish from
    other systemic diseases
  • Severe cases may progress to MOF and death
  • Delivery of the child and placenta is the only
    specific treatment other lines of teatment are
    only supportive
  • There are several issues regarding diagnostic
    techniques and treatment options that need
    further evaluation
Write a Comment
User Comments (0)
About PowerShow.com