MAJ Marvin Williams, MC, USA
Introduction: Preeclampsia is maternal hypertension accompanied by proteinuria or edema, seen from the 20th week of gestation through delivery. If these symptoms are complicated by seizures or coma, the mother has eclampsia. Hypertensive disorders are the most common medical complications of pregnancy, effecting approximately 5-14 percent of pregnancies, and are more common in first-time mothers. The etiology of preeclampsia is unknown and it can be defined as mild or severe. Approximately 1% of patients with preeclampsia develop eclampsia.
Subjective: Symptoms
Visual disturbances (usually irregular luminous patches in the visual fields after physical or mental labor), headaches, nausea, vomiting, epigastric pain and generalized edema, seizures or coma.
Objective: Signs
Mild Preeclampsia (1 of the following):
1. Blood pressure changes (measure on two occasions at least 6 hours apart):
a. Systolic blood pressure (SBP) of 140 mm Hg or greater OR b. Diastolic BP (DBP) of 90 mm Hg or greater (< 110) OR
c. Mean arterial BP (MAP) (calculated as 1/3 the difference between SBP and DBP, plus the DBP) of 105 mm Hg and/or an increase of 20 mm Hg over baseline
2. Proteinuria 2+ or > on a urine dipstick
3. Pathologic edema: generalized or involving the hands or face (Note: Moderate edema is a feature of approx. 70-80% of normal pregnancies). Weight gain greater than 4 pounds/week in the third trimester may be one of the first signs of preeclampsia.
Severe Preeclampsia (1 of the following):
1. Blood pressure changes (measure on two occasions at least 6 hours apart):
a. SBP of 160 mm Hg or greater OR b. DBP of 110 mm Hg or greater 2. Proteinuria 3+ OR 4+ on dipstick 3. Severe edema, including pulmonary edema
4. Evidence of end organ compromise (cerebral or visual disturbances) 5. Persistent abdominal pain with nausea and vomiting.
May also see:
a. Oliguria (< 400 ml in 24 hr).
b. Decreased platelet count (thrombocytopenia <100,000) c. Hyperreflexia
Eclampsia
1. Convulsions (seizures) during pregnancy with history of preeclampsia, or without other explanation.
2. Hypertension.
May also see weight gain, edema, proteinuria, visual disturbances, and right upper quadrant/epigastric pain.
Figure 3-12
Episiotomy
Figure 3-13
Laceration extends deeply into soft tissues of the perineum down to, but not including, the external anal sphincter.
Repair vaginal wound by applying locking, continous suture through to the hymenal ring, as in 1st degree repair.
Repair of 2nd Degree Episiotomy:
3-4 interupted sutures through the subcutaneous fascia, muscle and fat of the peritoneum
Figure 3-14
Approximate the edges of the perineal fascia with continuous, non-locking suture sewing towards the anus
Repair of 2nd Degree Episiotomy, cont’d
Using Advanced Tools: Lab: Urinalysis for urine protein (dipstick); platelet count.
Assessment:
Differential Diagnosis
Appendicitis, diabetes, gallbladder disease, gastroenteritis, glomerulonephritis, hyperemesis gravidarum (excessive vomiting in pregnancy), kidney stones, peptic ulcer, pyelonephrits, lupus, viral hepatitis. See appropriate sections of this book.
Plan:
Stabilize and evacuate. Definitive therapy in the form of delivery is the only cure for preeclampsia. The difficulty in therapy is deciding when to deliver the infant. The decision to deliver will depend on the severity of the disease, the status of the mother and the fetus, and the gestational age at the time of the evaluation.
Take the severity of the condition and the fetal gestational age into consideration, and either deliver the pregnancy or place the patient on bed rest. Perform close surveillance until the pregnancy reaches term or the preeclampsia worsens, dictating the need to deliver. There is no advantage to cesarean delivery over vaginal delivery for preeclampsia. Therefore, delivery route should be based on obstetric indications (worsening condition).
Treatment Mild Preeclampsia:
1. Observe for worsening signs of the disease.
Repair of 3rd and 4th Degree Episiotomy
Reapproximate rectal mucosa with interupted, fine 4-0 sutures (usually two layers), taking care not puncture the mucosa and to leave the ends of the suture in the tissue, not the rectal lumen.
Repair the torn ends of the donut-shaped anal sphincter with four well-spaced interrupted sutures that traverse through the capsule of the muscle.
Figure 3-15
2. If patient’s condition does not progress, discharge and follow on a twice weekly basis.
3. In a field or remote setting, manage aggressively with dexamethasone 6 mg IM q 12 hours for a total of 4 doses to prevent fetal respiratory distress syndrome and maternal thrombocytopenia, and to improve perinatal outcome in severe preeclampsia.
4. Give magnesium sulfate (to prevent seizures) by a controlled continuous infusion with a loading dose of 4-6 gm in 100 ml over 15-20 min. followed by a continuous infusion of 2-3 gm/hr. Toxic levels cause muscle weakness, respiratory paralysis, and cardiac arrest. Administer calcium gluconate 1 gm slow IV push over 2-3 minutes to counteract magnesium toxicity.
Severe Preeclampsia:
1. With SBP > 180 mm Hg or the DBP > 110 mm Hg, the possibility of intracerebral damage increases warranting antihypertensive medication. Give Hydralazine (Apresoline) 5-10 mg IV every 20 minutes as indicated, or labetalol 20 mg IV q 10 min with a max dose of 300 mg, to reduce BP. Monitoring BP q 5 minutes for at least 30 min. after giving the drug. Please note that some of the side effects with labetalol are maternal tachycardia, headache and flushing.
2. Give magnesium sulfate as above.
3. Evacuate.
Eclampsia:
1. Give magnesium sulfate as above.
2. Provide oxygen and airway support as needed.
3. Evacuate.
4. If evacuation not feasible deliver the fetus after seizure activity has abated.
5. If magnesium sulfate is not available, consider cesarean section as only option to save both mother and fetus (see Cesarean Section procedure).
Patient Education
Activity: Remain at bedrest on left side to minimize symptoms.
Prevention: Increase water intake, but maintain normal salt intake.
Follow-up Actions
Evacuation/Consultant Criteria: Evacuate early to avoid complications of eclampsia. Consult experts for management in remote settings (to include C-Section if necessary).