Critical care management of preeclampsia and eclampsia

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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

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The obstetric ICU patient
Intensive Care Unit
Delivery room
Post Anesthesia Care Unit
Operating room
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The cause of preeclampsia is unknown

• Primary placental causes
• Secondary maternal systemic illness
• Ill-defined links between the two (maternal
  systemic inflammatory response?)

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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
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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

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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
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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
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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

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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

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Fetal complications of severe preeclampsia

• Intrauterine growth retardation
• Premature delivery
• Abruptio placentae
• Fetal distress/fetal demise

Associated maternal risks General/regional
anesthesia DIC Hemorrhage
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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)

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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
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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
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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)

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Cardiac failure?

• Untreated preeclamptic women almost always have
  low filling pressures and a hyperdynamic
  circulation

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

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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

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

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Pulmonary edema Best Pract Res Clin Obst Gyn
2001 15 605-622
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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

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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
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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
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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

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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

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Lancet 1995 345 1455-1463
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Lancet 2002 359 1877-1890
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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!

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

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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