Principes généraux de la prise en charge hospitalière de la prééclampsie

Identifying predictive factors for admitting patients with severe pre-eclampsia to intensive care unit

BACKGROUND

Traditional obstetric units are inadequate for the level of monitoring required in pre-eclamptic patients. It remains to be determined which facility and tools should be implemented. The aim of this work was to identify predictive factors of admission to Intensive Care Unit (ICU) admissions for pregnancy-related hypertensive complications.

METHODS

We conducted an observational, retrospective multicenter study (Toulouse, Nantes). Both have a level III maternity unit and an ICU. The selected patients had one or more of the following diagnoses on admission in the ICU or during hospitalization: pre-eclampsia, eclampsia, HELLP syndrome, Acute Fatty Liver of Pregnancy (AFLP), Hemolytic Uremic Syndrome (HUS). SAPS II, SOFA and APACHE II on admission, and a validated nursing workload assessment score: TISS 28, were collected.

RESULTS

211 parturient women were included. According to the multivariate analysis: APACHE II and SAPS 2 severity scores >15 were significantly higher in the TISS 28 ≥ 20 group. There were also higher rates of uricemia >360 mmol/l.

CONCLUSIONS

To date, there are no reliable and validated predictive factors of severity to guide the transfer of pre-eclamptic patients to an ICU. The combination of an increased APACHE II score and uricemia, as well as a high care workload score that could help with the transfer of high-risk pre-eclamptic patients to a specific care facility. This hypothesis should be tested prospectively. This work could incite reflection on the value of creating obstetric intensive care units, according to the size of the maternity unit.

[Medical approaches for managing preeclampsia]

Preecalmpsia is an hypertensive disease of pregnancy complicating 1-5 % of all pregnancies. Although symptomatic management has improved, there is currently no curative treatment, and only childbirth and delivery of the placenta, usually prematurely, alleviate the mother's symptoms. When preeclampsia occurs before 37 weeks of gestation expectant management is often possible in order to reduce post-natal complications related to prematurity. The management depends on the severity of the disease and gestational age. The modalities of this management are reviewed in this article.

[Use of magnesium sulfate in obstetrics]

Magnesium sulfate (MgSO(4)) is the best treatment of eclampsia, reduces the risk of recurrence better than other anticonvulsants and is recommended as first line in cases of eclampsia. In cases of severe pre-eclampsia and especially when prodromes are present, MgSO(4) reduces better than conventional anticonvulsants the risk of eclampsia. More recently, MgSO(4) was used in cases of preterm delivery to reduce the risk of cerebral palsy in premature infants. Three large randomized trials have obtained convergent results which all tended to show a neuroprotective effect of MgSO(4). These trials were included in three meta-analyzes that showed a 30% reduction in the incidence of cerebral palsy before 32 weeks gestation suggesting that this drug should be used in cases of preterm birth. A protocol using low doses associated with a well-conducted maternal surveillance reduces of maternal hypermagnesemia and the risk of maternal toxicity.

[Prehospital management of severe preeclampsia]

Prior to transport, agreement must be reached among all the senior medical staff members involved in the transfer. Tight clinical surveillance is necessary during the transport. The aim of the pharmacological control of a severe hypertension is to allow a moderate reduction of the mean arterial blood pressure as well as dampening the large pressure variations. Boluses of calcium channel inhibitors, eventually combined with labetalol, are to be used as first line treatment. Systematic fluid expansion prior to admission is not recommended. However, it is indicated if obvious signs of hypovolaemia are present, such as a sudden drop in blood pressure, secondary to the initiating of an antihypertensive therapy. It is possible to use i.v. benzodiazepines for the treatment of eclampsia in the prehospital setting. If magnesium sulfate therapy has been initiated in a preeclamptic woman with neurological signs, it may be continued during her transport.