EMERGENT MANAGEMENT OF PUERPERAL ECLAMPSIA

Maternal and perinatal outcomes of eclampsia with and without HELLP syndrome in a teaching hospital in western Turkey

In this study, we compared the perinatal and maternal outcomes of women with eclampsia with and without HELLP syndrome. A total of 219 pregnancies complicated by eclampsia with and without HELLP syndrome managed between January 2002 and December 2011, were reviewed. The incidence of eclampsia was 1.7/1,000 deliveries. Among 219 patients with eclampsia, 141 (64.4%) did not develop HELLP syndrome and 78 (35.6%) did develop HELLP syndrome. Maternal age and the rates of nulliparity were similar in both groups. Interval time from eclamptic seizure to delivery was significantly longer in the without-HELLP syndrome group (0.92 ± 0.29 weeks vs 0.16 ± 0.12 weeks, p = 0.028). Furthermore, overall perinatal mortality (particularly after gestational week 32) was significantly higher in the with-HELLP syndrome group (20.5% vs 9.9%, p = 0.029). In conclusion, patients with HELLP syndrome had significantly higher perinatal mortality than those with eclampsia without HELLP syndrome and no regular prenatal care.

Factors influencing the postpartum length of hospital stay in eclamptic women

OBJECTIVE

To determine which variables are associated with postpartum length of hospital stay in eclamptic patients.

MATERIALS AND METHODS

The study sample comprised 98 eclamptic patients who were admitted to our perinatology unit during the period between January 1998 and May 2003. The study sample was divided into two postpartum length-of-stay groups: the short-stay group (1-3 days) consisted of 33 patients and the long-stay group (4 days and longer) consisted of 65 patients. The groups were compared with respect to the demographic characteristics, clinical and laboratory variables, and complications.

RESULTS

The mean hospitalization periods for the short-stay and long-stay groups were 2.48 +/- 0.79 and 5.60 +/- 2.12 days, respectively ( p = 0.010). The mean prepartum follow-up period after the onset of eclampsia was longer in the long-stay group than in the short-stay group (12.11 +/- 27.63 vs. 5.08 +/- 6.08 hours). The proportion of patients receiving magnesium sulfate therapy longer than 12 hours was higher in the long-stay group ( p = 0.014). The long-stay group had higher diastolic arterial blood pressure than that of the short-stay group ( p = 0.006). The total cesarean delivery rate for the short-stay group was 48.5%, compared with 67.7% in the long-stay group ( p = 0.081).

CONCLUSION

The duration of magnesium therapy, the timing, and the mode of delivery should be individualized to reduce the length of hospital stay in eclamptic patients.

A prospective randomized trial of magnesium sulfate in severe preeclampsia: use of diuresis as a clinical parameter to determine the duration of postpartum therapy

OBJECTIVE

The purpose of this study was to assess the use of the onset of diuresis in the determination of the duration of postpartum magnesium sulfate therapy among patients with severe preeclampsia.

STUDY DESIGN

A prospective randomized trial of postpartum therapy with magnesium sulfate was conducted. The control group received 24 hours of therapy, and the study group received therapy until the onset of diuresis (urine output >100 mL/hr for 2 consecutive hours). The Student t test, chi 2 test, and Fisher's exact test were used for analysis of data; a probability value of <.05 was considered statistically significant.

RESULTS

There were 50 patients in the control group and 48 patients in the study group. There was no difference in maternal demographic data, severe disease criteria, blood pressure, 24-hour postpartum urine output, or need for antihypertensive therapy. The study group had a significantly shorter duration of therapy, and no patient had eclampsia or required the re-initiation of therapy.

CONCLUSION

The use of the onset of diuresis in the postpartum period as the determinant clinical parameter for the discontinuation of magnesium sulfate in patients with severe preeclampsia was associated with no untoward outcomes or need for the re-initiation of treatment.

A current concept of eclampsia

Eclampsia is defined by the occurrence of seizures resulting from hypertensive encephalopathy on the background of preeclampsia. The development of hypertension during pregnancy, a serious and potentially fatal condition, is a leading cause of maternal and fetal morbidity and death in the United States.(1-3) It is a disease with preventable complications. The pathophysiology of hypertension during pregnancy is unclear, but there is consensus that aggressive treatment is warranted to prevent complications to both fetus and mother. A current concept of pathophysiological character, diagnosis, prevention, and management of eclampsia is discussed.

Maternal mortality associated with eclampsia and severe preeclampsia of pregnancy

OBJECTIVE

To analyse factors associated with maternal mortality in eclampsia and preeclampsia.

METHOD

Retrospective analysis of 69 maternal deaths due to (eclampsia-61; severe preeclampsia-8) was carried out during a period of 17 years (1982-1998). Maternal condition on admission, associated complications and principal cause of death was analysed in each case.

RESULTS

Mean time interval between hospitalization and maternal death was 49.56 +/- 62.01 hrs (1-240 hrs). Twenty (28.9%) women died undelivered. Twenty-three (37.7%) women were in grade IV coma and 52.4% of eclampsia patients had recurrent convulsions (> 10) prior to admission. Associated complications in form of hemorrhage, cerebrovascular accidents, acute renal failure, jaundice, aspiration pneumonia and pulmonary oedema were 30.4, 31.8, 34.8, 18.8, 17.8, and 5.8%, respectively. Maternal mortality in eclampsia was significantly low in time period B (4.1%) when magnesium sulphate was used as an anticonvulsant.

CONCLUSIONS

Maternal condition on admission and associated complications are the major determinant of maternal outcome. Use of magnesium sulphate is associated with significant reduction of maternal mortality.

Intensive care unit morbidity and mortality from eclampsia: an evaluation of the Acute Physiology and Chronic Health Evaluation II score and the Glasgow Coma Scale score

OBJECTIVE

To determine the maternal morbidity and mortality in patients with eclampsia admitted to an intensive care unit (ICU), and to establish the efficacy of the Acute Physiology and Chronic Health Evaluation (APACHE) II score, the organ system failure score as defined by Knaus, and the Glasgow Coma Scale (GCS) score in predicting outcome.

DESIGN

Retrospective analysis of a 3.5-yr period.

SETTING

Surgical ICU in a university hospital.

PATIENTS

A total of 105 patients who were admitted with a diagnosis of eclampsia were studied.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The data captured included the reason for admission, maternal age, gestational age, parity, number of seizures, duration of ICU stay, anticonvulsant therapy, drug therapy, GCS score, APACHE II score, and the occurrence of organ failure. Of the 126 patients with eclampsia who were admitted to the ICU, records of 105 patients (83%) were found. The overall mortality was 10.5% (n = 11). The mean age, gestation, parity, number of preadmission seizures, and duration of stay were similar in survivors and nonsurvivors. Although the APACHE II score was significantly higher in nonsurvivors, multiple logistic regression analysis suggested that the goodness-of-fit scores for GCS and APACHE II were similar (38.29 vs. 38.01). The GCS scores of survivors were significantly higher than those of nonsurvivors (10.61 vs. 5.0; p<.001). Respiratory failure was the most common organ failure in both groups. The mean number of organ failures was higher in nonsurvivors compared with survivors (2.9 vs. 1.3; p<.001). An occurrence of more than two organ failures that persisted for >48 hrs was invariably associated with a fatal outcome. Anticonvulsant therapy consisted of magnesium sulfate or phenytoin and a midazolam infusion. Only one patient (0.9%) had a seizure, and this occurred en route to the ICU. No seizures occurred after admission to the ICU.

CONCLUSIONS

The organ system failure score and the GCS score are good predictors of outcome in eclampsia. Apart from the GCS score, other variables in the APACHE II score are not valuable for outcome prediction. The low GCS score in nonsurvivors suggests that closer attention to the neurologic management may be beneficial. A prospective study is indicated to validate these findings.

Individually determined postpartum magnesium sulfate therapy with clinical parameters to safely and cost-effectively shorten treatment for pre-eclampsia

OBJECTIVE

The purpose of this study was to investigate the safety of treating pre-eclampsia with magnesium sulfate, with clinical determinants used for drug discontinuation.

STUDY DESIGN

One hundred sixty-eight patients were enrolled. After delivery, women with mild pre-eclampsia received a minimum of 6 hours of intravenous magnesium sulfate, whereas women with severe pre-eclampsia received a minimum of 12 hours. Magnesium sulfate was discontinued in the absence of clinical symptoms associated with spontaneous diuresis, minimal protein by urinary dipstick, and satisfaction of predetermined blood pressure criteria.

RESULTS

Patients with mild pre-eclampsia required significantly less magnesium sulfate (mean 9.5 +/- 4.2 hours) than did those with severe pre-eclampsia alone (mean 16 +/- 5.9 hours); pre-eclampsia superimposed on chronic hypertension (mean 16 +/- 5.8 hours); or hemolysis, elevated liver enzyme, and low platelet count syndrome (mean 20 +/- 6.7 hours). With this protocol there was no eclampsia, and recovery room time was reduced by 50%.

CONCLUSION

Individual determination of postpartum magnesium sulfate therapy for pre-eclampsia appears to be a safe approach that carries minimal risk of eclampsia.

Medication use during pregnancy for neurologic conditions

Care of the pregnant patient is challenging because of the multiple physiologic changes associated with pregnancy and the need to consider the impact of any intervention on the fetus. This article addresses management issues that arise while caring for patients with epilepsy, eclampsia, stroke, multiple sclerosis, and headache. An emphasis is placed on considerations involving medication use and approaches to patient care are suggested.

Clinical biochemistry of pregnancy

Major adaptations in maternal physiology and metabolism are required for successful pregnancy outcome. Hormonal changes initiated even before conception significantly alter maternal biochemistry early in pregnancy. Steroid hormones, peptide hormones, and prostaglandins interact to expand blood and plasma volume and modulate the maternal capacity to supply energy and nutrients to the fetoplacental unit. As gestation progresses, reference ranges for the concentration of many biochemical parameters change significantly from those found in the nonpregnant state. Gestation-specific reference ranges are essential for correct interpretation of tests used in screening, diagnosis, and monitoring during pregnancy. The use of clinical laboratory tests in the management of high-risk pregnancy are discussed from the perspective of testing before conception and during pregnancy.