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Eclampsia
Thrombocytopenia with a platelet level of less
than 100,000/mm3
Hemolysis (seen on peripheral blood smear)
Elevated liver enzyme levels
Pulmonary edema
Oliguria
Persistent need for antihypertensive medication,
except in selected cases between 25 and 27
weeks' gestation
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is indicated for antepartum, intrapartum,
and postpartum patients with a diastolic
BP of 105 mm Hg or higher. Acute
treatment for severe hypertension in
pregnancy involves reducing BP in a
controlled manner without reducing
uteroplacental perfusion.
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The goal is not to make the patient
normotensive but rather to reduce the
patient's diastolic BP to 90±100 mm Hg. A
rapid or significant drop in BP interferes
with uteroplacental perfusion and results in
fetal heart rate decelerations.
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|- , administered
IV, is the drug of choice for acute BP
control.
( , administered
IV, is an alternative therapy to IV
hydralazine for women who cannot be
given or have not responded to
hydralazine.
'
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Trimethaphan can be used to treat
sudden-onset extreme hypertension
requiring minute-to-minute titration.
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Patients with preeclampsia frequently are
hypovolemic because of loss of fluid into
the interstitial spaces due to low serum
oncotic pressure and because of
increased capillary permeability. These
same abnormalities, however, also put
these patients at increased risk for
pulmonary edema. IV fluids should be
restricted to 84±125 mL/hour.
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is defined as urine output of less than 100
mL in 4 hours; it is treated with a 500-mL
bolus of crystalloid fluid if the lungs are
clear. If no response to this treatment
occurs, then another 500-mL bolus can be
given. If there is still no response after a
total of 1 L has been administered, central
hemodynamic monitoring should guide
further management.
! $
Pulmonary artery catheterization is
required to guide therapy for pulmonary
edema.
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renal failure (acute tubular necrosis),
acute cortical necrosis,
cardiac failure,
pulmonary edema,
thrombocytopenia,
disseminated intravascular coagulopathy,
and
cerebrovascular accidents.
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Complication of pregnancy by severe
preeclampsia is associated with high
perinatal mortality and morbidity rates.
These high rates are attributable to
extreme prematurity, intrauterine growth
retardation (IUGR), abruptio placentae,
and perinatal asphyxia.
is defined as the development of convulsions,
coma, or both in a patient with preeclampsia.
Eclampsia occurs in 1% of patients with
preeclampsia. Although many other conditions
can result in seizures during pregnancy,
obstetric patients with seizures should be
considered eclamptic until proven otherwise.
Perinatal mortality in one U.S. series was 12%,
attributable to extreme prematurity, abruptio
placentae, and IUGR.
Although many other conditions can result
in seizures during pregnancy, obstetric
patients with seizures should be
considered eclamptic until proven
otherwise.
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Maternal complications may include
pulmonary edema, aspiration pneumonitis,
abruptio placentae with hemorrhage,
cardiac failure, intracranial hemorrhage,
and transient blindness.
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The etiology of eclamptic seizures is
unknown. It is thought that eclampsia
occurs when the patient's mean arterial
pressure exceeds the upper limit of
cerebral autoregulation. The arterioles
then fail to protect the cerebral capillaries
from the systemic hypertension. Increased
cerebral edema, increased intracranial
pressure, or both may play a role.
×"$
Eclampsia is an obstetric emergency
requiring immediate treatment.
Goals of therapy include the following:
± Control of seizures
± Correction of hypoxia and acidosis
± Control of severe hypertension
± Delivery
×
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×"! !, administered
parenterally, is the treatment of choice for
eclamptic seizures.
The alternative treatment is phenytoin.
The magnesium maintenance dosage
should be decreased as indicated by
clinical factors (absent deep tendon
reflexes, decreased respiratory rate,
oliguria, or renal insufficiency) or plasma
magnesium levels.
Duration of therapy is 24 hours
postdelivery or 24 hours after a
postpartum seizure.
The loading dose of MgSO4 is 6 g over
15±20 minutes IV. If the patient has a
seizure after administration of the loading
dose, another bolus of 2 g of MgSO4 can
be administered over 3±5 minutes.
! ! is treated with
diazepam, administered IV at a rate of 1
mg/minute, or up to 250 mg of sodium
amobarbital, slowly administered IV.
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The patient must never be left unattended.
Bedside rails should be elevated, and a
padded tongue depressor should be
available to prevent oral lacerations.
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Pulse oximetry should be performed or
arterial blood gas levels obtained. The
patient may require oxygen administration
by mask or endotracheal tube. Difficulty in
oxygenating patients with repetitive
seizures warrants a chest radiographic
examination to rule out aspiration
pneumonia.
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Treatment of hypertension in eclampsia is
the same as treatment in preeclampsia
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Induction of labor may begin, or a cesarean
section may be performed, after the patient is
stabilized.
Although prompt delivery is desirable, vaginal
delivery may be attempted in the absence of
other maternal or fetal complications.
Preparation for emergency cesarean section
should always be made in case maternal or fetal
condition deteriorates.
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Long-term neurologic sequelae of
eclampsia are rare. CNS imaging with CT
or MRI should be performed if seizures are
of late onset (longer than 48 hours after
delivery) or if neurologic deficits are
clinically evident.
The signs and symptoms of preeclampsia
usually resolve within 1±2 weeks
postpartum. Approximately 25% of
eclamptic patients develop preeclampsia
in subsequent pregnancies, with a
recurrence of eclampsia in 2% of cases.