1. Critical care management of preeclampsia and eclampsia
Gunnar Dahlgren, MD, PhD
Department of Anesthesia and Intensive Care
Karolinska University Hospital
Stockholm

2. The obstetric ICU patient
Intensive Care Unit
Delivery room
Post Anesthesia
Care Unit
Operating room

3. The cause of preeclampsia is unknown
Primary placental causes
Secondary maternal systemic illness
Ill-defined links between the two (maternal systemic inflammatory response?)

4. 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

5. 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

6. 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

7. 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:

8. Preeclampsia/eclampsia definitions
Preeclampsia: Hypertension >140/90 with proteinuria of at least 0.3g/24h
Severe preeclampsia: Preeclampsia with hypertension >160/110 or proteinuria >5g/24h or multiorgan involvement
Eclampsia: Convulsions in any woman who has, or then presents with, hypertension in pregnancy of any cause

9. Symptoms other than hypertension and proteinuria in severe preeclampsia
Oliguria (<400 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

10. Fetal complications of severe preeclampsia
Intrauterine growth retardation
Premature delivery
Abruptio placentae
Fetal distress/fetal demise
Associated maternal risks
General/regional anesthesia
DIC
Hemorrhage

11. 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)

12. ”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:

13. 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:

14. 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)

15. Cardiac failure?
Untreated preeclamptic women almost always have low filling pressures and a hyperdynamic circulation

16. Untreated pre-eclampsia
Best Pract Res Clin Obst Gyn 2001: 15:

17. 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

18. Treated pre-eclampsia
Best Pract Res Clin Obst Gyn 2001: 15:

19. 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

20. Pulmonary edema
Best Pract Res Clin Obst Gyn 2001: 15:

21. 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

22. 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:

23. 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 <100 ml/4h
Plasma volume expansion if CVP is <5 mmHg
Furosemide if fluid balance is positive
Echocardiography
PA catheter to optimize left ventricular preload (PCWP mmHg) and reduce afterload appropriately

24. 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

25. 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

26. Lancet 1995: 345:

27. Lancet 2002: 359:

28. Eclampsia
The treatment of choice for eclampsia and prophylaxis against recurrent convulsions is magnesium sulphate (Lancet 1995: 345: )
Magnesium sulphate is also the drug of choice for seizure prophylaxis in patients with preeclampsia (Lancet 2002: 359: )
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!

29. Impending eclampsia
Severe preeclampsia with signs of cerebral affection like visual disturbancies, headache, increased reflexes, and clonus
BJA 1996: 76:

30. 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