by\ِMarwa Mahrous

ICU Protocol for pre-eclampsia-eclampsia

Obstetrics critical care Respiratory distress in pregnant patient Hemodynamic instability Altered mental status/neurological

abnormalities

Step 1: Initial assessment and resuscitationStep 2: Taking history and physical examinationStep 3: Send investigationsStep 4: Make a differential diagnosisStep 5: Admit to the ICU and monitor closelyStep 6: Management of severe preeclampsiaStep 7: Watch for complicationsStep 8: Managing complications

Step 1: Initial assessment and resuscitation

• Always anticipate difficult airway in pregnant patients.• Endotracheal intubation should be performed by a senior intensivist/anesthesiologist.• Difficult airway equipment for airway management must be thoroughly checked before proceeding to intubation, and alternative plan for definitive airway including surgical access should already be identified.• Supplemental oxygen may be required in some patients depending on theiroxygen saturation.• Target SpO 2 more than 95% with oxygen or ventilation.

Circulation• Two large-bore intravenous cannulae (14G or 16G) should be placed to administer fluids.• The Foley catheter should be placed to monitor urine output.• Judicious fluid administration is needed to optimize preload and at the same time to avoid overload.• Nurse in the left lateral position (30° wedge to the right hip) to prevent supine hypotension syndrome.Disability (neurological)• Magnesium sulfate is a drug of choice for control of seizures.• 4–6 g is diluted in 100 mL of IV fluid bolus over 20 min.

Step 2: Taking history and physical examination

• Detailed history should be taken about pregnancy, antenatal evaluation, immunization, hypertension, and PIH (pregnancy induced hypertension) during the previous pregnancy.• Complications and outcome of the previous pregnancy and family history of hypertension should be required.

• History includes symptoms displaying end-organ effects to detect presence ofsevere preeclampsia:– Headache– Visual disturbances—blurred, scintillating scotomas– Altered mental status– Blindness– Dyspnea– Edema– Epigastric or right upper quadrant abdominal pain– Weakness or malaise—may be evidence of hemolytic anemia• The physical examination includes the evaluation of end-organ dysfunction fordiagnosis of severe preeclampsia:– Altered mental status– Decreased vision or scotomas

– Papilledema– Epigastric or right upper quadrant abdominal tenderness– Peripheral edema– Seizures– Focal neurologic deficit• PIH (preeclampsia) is defined as presence of hypertension (BP ³ 140/90 mmHg) on two occasions, at least 6 h apart in more than 20 weeks’ gestation in women with previously normal BP and who have proteinuria ( ³ 0.3 g protein in 24-h urine specimen), with or without pedal edema.• Severe preeclampsia is defined in Table 7 5.2 .• Eclampsia is defined as seizures that cannot be attributable to other causes in a woman with preeclampsia.

Step 3: Send investigations

• Complete blood cell count.• Liver function tests.• Renal function tests and serum electrolytes.• Arterial blood gas and blood glucose.• Coagulation profile (prothrombin time [PT], activated partial thromboplastintime [aPTT], and fibrinogen, international normalized ratio).• Lactate dehydrogenase.• Uric acid.• Urine routine microscopy, 24-h urine protein, and creatinine.• Additional tests—peripheral smear, serum magnesium levels.• Ultrasonography is used to assess the status of the fetus as well as to evaluategrowth retardation.• Transthoracic echocardiography.

Step 4: Make a differential diagnosis

Step 5: Admit to the ICU and monitor closelyICU admission is indicated with:• Obstetric hemorrhage• Placental abruption• Severe preeclampsia/eclampsia• Hemolysis, elevated liver enzymes, and low platelet (HELLP) syndrome• Chorioamnionitis• Acute pulmonary edema• Respiratory failure• Acute respiratory distress syndrome• Acute renal failure

Maternal monitoring is required with severe preeclampsia:• Repeated clinical assessment including neurological examination (deep tendon reflexes for magnesium toxicity).• ECG.• Arterial BP—noninvasive BP can be tried initially but may be incorrect withinadequate cuff size.• Pulse oximetry.• Foley catheterization—urine output monitoring.• Blood gas monitoring.• CVP monitoring—infusion of vasopressors.• Additional—intra-abdominal pressure during resuscitation, serum magnesiumlevels.

Step 6: Management of severe preeclampsia

The most important aspect in the management of severe preeclampsia is control of hypertension.A . BP control• Arterial pressure greater than 160/110 mmHg in preeclampsia can increasethe risk of complication, and it should be controlled.• BP control should only be done in the ICU, preferably with arterial linemonitoring.• BP control should also be done along with fetal monitoring. Avoid suddenfall in BP as it can result in fetal distress.• Goal of BP control is 15–25% reduction in the mean arterial pressure, andreduction of pressure to normal levels (<140/90 mmHg) should be avoided asit may compromise placental perfusion.

• Drugs– Labetalol (IV 20 mg) can be given initially followed by doubling the doseevery 10 min to a cumulative dose of 300 mg. This drug can result insevere bradycardia. A continuous infusion of labetalol at a rate of 0.5–2 mg/min can also be used.– Hydralazine (5–10 mg) can be given every 20 min (maximum of 40 mg)until BP is controlled.– Nifedipine or nicardipine can be given (sudden precipitous decrease in BPor bradycardia can occur).– Intravenous nitroglycerin (10–100 mg/min) or sodium nitroprusside (2–8 mg/min) can be given. Prolonged use of nitroglycerin may lead to methemoglobinemia.Cyanide toxicity in the mother and fetus may occur with sodiumnitroprusside, limiting its use to less than 4 h and only as a last resort.

B. Seizure control• The initial management of eclampsia includes airway, breathing, andcirculation.• The initial bolus of magnesium (4 g over 20 min) is followed by an infusionof 1–2 g/h.• The mechanism of action of magnesium is unknown, but magnesium suppressesexcitatory neurotransmitter release by replacing calcium at nerve endings.• Monitor toxicity—loss of deep tendon reflexes; loss of patellar reflex occurswhen the plasma magnesium level is more than 10 mg%. Look for respiratorymuscle weakness.• Magnesium has a relatively narrow therapeutic range, and target magnesiumserum concentrations are 5–8 mg/dL.

• Infusion dose should be reduced in case of renal dysfunction. Serum magnesiumlevel should be monitored Table 75.4 .• In recurrent seizure, additional 2 g of magnesium sulfate can be given concurrentlywith the magnesium sulfate infusion.• If seizures are not controlled by repeat magnesium bolus, then diazepam orlorazepam can be administered (See chap. 28).• Discontinue magnesium sulfate 24 h after delivery.

C. Fluid management• Despite the peripheral edema, patients with preeclampsia are volume depleted with high peripheral vascular resistance. Diuretics should be avoided .• Aggressive volume resuscitation, on the other hand may lead to pulmonary edema, which is a common cause of maternal morbidity and mortality.Because volume expansion has no demonstrated benefit, patients should be fluid restricted when possible, at least until the period of postpartum diuresis.• Central venous or pulmonary artery pressure monitoring or other hemodynamic monitoring modality may be indicated in critical cases.• Careful measurement of fluid input and output is advisable, particularly in the immediate postpartum period.

D. Delivery• Women with severe preeclampsia who are managed expectantly must bedelivered under the following circumstances:• Nonreassuring fetal heart status• Uncontrollable BP• Oligohydramnios, with amniotic fluid index of less than 5 cm• Severe intrauterine growth restriction• Oliguria (<500 mL/24 h)• Serum creatinine level of at least 1.5 mg/dL• Pulmonary edema• Shortness of breath or chest pain with pulse oximetry of <94% on room air• Headache that is persistent and severe• Right upper quadrant tenderness with deteriorating liver function test• Development of HELLP syndrome

Step 7: Watch for complications• Abruptio placentae• Disseminated intravascular coagulopathy (DIC)• Renal insufficiency and acute renal failure• HELLP syndrome• Eclampsia• Cerebral hemorrhage• Fetal changes—intrauterine growth restriction, abruptio placentae, oligohydramnios • Intrauterine fetal death

Step 8: Managing complicationsHELLP syndrome• HELLP syndrome can complicate 4–12% of patients with severe preeclampsia.• Signs and symptoms are right upper quadrant or epigastric pain, nausea and vomiting,malaise, and nonspecific viral-like symptoms. Physical examination findingsinclude right upper quadrant or epigastrium tenderness and generalized edema.• Delivery is the definitive treatment for HELLP syndrome.• Delivery is indicated for women with HELLP syndrome at greater than 34 weeks’gestation. During labor and for 24-h postpartum, patients should receive intravenousmagnesium sulfate for seizure prophylaxis.• If gestation is less than 34 weeks, delivery may be delayed for a steroid course ofbetamethasone (12 mg intramuscularly, every 24 h) in two doses, with delivery24 h after the last dose.• Platelets are generally transfused when the platelet count is less than 20,000/mm 3 . For cesarean delivery or with any significant bleeding, platelets should betransfused if the platelet count is less than 50,000/mm 3 .

Acute pulmonary edema• Management is similar as in nonpregnant patients.• Intravenous furosemide (bolus 20–40 mg over 2 min) is used to promote diuresis. The repeated doses of 40–60 mg are given after 30 min or infusion if there is inadequate diuretic response (maximum dose 120 mg/h).• Careful fetal monitoring, fluid restriction, and strict fluid balance and positioning (such that the head is elevated) are required.

R. Chawla and S. Todi (eds.), ICU Protocols: A stepwise approach, DOI 10.1007/978-81-322-0535-7_76, © Springer India 2012