Eclampsia

Eclampsia is the development of a convulsive attack, a series of convulsive seizures in women against gestosis in the absence of other causes that can cause a seizure.

Eclampsia is considered to be one of the most severe complications in obstetrics, determining high rates of maternal (annually, up to 50,000 women die from eclampsia) and perinatal morbidity and mortality in developing countries. The incidence of eclampsia in developed countries averages 1 in 2000-3500 births and varies considerably depending on the quality of antenatal care and the socioeconomic status of women.

[1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11]

Causes Eclampsia

Causes of eclampsia

Eclampsia is a complication of gestosis, the etiology of which is not precisely defined at the present time. A number of risk factors for the development of gestosis have been described - from genetic defects to infection, but none gives a reliable prognosis. This also explains the lack of effective measures for the prevention and treatment of gestosis and eclampsia, with the exception of delivery.

[12], [13], [14], [15], [16]

Pathogenesis

How does eclampsia develop?

In case of physiologically occurring pregnancy, the upper limit of MC autoregulation is reduced in women, vascular permeability is increased and the content of extravascular fluid is increased. With pre-eclampsia, vascular spasm with arterial hypertension, damage to the vascular endothelium, further increase in interstitial edema lead to a disturbance of MC autoregulation, increased cerebral vascular tone, hyperperfusion, and vasogenic brain edema. These changes in the majority serve as a basis for the development of such neurological symptoms as headache, visual disturbances and convulsive attacks. Hemorrhages in the substance of the brain are much less common, and they are mostly shallowly focal.

Timely not eliminated violations of cerebral circulation lead to an increase in hypoxia, vasogenic and cytotoxic edema of the brain and the formation of encephalopathy of complex genesis, which manifests itself more pronounced neurologic symptoms (cortical blindness, hemiparesis), up to the development of coma.

It should be borne in mind that eclampsia occurs in conditions of MI against the background of gestosis. This leads to the development of complications such as premature placental abruption (7-11%), DIC (8%), AL (3-5%), OPN (5-9%), HLLR syndrome (10 -15%), hematoma of the liver (1%), aspiration pneumonia (2-3%), pulmonary-cardiac failure (2-5%).

Diagnostics Eclampsia

Diagnosis of eclampsia

Most often (in 91%), eclampsia occurs after the 28th week of pregnancy. Less often it is observed between the 21st and 27th (7.5%) or until the 20th week of pregnancy (1.5%). At the same time, eclampsia occurs during pregnancy in 38-53%, during childbirth - in 18-36% and in the puerperium - in 11-44% of cases, and this can occur both in the first 48 hours and for 28 days after childbirth, which is called late eclampsia.

When assessing the risk of developing eclampsia, it is necessary to take into account the presence of symptoms of severe gestosis and pre-eclampsia.

Eclampsia in 30% of cases can occur against the background of minimal symptoms of gestosis, which significantly reduces the effectiveness of the prognosis and ongoing preventive measures. This point is extremely important for understanding that very often eclampsia is not a logical conclusion of the progression of preeclampsia and can occur at any of its severity.

[17], [18], [19], [20], [21], [22], [23]

Laboratory research

Same as with severe gestosis.

Instrumental methods

CT or MRI of the brain is shown:

• when developing a convulsive attack before the 20th week of pregnancy or 48 hours after birth,
• eclampsia, resistant to magnesium sulfate therapy,
• presence of rough focal neurological symptoms (hemiparesis),
• coma.

To verify the vascular spasm, transcranial dopplerometry of cerebral vessels is indicated.

Evaluation of the fetus is carried out by standard methods.

Differential diagnostics

The development of a seizure during pregnancy can be associated with many diseases:

• Vascular diseases of the central nervous system.
• Ischemic stroke.
• Intracerebral hemorrhage or aneurysm rupture.
• Thrombosis of veins of cerebral vessels.
• Tumors of the brain.
• Abscesses of the brain.
• Arteriovenous malformation.
• Arterial hypertension.
• Infections (encephalitis, meningitis).
• Epilepsy.
• Strong substances (amphetamine, cocaine, theophylline, chlordiazepoxide).
• Hyponatremia, hypokalemia, hyperglycemia.
• Thrombotic thrombocytopenic purpura.
• Post-puncture syndrome.

Great importance in the differential diagnosis of eclampsia and other diseases have CT or MRI of the brain, especially in situations requiring neurosurgical treatment. If it is impossible to accurately verify the diagnosis, convulsive seizure should be considered as eclampsia.

[24], [25], [26], [27], [28], [29], [30], [31], [32]

Treatment Eclampsia

Treatment of eclampsia

Intensive treatment of eclampsia in the prenatal period:

• stabilization of the state,
• achieving an anticonvulsant effect,
• a decrease in blood pressure.

Non-drug treatment

• Assessment of airway patency, pressure on the cricoid cartilage (to prevent aspiration of gastric contents), oxygen therapy.
• Turn on the left side.
• Non-invasive monitoring of blood pressure, heart rate, saturation, diuresis control.

Medication

Within the framework of anticonvulsant therapy, several drugs are used in the order listed.

Magnesium sulfate is the main drug for the treatment of severe gestosis and eclampsia. The scheme of application of 5 g intravenously for 10-15 minutes, then - 2 g / h drip dropper.

Effects of magnesium sulfate sedative, anticonvulsant, hypotensive, tocolytic, prolonging effect of muscle relaxants. Magnesium sulfate is superior to benzodiazepines, phenytoin and nimodipine for the effectiveness of prevention of eclampsia, does not increase the frequency of cesarean delivery, bleeding, infectious diseases and drug-induced neonatal depression. Magnesium sulfate is contraindicated for individual intolerance, Addison's disease, myasthenia gravis, anuria and severe liver damage. Carefully used in oliguria and anuria.

Benzodiazepines - diazepam 20 mg intramuscularly or intravenously. Effects of diazepam are sedative, anticonvulsant, anxiolytic, myorelaxing. Do not recommend the use in large doses.

Barbiturates - phenobarbital 0.2 g / day inside. Effects of phenobarbital anticonvulsant, sedative, anxiolytic, myorelaxing.

If inefficiency is shown, additional administration of 2 g of magnesium sulfate, benzodiazepines and intravenous application of general anesthetics, muscle relaxants and transfer to mechanical ventilation.

Stabilization of blood pressure

There are no uniform standards for the use of antihypertensive drugs. In the literature, it is believed that antihypertensive therapy for eclampsia is recommended in accordance with regional standards, since no single drug has been proven to be effective to date. Given all the adverse effects, diazoxide, ketanserin and atenolol are not recommended. Also do not recommend any diuretics. Absolutely contraindicated angiotensin-converting enzyme inhibitors and angiotensin receptor antagonists. Hypotensive therapy is performed with an increase in diastolic blood pressure of more than 90 mm. Gt; Art.

Infusion therapy

At present, the advantages of none of the plasma substitutes in intensive eclampsia for the outcome of pregnancy and childbirth have been proven. It was shown that the restriction of the injected fluid positively influences the result, and first of all it concerns the progression of ARDS. Infusion (only crystalloids) is carried out in a volume of up to 80 ml / h, optimally - 40-45 ml / h. The control of the infusion therapy is carried out with the help of the diuresis rate estimation:

• less than 30 ml / h - oliguria,
• 30-50 ml / h - reduced diuresis,
• 50-60 ml / h and more - adequate diuresis.

With eclampsia, CVP is not so informative and therefore, in the absence of other indications, there is no need for catheterization of the subclavian vein in the acute period.

The protocol of drug therapy of eclampsia before delivery

• Intravenously magnesium sulfate 5 g for 5-10 minutes, and then at a speed of 2 g / h.
• Benzodiazepines (diazepam 20 mg).
• Barbiturates (phenobarbital 0.2 mg). With preservation of convulsive readiness - thiopental sodium 100-200 mg intravenously drip and IVL.
• Infusion therapy in the volume up to 40-45 ml / h (only crystalloids).

Hypotensive therapy

With preserved consciousness after an attack of seizures, one should continue conservative therapy for 1-4 hours with saturation of magnesium with sulphate and observation of the neurological status. At the same time, delivery is necessary.

In the absence of consciousness after an attack of convulsions (coma), it is necessary to start the IVL under the conditions of an initial anesthesia with sodium thiopental followed by an urgent delivery.

In the past 20 years, randomized controlled trials have not been conducted on the use of the following drugs and treatments, such as:

• o-neuroleptics (droperidol),
• FFP, albumin,
• plasmapheresis, UV,
• dipyridamole, pentoxifylline,
• diuretics (furosemide, mannitol),
• narcotic analgesics (morphine, trimeperidine, promedol),
• heparin sodium.

Delivery

Eclampsia is an indication for emergency delivery. The preferred method of delivery after an eclampsia attack is a cesarean section. The operation of superimposing obstetric forceps is indicated if an eclampsia attack occurred during an attempt and the fetal head is in a narrow part or in the plane of exit from the pelvic cavity. Conservative completion of labor through the natural birth canal with eclampsia is possible only when the fetal head is cut in.

At the gestational age of less than 34 weeks, in the absence of a critical condition, a woman should be recommended to prevent ARDS of the fetus with glucocorticoids within 24 hours, but in practice this is very rare.

[33], [34], [35]

Intensive care for eclampsia and anesthesia for caesarean section

After an attack of eclampsia and lack of consciousness during the operation of cesarean section, the method of choice is general anesthesia, which is carried out according to the scheme below:

• Introductory anesthesia, taking into account the risk of developing high AH thiopental sodium - 6-7 mg / kg and fentanyl - 50-100 mcg.
• To prevent the progression of hypertension in the operation stage prior to fetal extraction, an inhalation anesthetic enflurane can be used up to 1.0 vol%, isoflurane up to 1.0 vol%, or sevoflurane up to 1.5 vol%.
• The quality of induction anesthesia in women with eclampsia should be paid special attention, it should not be superficial, ostensibly in order to avoid drug-induced depression of the fetus, and just the opposite - as deep as possible.
• After an attack of eclampsia and a saved consciousness, caesarean section is possible in the background of spinal anesthesia.
• Immediately after the operation, the introduction of magnesium sulfate in a dose of 2 g / hr (continued) to achieve an anticonvulsant effect.
• For the prevention of postpartum hemorrhage during the suturing of the uterine wound, only oxytocin is used, and methylergometrine is absolutely contraindicated.

Intensive Care Tactics after Delivery

After the cesarean section is completed, under the conditions of general anesthesia, the patient undergoes prolonged ventilation under conditions of sodium thiopental sedation and total myoplegia. There should be no temporary guidelines for prolonged ventilation, since it does not really need more than 50% of women with eclampsia.

Indications for prolonged ventilation

• coma,
• hemorrhage in the brain,
• coagulopathic bleeding,
• shock (hemorrhagic, septic, anaphylactic, etc.),
• syndrome of acute damage to lung APL, ORD C, alveolar AL,
• unstable hemodynamics,
• progressive PON.

Anesthesiologist-resuscitator should take into account that without adequate complex therapy of severe gestosis and eclampsia aimed at eliminating cerebral circulation disorders and, accordingly, providing an anticonvulsant and hypotensive effect, the ventilator will not in itself provide a favorable outcome. For this reason, the duration of the ventilation will be determined in each specific case and can range from a few hours to several days and weeks.

When carrying out prolonged ventilation, it is necessary to provide a mode of normoventilation and to determine the extent of neurological disturbances in the first hours after delivery. For this purpose, at the first stage, muscle relaxants are canceled and convulsive readiness is evaluated. In its absence, the next step is the removal of all sedatives except magnesium sulfate, which provides an anticonvulsant effect in these conditions. After the end of the effect of sedatives, the level of consciousness is determined, with uncomplicated course of eclampsia, the elements of consciousness should appear within 24 hours. If this does not happen with complete cancellation of sedatives within 24 hours, CT and MRI of the brain should be performed. In this situation, the ventilation continues until the diagnosis is clarified.

Intensive drug therapy for eclampsia after delivery

• Continuation of magnesium sulfate in a dose of 1-2 g / h intravenously for at least 24 hours.
• Hypotensive therapy with a diastolic blood pressure of more than 90 mm. Gt; Art.
• Intravenous infusion of oxytocin (10 units to 2-3 hours).
• Prevention of thromboembolic complications, the introduction of prophylactic doses of low-molecular heparins begin 12 hours after the delivery and continue until discharge. Elastic compression of the lower limbs.
• Antibacterial therapy (cephalosporins III-IV generation, carbapenems - according to indications).
• Early nutritional support up to 2000 kcal / day (through a nasogastric tube from the first hours after surgery).

Depending on the specific situation (the volume of intraoperative blood loss, the degree of damage to the liver, kidneys, etc.), the infusion therapy program can be extended by including solutions of 6% hydroxyethyl starch of average molecular weight (200/05, 130 / 0.42) or modified gelatin and crystalloids. However, if in a postoperative period the patient is undergoing artificial ventilation with cerebral edema or pulmonary insufficiency (ARDS), the volume of intravenous fluid must be minimized, and more attention should be paid to enteral feeding.

• The most significant recommendations for intensive care for eclampsia, which have a high level of evidence.
• The etiology and pathogenesis of eclampsia is not fully understood, and in 30% of cases eclampsia occurs suddenly with any degree of preeclampsia severity.
• Laboratory and instrumental diagnostic methods have low prognostic value for the development of eclampsia.
• A seizure attack with eclampsia is associated with a violation of MC autoregulation, increased tonus of cerebral vessels, hyperperfusion and vasogenic edema of the brain. The development of coma is due to timely not eliminated impaired cerebral circulation, which leads to an increase in hypoxia, vasogenic and cytotoxic edema of the brain and the formation of encephalopathy of complex genesis.
• Prophylaxis of eclampsia is based on anticonvulsant and antihypertensive therapy.
• The drug of choice for the prevention and treatment of eclampsia is magnesium sulfate 5 g intravenously by bolus for 10 min, then intravenously strontaneously at a rate of 2 g / h. Magnesium sulfate surpasses all anticonvulsants currently used to prevent eclampsia.
• Hypotensive therapy includes a complex of drugs, the use of which should be based on regional standards. It is necessary to take into account contraindications to the use of antihypertensive drugs during pregnancy.
• When carrying out infusion therapy, you should limit the amount of intravenously injected liquid to 40-45 ml / h (maximum - 80 ml / h) and use only crystalloids.
• Before delivery, a constant monitoring of the fetal heartbeat is necessary.
• To prevent the development of eclampsia in women with preeclampsia for analgesia of labor and obstetrical operations, regional anesthesia (epidural, spinal) should be used.
• To prevent postpartum hemorrhage, only oxytocin is used. Methylergometrine in women with eclampsia is contraindicated.
• After delivery, an early evaluation of the neurological status is necessary to exclude the need for neurosurgical intervention and correction of treatment tactics.