Preeclampsia and Eclampsia Management

Preeclampsia: Definition & Dx - Spotting the Signs

• New HTN >20 wks gestation + Proteinuria OR End-organ dysfunction.
• Diagnostic Criteria:

• 📌 HELLP: Hemolysis, EL (Elevated Liver enzymes), LP (Low Platelets).

⭐ Postpartum preeclampsia can occur, usually within 48h but up to 6 weeks.

Pathophysiology: Preeclampsia - Systemic Storm

• Abnormal Placentation: Defective spiral artery remodeling by cytotrophoblasts → placental hypoperfusion & ischemia.
  • Release of anti-angiogenic factors (sFlt-1, sEng) & pro-inflammatory mediators.
• Endothelial Dysfunction: Systemic maternal endothelial cell activation/damage → ↑vascular permeability, ↓vasodilation (↓NO, ↑endothelin).
• Vasospasm: Generalized vasoconstriction → hypertension, reduced organ perfusion (kidney, liver, brain, placenta).

⭐ Imbalance between thromboxane A2 (vasoconstrictor, platelet aggregator) and prostacyclin (vasodilator, platelet inhibitor) is a key feature, with ↑Thromboxane A2 / ↓Prostacyclin ratio.

This leads to a multi-systemic disorder characterized by hypertension and end-organ damage.

Complications: Maternal & Fetal - Double Danger

• Maternal:
  • CNS: Eclampsia (seizures), CVA (stroke), PRES (Posterior Reversible Encephalopathy Syndrome)
  • CV: Severe HTN, pulmonary edema, cardiac failure
  • Hematologic: HELLP (📌 Hemolysis, Elevated Liver enzymes, Low Platelets), DIC
  • Renal: AKI (Acute Kidney Injury), oliguria
  • Hepatic: Subcapsular hematoma, rupture
  • Respiratory: ARDS (Acute Respiratory Distress Syndrome), laryngeal edema
• Fetal:
  • Placental insufficiency: IUGR (Intrauterine Growth Restriction), oligohydramnios
  • Abruptio placentae
  • Prematurity & sequelae
  • HIE (Hypoxic Ischemic Encephalopathy), IUFD (Intrauterine Fetal Demise)

⭐ HELLP syndrome: major risk for mother & fetus. Suspect with RUQ pain, N/V, malaise in preeclampsia.

Anesthesia: Preeclampsia - Navigating Safely

• Goal: Maternal-fetal safety, stable hemodynamics, prevent eclampsia.
• Pre-anesthetic: Airway (edema!), platelets (neuraxial if >70-80k/µL), BP control (SBP <160, DBP <110 mmHg).
• Neuraxial (Epidural/Spinal): Preferred. Gradual onset aids BP stability. Avoid if coagulopathy.
• General Anesthesia (GA):
  • For severe thrombocytopenia (<70k), urgent C/S, failed/contraindicated regional.
  • Risks: Difficult intubation (anticipate!), hypertensive response, aspiration.
  • Mgmt: RSI, short-acting agents, attenuate pressor response (Labetalol).
• Key: Continue $MgSO_4$ (potentiates NMBs). Judicious IV fluids (pulmonary edema risk).

⭐ $MgSO_4$ is the primary anticonvulsant; it also decreases MAC of volatile anesthetics and potentiates neuromuscular blockade.

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Eclampsia & HELLP Mgmt - Crisis Control Now

• Eclampsia:

  • Immediate: ABCs, Left lateral. Prevent injury.
  • Seizure control: MgSO4
    • Loading: 4-6g IV (15-20 min).
    • Maintenance: 1-2g/hr IV.
    • Antidote: Ca Gluconate 1g IV.
  • BP control: If SBP ≥160 / DBP ≥110 mmHg (Labetalol, Hydralazine).
  • Definitive: Prompt delivery post-stabilization.

• HELLP Syndrome:

  • Diagnosis (📌 HELLP):
    • Hemolysis: LDH >600 U/L.
    • Elevated Liver enzymes: AST/ALT >2x ULN or >70 U/L.
    • Low Platelets: <100,000/mm³.
  • Management:
    • Stabilize: MgSO4 (prophylaxis), BP control.
    • Corticosteroids: If <34 wks (fetal lungs); may aid maternal PLT.
    • Delivery: Definitive. Prompt if >34 wks or unstable.

⭐ For HELLP syndrome, delivery is indicated regardless of gestational age with maternal multi-organ dysfunction or non-reassuring fetal status. """

High‑Yield Points - ⚡ Biggest Takeaways

• Preeclampsia: New-onset hypertension (>140/90 mmHg) after 20 weeks gestation + proteinuria or end-organ dysfunction.
• Eclampsia: Preeclampsia + new-onset grand mal seizures.
• Magnesium sulfate (MgSO4): Key for seizure prophylaxis and treatment; monitor for toxicity.
• Definitive management: Prompt delivery of the fetus and placenta.
• Neuraxial anesthesia (epidural/spinal) is preferred if platelets >75,000/µL and no coagulopathy.
• HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets) is a critical variant requiring urgent multidisciplinary care and often prompt delivery.