Preeclampsia, Eclampsia and HELLP Syndrome
The patient with severe preeclampsia and its associated conditions of eclampsia and HELLP (Hemolysis, Elevated Liver enzymes and Low Platelets) syndrome usually present to Labor and Delivery and are often cared for completely by the obstetrical team, howe
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Meike Schuster, Emmie Ruth Strassberg, and Mary Jane Reed
Case Presentation A 36 year old primiparous woman at 32 weeks gestation with a past medical history of morbid obesity (BMI is 43 kg/m2) and tobacco use presents to Labor and Delivery complaining of headache and abdominal pain. On arrival to Labor and Delivery her blood pressure is 160/92 mmHg, her pulse is 110 beats per minute (bpm), respirations are 20 breaths per minute and oxygen saturation is 96 % on room air. She feels occasional contractions but denies any vaginal bleeding or leakage of fluid and appreciates good fetal movement. Her abdominal pain is located on the right side under her ribcage, and she has had nausea and vomiting. The headache woke her from sleep; she had taken acetaminophen 1000 mg at home with no relief. On physical exam, she has tenderness in the right upper quadrant but no guarding or rebound. She has edema in her face, hands, and lower extremities. Her reflexes are +3/4 bilaterally, and clonus is present. A repeat blood pressure 15 min later is 155/90 mmHg. Fetal heart tracing shows minimal variability and a baseline of 130 beats per minute. Irregular contractions
M. Schuster • E.R. Strassberg Maternal Fetal Medicine, Geisinger Medical Center, Danville, PA, USA M.J. Reed (*) Critical Care Medicine, Geisinger Medical Center, Danville, PA, USA e-mail: [email protected]
every 3–7 min are noted on tocometer. She reports that her headache is worse with accompanying “spots” in her vision. Laboratory tests including complete blood count and urinalysis were performed. Her protein/creatinine ratio results at 0.63, platelets are 90 K/uL, hemoglobin is 10 mg/dL, creatinine is 1.2 mg/dL, aspartate aminotransferase (AST) is 295 U/L and alanine aminotransferase (ALT) is 316 U/L. A bedside glucose is 82 mg/dL. Question What initial therapy should be started in this patient? Answer Magnesium Sulfate This patient meets criteria for preeclampsia with severe features, and, therefore, her initial treatment should be intravenous magnesium sulfate for seizure prophylaxis. A 6 g bolus of intravenous magnesium sulfate over 30 min and then a maintenance dose of 2 g/h was ordered. Betamethasone 12 mg IM was given for fetal lung maturity development and a second dose was ordered for 24 h later. As her magnesium bolus is just being hung she appears agitated and begins to seize. The seizure last 30 s and the 6 g magnesium sulfate bolus is given over the next 20 min. Fetal monitoring demonstrates fetal heart rate deceleration down to 60 bpm lasting 4 min with a return to baseline at 120 bpm and minimal variability. She has no past medical history of seizures.
© Springer International Publishing Switzerland 2017 R.C. Hyzy (ed.), Evidence-Based Critical Care, DOI 10.1007/978-3-319-43341-7_90
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Question What is the diagnosis? Answer Eclampsia Eclampsia is diagnosed in a pregnant patient with new onset seizures that cannot be attributed to another cause in patients with hypertension or other signs or symptoms of preeclam
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