By Dr. Bill Young
As women progress through pregnancy, one of the more dangerous conditions that they may experience is that of eclampsia and preeclampsia. Both are classified as hypertensive disorders in the pregnant patient. An awareness of conditions that may predispose patients to preeclampsia and eclampsia are an important baseline for recognition. These disease processes are more common when the patient is
- in their teen years
- older than their mid-thirties or
- in their first pregnancy
- obese
- have a prior history of preeclampsia
- diabetic
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Preeclampsia
Preeclampsia is defined as the onset of hypertension after the 20th week of gestation and is accompanied by:
- protein in the urine
- a low platelet count
- poor renal and liver function
- pitting edema
- visual disturbances such as blurry or double vision
Preeclampsia is variable in its progression. The patient may be stable in the morning and in crisis by the afternoon. Cardiovascular effects of eclampsia include vascular vasospasm that can increase the workload of the left ventricle. The patient may experience blood clots. Pedal edema is common. Remember that such edema can be commonly found in women who are experiencing a normal pregnancy.
There is often a drastic drop in the renal filtration rate and a reduction in the renal blood flow. This often results in cerebral edema with an increase in the intracranial pressure leading to cerebral ischemia. This results in seizure activity and potential cerebellar necrosis. Mild preeclampsia is accompanied by an increase in the patients’ blood pressure and proteinuria. Preeclampsia will escalate with the mother’s blood pressure exceeding 160/110. Patients will commonly complain of severe headaches and pulmonary edema.
Eclampsia
Untreated preeclampsia will proceed into eclampsia. This often occurs after the 28th week. The patient will begin to suffer tonic clonic, generalized seizures lasting longer than a minute. During this period, patients will often be apneic leading to hypoxia for both mother and baby. You should suspect eclampsia for any patient who has seizure activity following trauma. A postictal period follows. The patient may exhibit tachypnea to combat the respiratory and lactic acidosis caused by her apnea.
Get a thorough history on your patient to differentiate the cause of seizures from other etiologies. One physical finding in these patients is that eclamptic patients will have high levels of body edema, whereas patient with a epilepsy will not.
Preeclampsia and eclampsia can occur after delivery. This is most common in the immediate days after delivery but may (rarely) present in the weeks immediately following delivery. Should you observe hypertension or seizures in this postpartum period, be aware that they may be eclampsia relater but be sure to aAssess your patient for other causes. The most serious presentations will be characterized by a blood pressure that is higher than 160/110.
If possible, determine the amount of weight gain as well as how quickly her weight increased. Assess for any vision disturbances or unexplained pain in the epigastrium or upper right quadrant of the abdomen. The skin may be pale. Listen to the patient’s breath sounds for rales.
Treatment
Delivery of the fetus is the definitive treatment for eclampsia. You are limited as to what can be done to speed this process along. This doesn’t mean that you cannot provide treatment for your patient. Ensure that your patient is placed in the left lateral recumbent position to offset supine fetal hypotension syndrome. This will also minimize aspiration if the patient vomits, which is common.
Start an IV on your patient at a KVO rate. Remember that the patient is moving fluid from the vascular system into the third space. Excessive amounts of fluid will only make her edema worse.
Magnesium sulfate is often administered to keep pre-eclampsia from progressing to eclampsia. Begin by giving a loading dose of 4 mg. Seizures will often be stopped by this initial dose. Many patients will see an improvement in their hypertension following this initial dose. Begin a maintenance dose at 1-2 g/hour. If seizure activity does not stop with magnesium, consider the use of diazepam by giving 1-2 mg very slow IV push.
Magnesium sulfate acts as a depressant on the central nervous system and can lead to respiratory depression or arrest. It is effective to reduce or eliminate seizure activity by forming a blockade of neuromuscular transmission. The antidote for toxicity of magnesium sulfate is to administer 5 to 10 mEq of a 10% calcium gluconate solution.
There are some important issues to remember when administering magnesium sulfate to the eclamptic patient. Inject the medication slowly to minimize the onset of respiratory issues. Monitor your patient’s respiratory rate. If administering multiple doses, test deep tendon reflexes prior to each administration; if absent, discontinue any additional doses.
Signs and symptoms of a magnesium sulfate overdose often include:
- a rapid drop in the blood pressure
- respiratory arrest
- ECG changes (increased PR, QRS, and QT intervals), heart block or asystole
When presented with a patient suffering from eclampsia or preeclampsia, rapid transport to the nearest facility that has obstetrical services. The definitive treatment for this disease process is the delivery of the baby. Make sure that you are going to a facility that can handle such an emergency.
Conclusion
While hypertensive disorders in pregnancy seem relatively rare—and are often identified through routine prenatal care–they are noted to be increasing. The rate of hypertensive disorders in pregnancy increased substantially over the years, from 528.9 in 1993 to 912.4 per 10,000 hospitalizations for pregnancy in 2014.
The role of the prehospital clinician is to be aware of these conditions in prenatal and postpartum states, apply therapeutic modalities as outlined above, and transport promptly to an appropriate facility.
About the Author
Dr. Bill Young began his EMS career in 1975 with a small fire department near Williamsburg, KY. They began running first responder calls long before the phrase ever existed. In addition to Kentucky, his career has taken him to Tennessee, Colorado, Georgia, and Kansas. He has served as a street medic, training officer, supervisor, state regulator, and educator. Currently, he is an Associate Professor in the Department of Paramedicine at Eastern Kentucky University located in Richmond KY.
References
- Bates, K., & Crozier, K. (2015). Managing Childbirth Emergencies in the Community and Low-Tech Settings. New York, New York: Palgrave Macmillan.
- Centers for Disease Control and Prevention. Data on Selected Pregnancy Complications in the United States. October 2016. www.cdc.gov/reproductivehealth/maternalinfanthealth/pregnancy-complications-data.htm. Accessed October17, 2021.
- Gabbe. Obstetrics: Normal and Problem Pregnancies. Hypertension. 5th ed. Churchill Livingstone, An Imprint of Elsevier; 2007.
- Kenny, L., English, F., & Mccarthy, F. (2015). Risk factors and effective management of preeclampsia. Integrated Blood Pressure Control, 7.
