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Eclampsia

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Eclampsia

Eclampsia
Classification and external resources
Specialty Obstetrics
ICD-10 O15
ICD-9-CM 642.6
DiseasesDB 4068
MedlinePlus 000899
eMedicine med/1905 emerg/796
MeSH D004461

Eclampsia is the onset of

External links

  1. ^ a b c d e f "40". Williams obstetrics (24th ed.). McGraw-Hill Professional. 2014.  
  2. ^ Lambert, G; Brichant, JF; Hartstein, G; Bonhomme, V; Dewandre, PY (2014). "Preeclampsia: an update.". Acta anaesthesiologica Belgica 65 (4): 137–49.  
  3. ^ "Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists’ Task Force on Hypertension in Pregnancy." (PDF). Obstet Gynecol. 122 (5): 1122–31. Nov 2013.  
  4. ^ WHO recommendations for prevention and treatment of pre-eclampsia and eclampsia. (PDF). 2011.  
  5. ^ Henderson, JT; Whitlock, EP; O'Connor, E; Senger, CA; Thompson, JH; Rowland, MG (May 20, 2014). "Low-dose aspirin for prevention of morbidity and mortality from preeclampsia: a systematic evidence review for the U.S. Preventive Services Task Force.". Annals of internal medicine 160 (10): 695–703.  
  6. ^ a b Smith, JM; Lowe, RF; Fullerton, J; Currie, SM; Harris, L; Felker-Kantor, E (5 February 2013). "An integrative review of the side effects related to the use of magnesium sulfate for pre-eclampsia and eclampsia management.". BMC pregnancy and childbirth 13: 34.  
  7. ^ McDonald, SD; Lutsiv, O; Dzaja, N; Duley, L (August 2012). "A systematic review of maternal and infant outcomes following magnesium sulfate for pre-eclampsia/eclampsia in real-world use.". International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics 118 (2): 90–6.  
  8. ^ Abalos, E; Cuesta, C; Grosso, AL; Chou, D; Say, L (September 2013). "Global and regional estimates of preeclampsia and eclampsia: a systematic review.". European journal of obstetrics, gynecology, and reproductive biology 170 (1): 1–7.  
  9. ^ Arulkumaran, N.; Lightstone, L. (December 2013). "Severe pre-eclampsia and hypertensive crises". Best Practice & Research Clinical Obstetrics & Gynaecology 27 (6): 877–884.  
  10. ^ GBD 2013 Mortality and Causes of Death, Collaborators (17 December 2014). "Global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013.". Lancet.  
  11. ^ Emile R. Mohler (2006). Advanced Therapy in Hypertension and Vascular Disease. PMPH-USA. pp. 407–408.  
  12. ^ Kane SC, Dennis A, da Silva Costa F, Kornman L, Brennecke S (2013). "Contemporary Clinical Management of the Cerebral Complications of Preeclampsia".  
  13. ^ a b c d "ACOG practice bulletin. Diagnosis and management of preeclampsia and eclampsia. Number 33, January 2002". Obstet Gynecol 99 (1): 159–67. January 2002.  
  14. ^ Cunningham FG, Fernandez CO, Hernandez C (Apr 1995). "Blindness associated with preeclampsia and eclampsia".  
  15. ^ Chesley LC, Annitto JE, Cosgrove RA (September 1968). "The familial factor in toxemia of pregnancy". Obstet Gynecol 32 (3): 303–11.  
  16. ^ a b c d Roberts JM, Cooper DW (January 2001). "Pathogenesis and genetics of pre-eclampsia". Lancet 357 (9249): 53–6.  
  17. ^ Zhou Y, Fisher SJ, Janatpour M, et al. (May 1997). "Human cytotrophoblasts adopt a vascular phenotype as they differentiate. A strategy for successful endovascular invasion?". J. Clin. Invest. 99 (9): 2139–51.  
  18. ^ Li H, Dakour J, Kaufman S, Guilbert LJ, Winkler-Lowen B, Morrish DW (November 2003). "Adrenomedullin is decreased in preeclampsia because of failed response to epidermal growth factor and impaired syncytialization". Hypertension 42 (5): 895–900.  
  19. ^ "Sex Primes Women for Sperm". BBC News. 6 February 2002. Retrieved 2007-11-19. 
  20. ^ Cipolla MJ (July 2007). "Cerebrovascular function in pregnancy and eclampsia". Hypertension 50 (1): 14–24.  
  21. ^ Richards A, Graham D, Bullock R (March 1988). "Clinicopathological study of neurological complications due to hypertensive disorders of pregnancy". J. Neurol. Neurosurg. Psychiatr. 51 (3): 416–21.  
  22. ^ Rozenberg, P. (Jan 2006). "[Magnesium sulphate for the management of preeclampsia]". Gynecol Obstet Fertil 34 (1): 54–9.  
  23. ^ Pritchard JA (February 1955). "The use of the magnesium ion in the management of eclamptogenic toxemias". Surg Gynecol Obstet 100 (2): 131–40.  
  24. ^ Lu JF, Nightingale CH (April 2000). "Magnesium sulfate in eclampsia and pre-eclampsia: pharmacokinetic principles". Clin Pharmacokinet 38 (4): 305–14.  
  25. ^ http://www.drugs.com/pro/magnesium-sulfate.html
  26. ^ Duley, L; Henderson-Smart, DJ; Walker, GJ; Chou, D (Dec 8, 2010). "Magnesium sulphate versus diazepam for eclampsia.". The Cochrane database of systematic reviews (12): CD000127.  
  27. ^ Duley, L; Henderson-Smart, DJ; Chou, D (Oct 6, 2010). "Magnesium sulphate versus phenytoin for eclampsia.". The Cochrane database of systematic reviews (10): CD000128.  
  28. ^ Duley, L; Gülmezoglu, AM; Chou, D (Sep 8, 2010). "Magnesium sulphate versus lytic cocktail for eclampsia.". The Cochrane database of systematic reviews (9): CD002960.  
  29. ^ Wictionary entry
  30. ^ Ong S. "Pre-eclampsia: A historical perspective", in Baker PN, Kingdom JCP, editors. Pr-eclampsia: Current perspectives on management; The Parthenon Publishing Group; New York, USA; 2004; pp. 15–24.
  31. ^ FAQ: Toxemia at the Pre-Eclampsia Foundation website

References

The Greek noun "ἐκλαμψία", eklampsía, denotes a "light burst"; metaphorically, in this context, "sudden occurrence."[29] The New Latin term first appeared in Johannes Varandaeus’ 1620 treatise on gynaecology Tractatus de affectibus Renum et Vesicae.[30] The term toxemia of pregnancy is no longer recommended: placental toxins are not the cause of eclampsia occurrences, as previously believed.[31]

Etymology

Invasive haemodynamic monitoring may be elected in an eclamptic woman at risk for or with cardiac disease, renal disease, refractory hypertension, pulmonary edema, or poor urine output.[13]

Monitoring

If the baby has not yet been delivered, steps need to be taken to stabilize the woman and deliver her speedily. This needs to be done even if the baby is immature, as the eclamptic condition is unsafe for both baby and mother. As eclampsia is a manifestation of a multiorgan failure, other organs (liver, kidney, lungs, cardiovascular system, and coagulation system) need to be assessed in preparation for a delivery (often a caesarean section), unless the woman is already in advanced labor. Regional anesthesia for caesarean section is contraindicated when a coagulopathy has developed.

Delivery

The agents of choice for blood pressure control during eclampsia are hydralazine and/or labetalol.[13] This is because of their effectiveness, lack of negative effects on the fetus, and mechanism of action.

Blood pressure management

Magnesium sulfate results in better outcomes than diazepam, phenytoin or a combination of chlorpromazine, promethazine and pethidine.[26][27][28]

Even with therapeutic serum magnesium concentrations, recurrent convulsions may occur, and additional magnesium may be needed, but with close monitoring for respiratory, cardiac, and neurological depression. If magnesium administration with resultant high serum concentrations fail to control convulsions, the addition of other intravenous anticonvulsants may be used, facilitate intubation and mechanical ventilation, and to avoid magnesium toxicity including maternal thoracic muscle paralysis.

With intravenous administration the onset of anticonvulsant action is fast and lasts about 30 minutes. Following intramuscular administration the onset of action is about one hour and lasts for three to four hours. Effective anticonvulsant serum levels range from 2.5 to 7.5 mEq/liter. Magnesium is excreted solely by the kidneys at a rate proportional to the plasma concentration and glomerular filtration.[25]

  • 7.0–10.0 mEq/L: loss of patellar reflex
  • 10.0–13.0 mEq/L: respiratory depression
  • 15.0–25.0 mEq/L: altered atrioventricular conduction and (further) complete heart block
  • >25.0 mEq/L: cardiac arrest

Convulsions are prevented and treated using magnesium sulfate.[22] The study demonstrating the effectiveness of magnesium sulfate for the management of eclampsia was first published in 1955.[23] Serum magnesium concentrations associated with maternal toxicity as well as neonatal depression, hypotonia, and low Apgar scores)[24] are:

Convulsions

The four goals of the treatment of eclampsia are to stop and prevent further convulsions, to control the elevated blood pressure, to deliver the baby as promptly as possible, and to monitor closely for the onset of multi-organ failure.

Treatment

Detection and management of pre-eclampsia is critical to reduce the risk of eclampsia. Appropriate management of women with pre-eclampsia generally involves the use of magnesium sulphate to prevent convulsions.

Prevention

Investigations include: CBC, renal function test (RFT), liver function tests (LFT), coagulation screen, 24-hour urine creatinine and protein, and fetal/placental ultrasound.

Convulsions during pregnancy that are unrelated to pre-eclampsia need to be distinguished from eclampsia. Such disorders include seizure disorders as well as brain tumor, aneurysm of the brain, and medication- or drug-related seizures. Usually the presence of the signs of severe pre-eclampsia precede and accompany eclampsia, facilitating the diagnosis.

Differential diagnosis

Eclampsia is a form of hypertensive encephalopathy: cerebral vascular resistance is reduced, leading to increased blood flow to the brain, cerebral edema and resultant convulsions.[20] An eclamptic convulsion usually does not cause chronic brain damage unless intracranial haemorrhage occurs.[21]

Placental hypoperfusion is linked to abnormal modelling of the fetal–maternal placental interface that may be immunologically mediated.[16] The invasion of the trophoblast appears to be incomplete.[17] The placenta produces the potent vasodilator adrenomedullin: it is reduced in pre-eclampsia and eclampsia.[18] Other vasodilators are also reduced, including prostacyclin, thromboxane A2, nitric oxide, and endothelins, also leading to vasoconstriction.[13] Many studies have suggested the importance of a woman's reduced immunological tolerance to her baby's father, whose genes are present in the young fetus and the placenta.[19]

The presence of a coagulation cascade may lead to microthrombi formation, which can further impair blood flow. Thirdly, increased vascular permeability results in the shift of extracellular fluid from the blood to the interstitial space, with further reduction in blood flow, and edema. These events lead to hypertension; renal, pulmonary, and hepatic dysfunction; and cerebral edema with cerebral dysfunction and convulsions.[16] Before symptoms appear, increased platelet and endothelial activation[16] may be detected.

Mechanism

Eclampsia, like pre-eclampsia, tends to occur more commonly in first pregnancies and young mothers where it is thought that novel exposure to paternal antigens is involved. Furthermore, women with pre-existing vascular diseases (hypertension, diabetes, and nephropathy) or thrombophilic diseases such as the antiphospholipid syndrome are at higher risk to develop pre-eclampsia and eclampsia. Having a large placenta (multiple gestation, hydatidiform mole) also predisposes women to eclampsia. In addition, there is a genetic component: a woman whose mother or sister had the condition is at higher risk than otherwise.[15] Women who have experienced eclampsia are at increased risk for pre-eclampsia/eclampsia in a later pregnancy. Pulmonary edema is a rather common complication of severe eclampsia affecting approximately 3% of the people with eclampsia: most is caused by too much intravenous fluid.

Risk factors

Sometimes the pregnant woman becomes comatose without preceding convulsions. Upon awakening from the coma, some experience amaurosis fugax: a "dark" and "fleeting" unilateral temporary blindness.[14]

The fetus may develop intrauterine growth retardation, and with maternal convulsions, bradycardia,[13] and fetal distress. Placental bleeding, and placental abruption may also occur.

Typically the pregnant woman develops hypertension and proteinuria before the onset of a convulsion, the hallmark of eclampsia.[12] Other cerebral signs may immediately precede the convulsion, such as nausea, vomiting, headaches, and cortical blindness. If the complication of multi-organ failure ensues, signs and symptoms of those failing organs will appear, such as abdominal pain, jaundice, shortness of breath, and diminished urine output.

Signs and symptoms

Contents

  • Signs and symptoms 1
  • Risk factors 2
  • Mechanism 3
  • Differential diagnosis 4
  • Prevention 5
  • Treatment 6
    • Convulsions 6.1
    • Blood pressure management 6.2
    • Delivery 6.3
    • Monitoring 6.4
  • Etymology 7
  • References 8
  • External links 9

[11] in the 5th century BCE.Hippocrates The word eclampsia is from the Greek term for lightning. The first known description of the condition was by [1] Around one percent of women with eclampsia die.[10] They resulted in 29,000 deaths in 2013 – down from 37,000 deaths in 1990.[9] Hypertensive disorders of pregnancy are one of the most common causes of death in pregnancy.[1] In the developed world rates are about 1 in 2,000 deliveries due to improved medical care.[8] Pre-eclampsia is estimated to affect about 5% of deliveries while eclampsia affects about 1.4% of deliveries.[1].cesarean section and emergency delivery of the baby either vaginally or by hydralazine Breathing may need to be supported. Other treatments may include blood pressure medications such as [6].developing world and developed This is true in both the [7][6] improves outcomes in those with eclampsia and is generally safe.magnesium sulfate The use of intravenous or intramuscular [1] Exercise during pregnancy may also be useful.[5][4] in areas with low intake, and treatment of prior hypertension with medications.calcium supplementation in those at high risk, aspirin Recommendations for prevention include: [1].hypertensive disorders of pregnancy. Preeclampsia and eclampsia are part of a larger group of conditions known as cardiac arrest, and kidney failure, cerebral hemorrhage, aspiration pneumonia. Complications include: coma or period of confusion type and typically last about a minute. Following the seizure there is typically either a tonic–clonic. Most often it is during the second half of pregnancy. The seizures are of the delivery Onset may be before, during, or after [3][2]

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