Eclampsia. Intrapartum Management of Pre-eclampsia. Mild v. Severe Preeclampsia. Mild v. Severe Preeclampsia

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1 Intrapartum Management of Pre-eclampsia William. M. Gilbert, MD Regional Medical Director, Women Services Sutter Health, Sac-Sierra Region & Professor of OB/GYN University of California, Davis Eclampsia From the Greek word Eklampsis - a shining forth Occurrence of one or more convulsions, not attributable to other cerebral conditions such as epilepsy or cerebral hemorrhage, in a patient with preeclampsia Stedman s 26 th Edition1995 Mild v. Severe Preeclampsia Blood pressure - 140/90 Proteinuria - <5 gms in 24 hours Laboratory values normal Fetal condition no IUGR or oligohydramnios Maternal signs/symptoms Headache, visual changes, epigastric pain Mild v. Severe Preeclampsia Eclamptic patients: 1in 5 have relatively normal BP 1in 4 have no proteinuria 1 in 3 have no edema Difference between mild and severe arbitrary Disease is more of a continuum

2 Magnesium sulfate used for decades in the US No prospective studies initially done Antidotal evidence suggesting it works Given IM at Parkland Given IV other locations Other countries did not use MgSO4 Prospective randomized study. Lucas (1995, NEJM) Greater than 2000 women in study MgSO4 10 gm IM then 5 gm IM q 4 hours Severe disease also 4 gm IV Phenytoin 1000 mg IV over 1 hour then 500 mg oral 10 hours later. Risk of eclampsia Phenytoin 10 of 1089 vs MgSO4 0 of 1049 (P< 0.04) C/S rate 22% vs 27% (P = 0.047) No other differences Conclusion: MgSO4 superior for seizure prevention. MgSO4 vs placebo Duley Cochrane (2003) 6 trials, 11,444 patients, reports of good quality Eclampsia RR 0.41 (0.29, 0.58) Maternal death RR 0.54 (0.26, 1.1) Serious morbidity RR 1.08 (0.89, 1.32) Abruption RR 0.64 (0.50, 0.83) Conclusion: MgSO4 substantially more effective than placebo

3 MgSO4 vs diazepam, Duley Cochrane (2003) 7 trials, 1441 patients reports of good quality Maternal death RR 0.59 (0.37, 0.94) Recurrent seizure RR 0.44 (0.34, 0.57) Low Apgars RR 0.72 (0.55, 0.94) Conclusion: MgSO4 substantially more effective than diazepam MgSO4 vs nimodipine, Belfort (2003, NEJM) Multicentered trial, 1650 patients Severe preeclampsia MgSO4 given per institutional protocols Nimodipine 60 mg orally q 4 hours Nimodipine vs MgSO4, Belfort (2003, NEJM) Seizures 2.6 vs 0.8% RR 3.2 (1.1, 9.1) More seizures postpartum MgSO4 required more hydralizine Conclusion: MgSO4 more effective than nimodipine for severe preeclampsia Livingston et al 2003 RCT of MgSO4 for mild preeclampsia 222 patients randomized No differences in outcomes Editorial comment by Dr. Scott Study was underpowered Large RCT should be undertaken

4 Sibia BM Am J O&G 2004, clinical opinion MgSO4 works for severe preeclampsia to decrease eclampsia No difference in maternal or neonatal morbidity Research on mild preeclampsia not clear, therefore MgSO4 should not be routinely used in mild preeclampsia. Controversial conclusion Dr Sibia is one of the leading authorities in US, if not the world. Numerous publications on subject Goes against dogma of training programs Raises medical legal issues Untreated patient has seizure Treated patient has complications Alexander et al. O&G 2006 Parkland Memorial Hospital 1999 switched to IV MgSO4 from IM 6 month period with IV MgSO4 4.5 year observational study of 72,004 patients Severe treated, mild not unless progressed Alexander et al. O&G 2006 MgSO4 was given if BP > 140/90, and severe by other factors 2+ proteinuria, Cr > 1.2, Pl Ct < 100,000, LFT 2 times normal, persistent HA, visual changes, persistent epigastric pain. 6,431 with preeclampsia, 3,935 with severe disease

5 Study period compared to prior 5 years 50% increase in seizures (P < 0.04) Seizure group more general anesthesia 23% vs 4% P < Infants had worse outcomes 12% v 1% Conclude: Increase in seizures with possible worse outcomes. Conclusions Incidence of eclampsia more than doubled. Increase in maternal and neonatal morbidity 2 nd to seizures 60% of women with PIH had severe disease and received MgSO4 No serious magnesium toxicity. Postpartum treatment of Preclampsia Ehrenberg et Mercer O&G (2006) 12 vs 24 hours postpartum tx of mild disease 200 patients randomized, 7% continued MgSO4 beyond 12 hours IDDM, higher BPs to start and at randomization Conclusion: With mild disease 12 hours = to 24 hours

6 Conclusions for prevention of eclampsia MgSO4 is drug of choice to prevent seizures or re-seizure MgSO4 for mild preeclampsia less clear but probably medically-legally indicated. Meet criteria for mild before starting MgSO4 140/90 or greater at least twice Rule out other causes of increase BP, i.e. pain Witlin et al O&G 92:883-9 Scott 2003 O&G 101:213 Livingston 2003 O&G 101: Sibia 2004 AJOG 190: Lucas 1995 NEJM 333:201 Duley 2003 Cochrane database review Belfort 2003 NEJM 348: Alexander 2006 O&G 108: Ehrenberg 2006 O&G 108: Witlin 1997 AJOG 176:623-7 References