75 Severe Preeclampsia |
605 |
|
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Step 8: Managing complications
HELLP syndrome
•HELLP syndrome can complicate 4–12% of patients with severe preeclampsia.
•Signs and symptoms are right upper quadrant or epigastric pain, nausea and vomiting, malaise, and nonspecific viral-like symptoms. Physical examination findings include right upper quadrant or epigastrium tenderness and generalized edema.
•Delivery is the definitive treatment for HELLP syndrome.
•Delivery is indicated for women with HELLP syndrome at greater than 34 weeks’ gestation. During labor and for 24-h postpartum, patients should receive intravenous magnesium sulfate for seizure prophylaxis.
•If gestation is less than 34 weeks, delivery may be delayed for a steroid course of betamethasone (12 mg intramuscularly, every 24 h) in two doses, with delivery 24 h after the last dose.
•Platelets are generally transfused when the platelet count is less than 20,000/ mm3. For cesarean delivery or with any significant bleeding, platelets should be transfused if the platelet count is less than 50,000/mm3.
Acute pulmonary edema
•Management is similar as in nonpregnant patients.
•Intravenous furosemide (bolus 20–40 mg over 2 min) is used to promote diuresis. The repeated doses of 40–60 mg are given after 30 min or infusion if there is inadequate diuretic response (maximum dose 120 mg/h).
•Careful fetal monitoring, fluid restriction, and strict fluid balance and positioning (such that the head is elevated) are required.
Suggested Reading
1.Munnur U, Bandi V, Guntupalli KK. Management principles of the critically ill obstetric patient. Clin Chest Med. 2011;32(1):53–60.
This review discusses the principles in the management of the critical illness during pregnancy such as peripartum cardiomyopathy, hypertensive crisis, cardiopulmonary resuscitation, and massive transfusion protocol.
2.Sibai BM. Imitators of severe preeclampsia. Obstet Gynecol. 2007;109:956–66.
3.Coppage KH, Sibai DM. Treatment of hypertensive complications in pregnancy. Curr Pharm Des. 2005;11:749–57.
The article reviews the management of severe hypertension during pregnancy.
4.Martin JN Jr, Thigpen BD, Moore RC, Rose CH, Cushman J, May W. Stroke and severe preeclampsia and eclampsia: a paradigm shift focusing on systolic blood pressure. Obstet Gynecol. 2005;105:246–54.
5.Sibai BM. Diagnosis, controversies, and management of the syndrome of hemolysis, elevated liver enzymes, and low platelet count. Obstet Gynecol. 2004;103:981–91.
This review emphasizes the controversies surrounding the diagnosis and management of the HELLP syndrome and gives recommendation for diagnosis, management, and counseling of these women.
Part XII
Perioperative Care
Prakash Shastri and Deepak Govil