Management of eclampsia in Assiut University Hospital, 15 years experience

The aim of this study was to evaluate the protocol used for management of eclampsia in Assiut University Hospital. This study was carried out in the Department of Obstetrics and Gynecology and Intensive Care Unit [ICU], Department of Anaesthesia; Assiut University Hospital. A prospective cross-sectional study from January 1990 till January 2005, all patients with eclampsia were included [1332 patients]. Patients studied were 1032 ante partum eclampsia, 75 intrapartum, 16 intercurrent and 209 postpartum eclampsia. The regimen included the use of Nifedipine as an antihypertensive, Magnesium sulfate as anticonvulsant, rapid termination of pregnancy and admission to the intensive care unit. Magnesium sulfate was effective in controlling convulsions in 98.1% of the cases. Nifedipine initiated a smooth decline in blood pressure [P > 0.0001]. The dose of Nifedipine needed to control the blood pressure was variable in the different groups of patients. There are 55 cases of maternal deaths [4.12%]. Maternal morbidity occurred in about 23% of cases. Vaginal delivery occurred in 23.3% of cases [most of them were admitted postpartum]. Perinatal morality was variable in the four groups with the highest rate in the antepartum group [7.9%]. The incidence of low Apgar score at 5 minutes was higher in the antepartum group. Combination of Niftdipine as an antihypertensive drug, magnesium sulfate as an anticonvulsant, rapid termination of pregnancy and managing the patients in the intensive care unit resulted in marked improvement of the outcome for both the mother and fetus

Preeclampsia: the effect of intravenous fluid preload on vasoactive peptide secretion during caesarean section under spinal anaesthesia

We followed the haemodynamic parameters and determined the peripheral venous levels of ANF, ET-1 and NO before and after, intravenous volume preload of I litre Ringer's solution, followed by a further load of the same volume under spinal anaesthesia in 15 healthy and I5pre-eelamptic women. Blood pressure was decreased significantly in both groups after spinal anaesthesia and such decrease was less in the preeclamptic group. The baseline concentration of ANP was higher in preeclamptic women than in normal pregnancy women. It increased significantly in both groups after the JSI infusion, the.2 nd infusion and after delivery. The CVP increased more during the preload period in the preeclamptic group than in healthy women. The increase in the concentrations of ANP correlated significantly with the increase in CVP in total study group. The baseline concentration of ET-1 was higher in preeclamptic women than in healthy women, it decreased significantly in both groups after the first and second infusions. The plasma concentrations of ET-1 increased significantly in the cord sample both groups. NO increased more in the preeclamptic group during the preload period in healthy women while the same increase was noted after the second infusion in groups. After delivery NO concentration in the cord sample was higher in the preeclamptic group than in healthy women. There was no significant difference in the number of neonates with Apgar score < 7, NACS and the parameters of arterial blood gas between the two groups. We conclude from this study that the release of ANP increases in response to a rapid intravenous infusion of a crystalloid solution during elective Caesarean delivery which is exaggerated in women with preeclampsia. This may help in the vasculatory adaptation to the volume load by increasing its capacity. The increase ANP release was not sufficient to decrease maternal arterial blood pressure, but may counteract vasospasm locally in the maternal and uteroplacental circulation

Lipoprotein a and fibrinolytic parameters in normal and pre-eclamptic pregnancies

This study aimed to evaluate the LP-a and fibrinolytic parameters [plasminogen, fibrinogen and D-dimer] in normotensive and preeclamptic pregnant and non-pregnant women, as well as to assess any association with severity of the disease. The study was carried out in 52 women with age range 17-38 years, including 10 normotensive pregnant women, 31 preeclamptic women [13 with mild preeclampsia [MPE] and 19 with severe preeclampsia [SPE]] and 10 non-pregnant women, as control group. The mean gestational age for MPE, SPE and normotensive pregnant women were 35.5 +/- 3.1 and 36 +/- 1.4 weeks, respectively. In conclusion, LP[a] levels are elevated in preeclampsia and associated with severity of the disease. So, it may serve as a marker of the pathogenic process. Abnormalities in fibrinolytic parameters [fibrinogen and D-dimer] indicated activation of fibrinolysis in response to intravascular coagulation, which may be prevented from reaching its full potential. On the other hand, the absence of significant changes in plasminogen may not be mediated by tissue plasminogen activator [tPA], but by urokinase, whose interaction with PLG is not affected by Lp-a

Sevoflurane versus isoflurane in normal and pre-eclamptic parturients undergoing cesarean delivery

One hundred and twenty pregnant women were randomly assigned to receive either isoflurane two groups] or sevoflurane [two groups] using on open [non-blinded] study design. Anesthesia was maintained with either isoflurane 0.5% end tidal or sevoflurane 1% end tidal in combination with nitrous [N2O] 50% in oxygen. Liver functions, kidney functions, complete blood count and coagulation profile were measured and recorded. Pharmacokinetic study included serum inorganic fluoride concentration and kinetics of serum inorganic fluoride. Also, blood pressure, heart rate, central venous pressure [CVP] monitoring, ECG, estimation of intra-operative blood loss, uterine tone, recovery profile and urine in 24 hours were also studied. Infant outcome was also evaluated by Apgar score, neurologic adaptive capacity score [NACS], umbilical artery blood gas, acid base status and serum fluoride level. From the results obtained, it was concluded that sevoflurane appears to be similar to isoflurane with a few exceptions. It appears similar to isoflurane in its effect on regional blood flows including the hepatic and renal circulation. The use of sevoflurane resulted in faster emergence than after isoflurane. The high serum fluoride levels associated with administration of sevoflurane anesthesia were not dangerous, because it did not reach the level that cause nephrotoxicity. Neonatal outcomes were similar after anesthesia with either isoflurane or sevoflurane. So, sevoflurane 1.0% is a suitable alternative to isoflurane 0.5% for maintenance of anesthesia in such cases, but in this era of cost containment and rationing of health resources, it remains to be seen whether sevoflurane will supplant isoflurane for obstetrical anesthesia

Vaso-active mediators and doppler indices in maternal and fetal vessels in pre-eclampsia

Pre-eclampsia is associated with increased vascular reactivity and vasoconstriction. Forty six women whose pregnancy were complicated with pre-eclampsia and twenty six normotensive pregnant women all at the same duration of pregnancy were studied. Pre-eclampsia occurred in the 2nd trimester only in two patients, in the sometime it occurred in 28 patients before the 37th weeks and 16 after the 37th weeks. Only eight patients were with moderate hypertension, while 38 patients were with severe disease. Blood flow velocity waveforms in both right and left uterine arteries, fetal umbilical artery and fetal descending aorta was done for both patients and controls. Serum levels of endothelin-I [ET1], prostaglandin E2 [PGE2], nitric oxide [NO], Von Willebrand factor [vWF] and angiotensin converting enzyme activities [ACE], were determined for both patients and controls. Serum levels of ET-1, ACE and vWF were higher, while serum levels of NO and PGE2 were lower to statistically significant levels [p<0.001] in pre-eclamptic women in all instances. Also, all Doppler indices were significantly higher in patients with pre-eclampsia than in normotensive women [p<0.001]. There was strong positive correlation between Doppler indices and serum levels of ET-1, ACE and vWP and strong negative correlation with NO and PGE2 in both patients with pre-eclampsia and in normotensive women [r<0.05]. These changes confirm the presence of highlight vascular reactivity and endothelial damage in cases of pre-eclampsia. The resulting endothelial damage and dysfunction may underlay the pathologic features of this disorder