pet/eclampsia george eliot hospital, nuneaton 1 pre-eclampsia and eclampsia dr suzy matts mrcog dept...

PET/EclampsiaPET/Eclampsia George Eliot Hospital, NuneatonGeorge Eliot Hospital, Nuneaton 11

Pre-Eclampsia and Pre-Eclampsia and EclampsiaEclampsia

Dr Suzy Matts MRCOGDr Suzy Matts MRCOG

Dept Obstetric and Dept Obstetric and GynaecologyGynaecology

George Eliot HospitalGeorge Eliot Hospital


IntroductionIntroduction

DefinitionsDefinitions PrevalencePrevalence Risk FactorsRisk Factors PathogenesisPathogenesis InterventionsInterventions

– PreventionPrevention– treatmenttreatment


DefinitionDefinition Hypertension and proteinuria with onset Hypertension and proteinuria with onset

≥20 weeks≥20 weeks– Oedema from classical definition dropped as not Oedema from classical definition dropped as not

discriminating clinicallydiscriminating clinically

Diastolic ≥90mmHg on 2 occasions 4-6 Diastolic ≥90mmHg on 2 occasions 4-6 hours apart OR ≥110mmHg on one hours apart OR ≥110mmHg on one occasionoccasion

Proteinuria >300mg/24 hoursProteinuria >300mg/24 hours SymptomsSymptoms Differentiation from PIH/renal diseaseDifferentiation from PIH/renal disease


Hypertensive disordersHypertensive disorders

N o p ro te inu ria -PIH

M ild a n d m o de ra te P E T Severe PET Eclampsia HELLP

P ro te in uria an d R a ised B PPre -eclampsia

Pregnancy induced hypertension(R a ised B P a fte r 2 0 w e e ks)

Chronic hypertension(R a ise d B P be fo re 2 0 w e eks ge s ta tio n )

R a ised B P in p re g na n cy> o r = 1 40 /90


IncidenceIncidence

2-3% pregnancies2-3% pregnancies 5-7% primips5-7% primips 1.8% PET will develop eclampsia (from 1.8% PET will develop eclampsia (from

Collaborative Eclampsia TrialCollaborative Eclampsia Trial = 49/ = 49/ 100000)100000)

Rates eclampsia 26.8/100 000 Rates eclampsia 26.8/100 000 maternities (UKOSS reporting system maternities (UKOSS reporting system 2003-5)2003-5)

Worldwide 1.5-8 million develop PET Worldwide 1.5-8 million develop PET with 150 000 deathswith 150 000 deaths


ImportanceImportance

Important cause of maternal and fetal Important cause of maternal and fetal death death

22ndnd most common cause maternal death most common cause maternal death over a number of yearsover a number of years– 15 deaths 1997-915 deaths 1997-9– 14 deaths 2000-214 deaths 2000-2– 18 deaths 2003-5 (=8.5/million maternities)18 deaths 2003-5 (=8.5/million maternities)– High rates of substandard care (72% 2003-High rates of substandard care (72% 2003-

5)5)


ImportanceImportance

Maternal morbidityMaternal morbidity– BlindnessBlindness– NeurologicalNeurological– renalrenal

Fetal deathFetal death– Abruption, hypoxia, IUGRAbruption, hypoxia, IUGR

Fetal morbidityFetal morbidity– Prematurity (PET is cause of >40% iatrogenic Prematurity (PET is cause of >40% iatrogenic

preterm dels) with risks respiratory and preterm dels) with risks respiratory and neurodevelopmental complications neurodevelopmental complications (inc.learning difficulty/(inc.learning difficulty/IQ in up to 60%) IQ in up to 60%)


Causes of deathCauses of death

0

5

10

15

20

25

30

1985-7

1988-90

1991-3

1994-6

1997-9

2000-2

2003-5

cerecral

PO+/-ARDS

hepatic

TOTAL


Pre-Eclampsia and EclampsiaPre-Eclampsia and EclampsiaDeaths 2003-5Deaths 2003-5

18 women18 women 10 died of cerebral haemorrhage10 died of cerebral haemorrhage 2 died of cerebral infarction (one with 2ry 2 died of cerebral infarction (one with 2ry

haemorrhage)haemorrhage) 2 from multiorgan failure (inc ARDS)2 from multiorgan failure (inc ARDS) 1 from massive liver infarction1 from massive liver infarction 3 from other causes3 from other causes

Rate of death overall unchanged from Rate of death overall unchanged from previous reportprevious report


Risk Factors:-Pre-EclampsiaRisk Factors:-Pre-Eclampsia

PrimiparousPrimiparous First pregnancy First pregnancy

with new partnerwith new partner Family history (1 in Family history (1 in

3 risk if mother had 3 risk if mother had PET)PET)

Twins/multiplesTwins/multiples Pregestational Pregestational

DiabetesDiabetes

Essential Essential hypertensionhypertension

Renal diseaseRenal disease SLESLE Antiphospholipid Antiphospholipid

syndromesyndrome ThrombophiliasThrombophilias Age >40Age >40 ObesityObesity


PathophysiologyPathophysiology

““The disease of theories”The disease of theories”

Pregnancy specific syndromePregnancy specific syndrome Placenta has a central role to playPlacenta has a central role to play

– Reduced placental perfusionReduced placental perfusion– Inadequate vascular remodelling at ~16 wksInadequate vascular remodelling at ~16 wks

Genetic component in some women tho’ Genetic component in some women tho’ not in othersnot in others– No candidate genes or consistent resultsNo candidate genes or consistent results


Pathophysiology of PETPathophysiology of PET


2 stage process2 stage process Inadequate implantationInadequate implantation Poor remodellingPoor remodelling Cytokines produced +Cytokines produced + growth factorsgrowth factors placental apoptosis/necrosisplacental apoptosis/necrosis Shedding of microparticles into circulationShedding of microparticles into circulation

Markers seen Markers seen preceding PETpreceding PET Inflammation andInflammation andendotheial activationendotheial activation

STAGE 1:Reduced placental perfusion

STAGE 2: Maternal syndrome (multisystem disorder)


Oxidative stressOxidative stress

Evidence includes Evidence includes superoxide superoxide dysmutase in placenta and maternal dysmutase in placenta and maternal blood in PETblood in PET

Stage 1: placental perfusion

Maternal constitutional factors eg obesity, genetic, diabetes, environment, diet

OXIDATIVE STRESS

Stage 2: Maternal syndrome (activation of maternal endothelium)


Angiogenic FactorsAngiogenic Factors

e.g. sFlt-1 or soluble endglin coreceptor-e.g. sFlt-1 or soluble endglin coreceptor-inhibit growth factors in placenta and inhibit growth factors in placenta and vasculaturevasculature

Stage 1: placental perfusion

Maternal constitutional factors eg obesity, genetic, diabetes, environment, diet

ANGIOGENIC FACTORS

Stage 2: Maternal syndrome (activation of maternal endothelium)


Prevention of PET: AspirinPrevention of PET: Aspirin Several small trials suggested reduction in Several small trials suggested reduction in

rates PET with low dose aspirin therapyrates PET with low dose aspirin therapy Large multicentre trial (CLASP) in 9364 Large multicentre trial (CLASP) in 9364

women did not demonstrate benefit for women did not demonstrate benefit for wholescale prophylaxis for low risk womenwholescale prophylaxis for low risk women– Trend towards reduction in likelihood to preterm Trend towards reduction in likelihood to preterm

deliverydelivery– No significant increased risk of haemorrhagesNo significant increased risk of haemorrhages– No statistically significant effect on stillbirths/ No statistically significant effect on stillbirths/

neonatal deathsneonatal deaths– Non significant (12%) reduction in incidence PETNon significant (12%) reduction in incidence PET

Lancet 1994; Lancet 1994; 343:343: 619-629 619-629


CLASPCLASP Trial suggested only Trial suggested only

benefits in women at benefits in women at high risk of severe high risk of severe early onset IUGR ? early onset IUGR ? How to identifyHow to identify

Benefits thus Benefits thus suggested in women suggested in women with with previous severe previous severe early onset PET and early onset PET and IUGRIUGR

?relationships to APLS ?relationships to APLS (not investigated in (not investigated in original trial)original trial)


Prevention: AspirinPrevention: Aspirin

More recent study showed aspirin More recent study showed aspirin treatment produced at RR of 0.9 treatment produced at RR of 0.9 (95% CI 0.84-0.97) for PET(95% CI 0.84-0.97) for PET

Moderate but consistent reductions Moderate but consistent reductions in PET, preterm delivery and serious in PET, preterm delivery and serious outcomesoutcomes

Lancet 2007Lancet 2007


Prevention: CalciumPrevention: Calcium

Calcium levels lower in women with Calcium levels lower in women with PET compared to ‘normal’ pregnancyPET compared to ‘normal’ pregnancy

Australian Randomised Study in 456 Australian Randomised Study in 456 singleton nullips from <24/40 singleton nullips from <24/40 showed reduction in risk PET with showed reduction in risk PET with 1.8g calcium/day compared to 1.8g calcium/day compared to placeboplacebo

RR 0.44 95% CI 0.21-0.90RR 0.44 95% CI 0.21-0.90Aus NZ J Obstet Gynaecol 1999; Aus NZ J Obstet Gynaecol 1999; 39:39: 12-18. 12-18.


Prevention: CalciumPrevention: Calcium

Calcium for Eclampsia Prevention Calcium for Eclampsia Prevention Study (CPEP) Study (CPEP) Am J Obstet Gynecol Am J Obstet Gynecol 1997; 1997; 177:177: 1003-10 1003-10

4589 US women in multicentre trial4589 US women in multicentre trial All nullipsAll nullips Analysis of risk factors for Analysis of risk factors for

development of subsequent PET did development of subsequent PET did not show any benefit from Ca++ not show any benefit from Ca++ supplementationsupplementation


Prevention: CalciumPrevention: Calcium Cochrane Review Cochrane Review Cochrane Database 2000 (3), OUS.Cochrane Database 2000 (3), OUS.

9 studies, all good quality9 studies, all good quality Ca++ dose > 1g/dayCa++ dose > 1g/day Modest reduction in risk PET for all women (RR 0.72, 95% Modest reduction in risk PET for all women (RR 0.72, 95%

CI 0.6-0.86)CI 0.6-0.86) Greatest effect where highest risk- RR 0.22, 0.11-0.43 and Greatest effect where highest risk- RR 0.22, 0.11-0.43 and

low dietary intake (0.32, 0.21-0.49)low dietary intake (0.32, 0.21-0.49) No effect on preterm deliveryNo effect on preterm delivery Smaller effects seen for hypertensionSmaller effects seen for hypertension

– Ca++ appears of benefit for women at high risk of developing PETCa++ appears of benefit for women at high risk of developing PET– Also women from communities with low dietary intakeAlso women from communities with low dietary intake– Optimum dosage requires further evaluationOptimum dosage requires further evaluation


Prevention: AntioxidantsPrevention: Antioxidants

Vitamin C 1000mg and Vit E 400 IU/dayVitamin C 1000mg and Vit E 400 IU/day 58% reduction in PET in treated group58% reduction in PET in treated group

Chappell et al, Lancet 1999 354: 810-5Chappell et al, Lancet 1999 354: 810-5

A number of trials ongoing globallyA number of trials ongoing globally All using above dosagesAll using above dosages 3 reported so far-NO difference in rates 3 reported so far-NO difference in rates

treatment vs placebo.treatment vs placebo.


Diagnosis: Pre-EclampsiaDiagnosis: Pre-Eclampsia

Classic triadClassic triad– Hypertension 140/90Hypertension 140/90– Proteinuria >300mg in 24 hours (RCOG)Proteinuria >300mg in 24 hours (RCOG)– Oedema (least reliable)Oedema (least reliable)

BP rise should be from booking >30/15BP rise should be from booking >30/15 Proteinuria and raised BP x 2 occasions 6 Proteinuria and raised BP x 2 occasions 6

hrs apart (or once if DBP ≥110 and heavy hrs apart (or once if DBP ≥110 and heavy proteinuria >2+ (=1g/24h))proteinuria >2+ (=1g/24h))


Mild PETMild PET

Classically asymptomaticClassically asymptomatic BP 140/90 (ish)BP 140/90 (ish) Maybe trace-+ proteinuriaMaybe trace-+ proteinuria Often incidental finding at CMW clinic Often incidental finding at CMW clinic

attendanceattendance


PET-InvestigationsPET-Investigations

FBC-FBC- platelet countplatelet count U+EU+Esigns renal dysfunction (late)signs renal dysfunction (late) UrateUrate hyperuricaemia ( early )hyperuricaemia ( early ) LFTsLFTs elevated transaminaseselevated transaminases ClottingClotting XXXX (not routinely if XXXX (not routinely if

plts>100)plts>100) MSUMSUto exclude UTI as cause of to exclude UTI as cause of

proteinprotein


PETPET

Fetal assessmentFetal assessment– ClinicalClinical– USS for growthUSS for growth– CTGs CTGs

?cervical assessment (depending on ?cervical assessment (depending on gestation)gestation)


MonitoringMonitoring

Monitor BPMonitor BP– CMWCMW– Day assessment or Triage UnitDay assessment or Triage Unit

Monitor bloodsMonitor bloods– Weekly or twice weekly (depends on Weekly or twice weekly (depends on

sitn)sitn) Monitor fetusMonitor fetus

– CTGCTG– Serial USSSerial USS


Definitive treatmentDefinitive treatment

Deliver whenDeliver when– BP/protein or clinical condition BP/protein or clinical condition

deteriorates so become moderate or deteriorates so become moderate or severe PETsevere PET

– Reaches 41 weeks and no change in Reaches 41 weeks and no change in conditioncondition

– Fetal condition mandates delivery even Fetal condition mandates delivery even if maternal condition stableif maternal condition stable


Severe pre-eclampsiaSevere pre-eclampsia

SYSTOLIC 160-180SYSTOLIC 160-180 DIASTOLIC >110DIASTOLIC >110 CNSCNS

– HeadacheHeadache– Visual disturbancesVisual disturbances– Disorientation/ Disorientation/

irritabilityirritability– HyperreflexiaHyperreflexia– clonusclonus

HepaticHepatic– Abnormal LFTs, Abnormal LFTs,

dysfunctiondysfunction– RUQ painRUQ pain– Epigastric painEpigastric pain

RenalRenal– Elevated creatnine, urea, Elevated creatnine, urea,

urateurate– OliguriaOliguria– Heavy proteinuria >5g in Heavy proteinuria >5g in

24 hrs24 hrs HaemtologicalHaemtological

– ThrombocytopaeniaThrombocytopaenia– haemolysishaemolysis


Multisystem diseaseMultisystem disease EyesEyes

– Arteriolar spasmArteriolar spasm– Retinal haemorrhagesRetinal haemorrhages– BlindnessBlindness– ScotomaScotoma– PapilloedemaPapilloedema

CNSCNS– SeizuresSeizures– EncephalopathyEncephalopathy– Cerebral haemorrhagesCerebral haemorrhages– CVACVA

RespiratoryRespiratory– Pulmonary oedemaPulmonary oedema– ARDSARDS

LiverLiver– Subcapsular Subcapsular

haemorrhageshaemorrhages– Liver ruptureLiver rupture

KidneysKidneys– Acute renal failureAcute renal failure

Fetoplacental UnitFetoplacental Unit– IUGRIUGR– AbruptionAbruption– Fetal compromiseFetal compromise– Fetal deathFetal death

HaemotologicalHaemotological– DICDIC– haemolysishaemolysis


SymptomsSymptoms

Headache (Headache (BP)BP) Flashing lights (lightning) (cerebral Flashing lights (lightning) (cerebral

oedema)oedema) Epigastric pain (stretching of liver Epigastric pain (stretching of liver

capsule)capsule) Oedema (Oedema (albumin/albumin/BP)BP)

AsymptomaticAsymptomatic


Management of severe pre-Management of severe pre-eclampsiaeclampsia

Immediate admission to hospitalImmediate admission to hospital

High dependency care/LW-QUIETHigh dependency care/LW-QUIET– Invasive monitoringInvasive monitoring– NICU for baby if early gestationNICU for baby if early gestation

Senior multidisciplinary involvement early-Senior multidisciplinary involvement early-obs and anaestheticsobs and anaesthetics


Aims of treatmentAims of treatment

AimsAims– Prevent seizuresPrevent seizures– Control hypertension (to prevent Control hypertension (to prevent

cerebral haemorrhage)cerebral haemorrhage)– Deliver safely (stabilise, +/- IUT, +/- Deliver safely (stabilise, +/- IUT, +/-

steroids)steroids)


Maternal AssessmentMaternal Assessment BP-check every 15 minutesBP-check every 15 minutes Urine output-hourlyUrine output-hourly Urinary protein dipstixUrinary protein dipstix Strict fluid balance chartStrict fluid balance chart BloodsBloods

– U+E, urea, creatnine, urateU+E, urea, creatnine, urate– FBC esp. platelets (G+S)FBC esp. platelets (G+S)– LFTsLFTs

Deep tendon reflexes and presence of clonusDeep tendon reflexes and presence of clonus CTGCTG


Control blood pressureControl blood pressure Antihypertensives – Antihypertensives – aim for diastolic 85-95aim for diastolic 85-95

– IV hydralazineIV hydralazine (5mg every 15 minutes to acutely (5mg every 15 minutes to acutely control BP)control BP)

– IV labetololIV labetolol (Not good if asthmatic or already signs (Not good if asthmatic or already signs of pulmonary oedema-first line in many places now)of pulmonary oedema-first line in many places now)

– Oral nifedipineOral nifedipine 10mg 10mg NOT SUBLINGUALNOT SUBLINGUAL

– Methyldopa TOO SLOW ONSET (24-48 hours) for Methyldopa TOO SLOW ONSET (24-48 hours) for use in acute situationuse in acute situation

– Titrate IV antihypertensive vs. BP then infusionTitrate IV antihypertensive vs. BP then infusion


KEY POINTS: HypertensionKEY POINTS: Hypertension

Systolic blood pressure of 160 mm/Hg Systolic blood pressure of 160 mm/Hg or more = anti-hypertensive or more = anti-hypertensive treatment. treatment.

(irrespective of diastolic)(irrespective of diastolic)

Consideration starting treatment at lower pressures Consideration starting treatment at lower pressures if the overall clinical picture suggests likely rapid if the overall clinical picture suggests likely rapid deterioration with anticipation of severe deterioration with anticipation of severe hypertension.hypertension.


Prevent FitsPrevent Fits Magnesium sulphateMagnesium sulphate

– All severe and moderate PET (MAGPIE)All severe and moderate PET (MAGPIE)– 4g IV over 15 minutes4g IV over 15 minutes– Then infusion 1g/ hourThen infusion 1g/ hour– Monitor reflexes (present) urine OP (>30ml/hr) Monitor reflexes (present) urine OP (>30ml/hr)

and respiratory rate (>12/minute)and respiratory rate (>12/minute)– Slows neuromuscular conduction and decreases Slows neuromuscular conduction and decreases

CNS irritabilityCNS irritability– Best anticonvulsant in these circumstances AND Best anticonvulsant in these circumstances AND

IN ECLAMPSIAIN ECLAMPSIA– No effect on BPNo effect on BP– Tell anaesthetist if GA as potentiates effects of Tell anaesthetist if GA as potentiates effects of

muscle relaxantsmuscle relaxants


Magnesium toxicityMagnesium toxicity

If urine OP OK then If urine OP OK then likely not to likely not to accumulate (85% accumulate (85% renal excretion)renal excretion)

If urine output falls, If urine output falls, reduce dose to reduce dose to 0.5g/hour0.5g/hour

If signs toxicity, stopIf signs toxicity, stop Antidote = Antidote = Calcium Calcium

gluconate 1g IV over gluconate 1g IV over 3 minutes3 minutes

Magnesium levelsMagnesium levels– Therapeutic Therapeutic 2-4 mmol/l2-4 mmol/l– Warmth, flushing, slurred Warmth, flushing, slurred

speech speech 3.8-5mmol/l3.8-5mmol/l– Loss of patellar reflexes Loss of patellar reflexes >5 >5

mmol/lmmol/l– Respiratory depression Respiratory depression >6 >6

mmol/lmmol/l– Respiratory arrest Respiratory arrest 6.3-6.3-

7mmol/l7mmol/l– Cardiac arrest, asystole Cardiac arrest, asystole

>12 mmol/l>12 mmol/l


MAGPIEMAGPIE 10141 women-99% received allocated treatment10141 women-99% received allocated treatment 24% of women with MgSO4 reported side-effects 24% of women with MgSO4 reported side-effects

compared to 5% of women on placebocompared to 5% of women on placebo MgSO4 produced 58% reduced risk of eclampsia MgSO4 produced 58% reduced risk of eclampsia

(0.8% cf. 1.9%)-across all categories of PET(0.8% cf. 1.9%)-across all categories of PET Maternal mortality lower as well RR 0.55, CI 0.26-Maternal mortality lower as well RR 0.55, CI 0.26-

1.141.14 Only improvement in maternofetal morbidity was Only improvement in maternofetal morbidity was

reduced risk of abruption (0.67, 99% CI 0.45-reduced risk of abruption (0.67, 99% CI 0.45-0.89) 0.89)

No substantial harmful risks to mother or fetusNo substantial harmful risks to mother or fetusLancet 2002; Lancet 2002; 359:359: 1877-90. 1877-90.


MAGPIE MAGPIE Lancet 2002; Lancet 2002; 359:359: 1877-90. 1877-90.


Deliver BabyDeliver Baby

If severe PET, should If severe PET, should NOTNOT transfer transfer Ensure SCBU aware if baby prematureEnsure SCBU aware if baby premature Give antenatal steroids if time but usually, Give antenatal steroids if time but usually,

if require IV therapy, delivery is indicated if require IV therapy, delivery is indicated once stabilisedonce stabilised

If cervix favourable and patient >36 If cervix favourable and patient >36 weeks, consider short trial IOLweeks, consider short trial IOL

If cervix unfavourable and/or <36 weeks, If cervix unfavourable and/or <36 weeks, deliver by LSCSdeliver by LSCS

Anaesthesia Anaesthesia epidural vs. generalepidural vs. general


DELIVERY: Key Points 1DELIVERY: Key Points 1

Risk of sharp rise of BP on intubationRisk of sharp rise of BP on intubation

This may be obtunded by large dose This may be obtunded by large dose alfentanyl or similaralfentanyl or similar

Need experienced and senior Need experienced and senior anaesthetist to give GA in these anaesthetist to give GA in these circumstancescircumstances


DELIVERY: Key Points 2DELIVERY: Key Points 2

Syntometrine should not be given for Syntometrine should not be given for the active management of the third the active management of the third stage if the mother is hypertensive, stage if the mother is hypertensive, or if her blood pressure has not been or if her blood pressure has not been checked.checked.

((ergometrine causes vasospasm and a sharp ergometrine causes vasospasm and a sharp rise in BP which may precipitate rise in BP which may precipitate hypertensive crisis, fits or cerebral hypertensive crisis, fits or cerebral haemorrhagehaemorrhage))


EclampsiaEclampsia Occurrence of fits Occurrence of fits

– 44% postpartum 44% postpartum – 38% antenatal) 38% antenatal) – ALWAYS GRAND MALALWAYS GRAND MAL

Due usually to cerebral vasospasmDue usually to cerebral vasospasm Do not try to shorten initial convulsion (self-Do not try to shorten initial convulsion (self-

limiting)limiting) Prevent maternal injuryPrevent maternal injury Maintain oxygenationMaintain oxygenation Prevent aspirationPrevent aspiration ABC…ABC…


EclampsiaEclampsia Beware known epilepticsBeware known epileptics

– If BP normal, no protein, typical for If BP normal, no protein, typical for their type of fit-may be epilepsy BUT their type of fit-may be epilepsy BUT any fit must be considered as any fit must be considered as eclampsia until proven otherwise eclampsia until proven otherwise especially of BP slightly up etcespecially of BP slightly up etc

Any FOCAL fit is not eclampsiaAny FOCAL fit is not eclampsia– Consider SOL eg cerebral Consider SOL eg cerebral

bleed/infarction due to severe PETbleed/infarction due to severe PET– Arrange head CT urgentlyArrange head CT urgently


Collaborative Eclampsia Collaborative Eclampsia TrialTrial

Multicentre international trialMulticentre international trialLancet 1995; Lancet 1995; 345:345: 1455-63 1455-63

1687 women1687 women Comparisons:Comparisons:

– MgSO4 vs. diazepamMgSO4 vs. diazepam 52% lower risk recurrent convulsions with MgSO452% lower risk recurrent convulsions with MgSO4

– MgSO4 vs. phenytoinMgSO4 vs. phenytoin 67% lower risk recurrent convulsions with MgSO467% lower risk recurrent convulsions with MgSO4

Maternal mortality nonsignificantly lower in MgSO4Maternal mortality nonsignificantly lower in MgSO4 Less risk of pneumonia, ventilation, ITU with Less risk of pneumonia, ventilation, ITU with

MagnesiumMagnesium Babies less likely to be intubated and go to SCBUBabies less likely to be intubated and go to SCBU


EclampsiaEclampsia

Treatment is IV magnesium sulphate-4g Treatment is IV magnesium sulphate-4g loading then 1g/hrloading then 1g/hr

If recurrent fits or fit already on MgSO4, If recurrent fits or fit already on MgSO4, then further 2g IV bolus/increase infusion then further 2g IV bolus/increase infusion to 1.5g/hrto 1.5g/hr

If fits persist, check magnesium levels, If fits persist, check magnesium levels, contact anaesthetists, consider CT, contact anaesthetists, consider CT, consider intubation and ventilationconsider intubation and ventilation

If antenatal, stabilise and DeliverIf antenatal, stabilise and Deliver


Following DeliveryFollowing Delivery

Watch closely on HDU/LW until diuresis Watch closely on HDU/LW until diuresis and condition improvingand condition improving

Anticipate possible worsening or seizures Anticipate possible worsening or seizures in first 18-24 hoursin first 18-24 hours

Continue MgSO4 for 24 hours and then Continue MgSO4 for 24 hours and then reviewreview

Do not need to taper off MgSO4Do not need to taper off MgSO4 Do not feed within 12 hours as significant Do not feed within 12 hours as significant

risk ileus-sips H2O only until next morning risk ileus-sips H2O only until next morning then review for bowel soundsthen review for bowel sounds


Postnatal carePostnatal care

Watch closely on HDU/LW until diuresis Watch closely on HDU/LW until diuresis and condition improvingand condition improving

Anticipate possible worsening or seizures Anticipate possible worsening or seizures in first 18-24 hoursin first 18-24 hours

Continue MgSO4 for 24 hoursContinue MgSO4 for 24 hours and then and then reviewreview

Do not need to taper off MgSO4Do not need to taper off MgSO4 Do not feed within 12 hours as significant Do not feed within 12 hours as significant

riskrisk ileusileus-sips H2O only until next morning -sips H2O only until next morning then review for bowel soundsthen review for bowel sounds


Postnatal CarePostnatal Care

Managing the postnatal pre-Managing the postnatal pre-eclamptic poses particular challengeseclamptic poses particular challenges– HypertensionHypertension– FitsFits– Fluid managementFluid management– GI managementGI management– Disease progressionDisease progression


Postnatal care-MortalityPostnatal care-Mortality

Most deaths occur after deliveryMost deaths occur after delivery

0

5

10

15

20

25

30

1988-9

0

1991-3

1994-6

1997-9

2000-2

2003-5

Totaldeaths

PNdeaths



0

5

10

15

20

25

30

1985-7

1988-90

1991-3

1994-6

1997-9

2000-2

2003-5

cerecral

PO+/-ARDS

hepatic

TOTAL


Postnatal Management-Postnatal Management-HypertensionHypertension

IV hydralazine or labetolol if severeIV hydralazine or labetolol if severe Oral route if less severeOral route if less severe Even mild may develop more marked Even mild may develop more marked

hypertension after deliveryhypertension after delivery Conversely, BP may settle rapidly Conversely, BP may settle rapidly

after deliveryafter delivery Aim for control with DBP <100Aim for control with DBP <100


Postnatal Management-Postnatal Management-HypertensionHypertension

Hypertension may persist for some Hypertension may persist for some weeksweeks

Switch to oral treatment when feasibleSwitch to oral treatment when feasible– AtenololAtenolol– NifedipineNifedipine

Polypharmacy may be required to Polypharmacy may be required to control BP-consult with physicianscontrol BP-consult with physicians

Ensure regular BP checks arranged on Ensure regular BP checks arranged on discharge with review and follow-up by discharge with review and follow-up by GPGP


Postnatal Management-FitsPostnatal Management-Fits

Eclampsia Survey showed 44% of Eclampsia Survey showed 44% of fits occur postpartumfits occur postpartum

High index of suspicionHigh index of suspicion Beware worsening of conditionBeware worsening of condition MgSO4 prophylaxis in all severe PET MgSO4 prophylaxis in all severe PET

and all eclampticsand all eclamptics All women with severe PET should All women with severe PET should

have MgSO4 for 24 hours following have MgSO4 for 24 hours following delivery or following last fit-delivery or following last fit-whichever is longerwhichever is longer


Postnatal Management-Postnatal Management-FluidsFluids

Fluid overload real danger after Fluid overload real danger after deliverydelivery– Relaxed vigilanceRelaxed vigilance– LSCSLSCS– PPHPPH– Physiological oliguriaPhysiological oliguria

STRICT FLUID BALANCESTRICT FLUID BALANCE



SHIP audit (1997) showed that many SHIP audit (1997) showed that many women have oliguria but intervention not women have oliguria but intervention not required unless UO <100ml in 4 hoursrequired unless UO <100ml in 4 hours

Fluid overload carries risks of pulmonary Fluid overload carries risks of pulmonary oedema-oedema-– Reduced plasma oncotic pressureReduced plasma oncotic pressure– Hypertension thus increased gradient across Hypertension thus increased gradient across

microvasculaturemicrovasculature– Filtration of fluid into tissuesFiltration of fluid into tissues– Pulmonary oedemaPulmonary oedema



Women with PET are very vulnerable Women with PET are very vulnerable to Pulmonary oedemato Pulmonary oedema

Carries risk of ARDS if severe or not Carries risk of ARDS if severe or not recognised rapidlyrecognised rapidly

ARDS may be fatalARDS may be fatal Fluid restriction is far SAFERFluid restriction is far SAFER

– Renal function more likely to recover Renal function more likely to recover than pulmonary and less likely to kill ptthan pulmonary and less likely to kill pt



11 10 118

10

5

10

15

20

25

30

1885-7 1988-90 1991-3 1994-6 1997-9

cerecral

ARDS/PO

hepatic

TOTAL

SHIP



FluidFluid restrictrestrict--60-86ml/hour TOTAL from all routes 60-86ml/hour TOTAL from all routes (inc. any MgSO4 and antihypertensives)(inc. any MgSO4 and antihypertensives)

ICE counts as fluid so measureICE counts as fluid so measure Strict fluid balance with 1 hourly UO via catheterStrict fluid balance with 1 hourly UO via catheter DO NOT ACT on oliguria unless <100ml urine over 4 DO NOT ACT on oliguria unless <100ml urine over 4

hours or no urine hours or no urine at allat all for 2 hours for 2 hours Do not forget to readjust catheter/flush before Do not forget to readjust catheter/flush before

trying to intervenetrying to intervene DO NOT GIVE FRUSEMIDEDO NOT GIVE FRUSEMIDE unless overt signs heart unless overt signs heart

failure (raised JVP or crepitations)-40mgfailure (raised JVP or crepitations)-40mg FRUSEMIDE FRUSEMIDE should always be discussed with should always be discussed with

consultantconsultant



One fluid challengeOne fluid challenge ONLYONLY-250ml -250ml crystalloid over 30 minutescrystalloid over 30 minutes

If no response, listen to chest base for If no response, listen to chest base for crepitations (signs LVF) and insert CVP line crepitations (signs LVF) and insert CVP line before any further challengebefore any further challenge

If CVP low, can give further fluids under If CVP low, can give further fluids under CVP guidance to achieve normal CVPCVP guidance to achieve normal CVP

If CVP high, give frusemide 40mg IVIf CVP high, give frusemide 40mg IV If CVP normal, consider dopamineIf CVP normal, consider dopamine Early transfer HDU/ITUEarly transfer HDU/ITU



Check U+E if concerned about fluid Check U+E if concerned about fluid management or if oliguria/anuriamanagement or if oliguria/anuria

If deteriorating, confer with renal If deteriorating, confer with renal team or intensiviststeam or intensivists

Multidisciplinary management is the Multidisciplinary management is the keykey


Fluid BalanceFluid Balance

Take Home messagesTake Home messages– Fluid restrict as pt already fluid Fluid restrict as pt already fluid

overloadedoverloaded– Scrupulous input and outputScrupulous input and output– Do not fluid challengeDo not fluid challenge– Do not give frusemideDo not give frusemide– Consider CVP line if urine output poorConsider CVP line if urine output poor– Seek senior advice early Seek senior advice early – Multidisciplinary Mx-obs/anaesth/renal Multidisciplinary Mx-obs/anaesth/renal

teamsteams


GI managementGI management

Don’t forget stress response to Don’t forget stress response to illness-illness-

H2 antagonists (eg Ranitidine)H2 antagonists (eg Ranitidine) Delay feeding until bowel sounds Delay feeding until bowel sounds

presentpresent– May develop ileus if v unwellMay develop ileus if v unwell


Disease ProgressionDisease Progression

Often improve quicklyOften improve quickly Some may deteriorate further Some may deteriorate further

immediately after delivery –may continue immediately after delivery –may continue to worsen for 24 + hoursto worsen for 24 + hours– Worsening BPWorsening BP– Worsening bloodsWorsening bloods– Oliguria/anuriaOliguria/anuria– Increased risk fitsIncreased risk fits

Consult seniors and manage with Consult seniors and manage with multidisciplinary teammultidisciplinary team


HELLP syndromeHELLP syndrome

HHaemolysisaemolysis EElevatedlevated LLiver Enzymesiver Enzymes LLowow PPlateletslatelets

1-12% PET (usually 1-12% PET (usually severe end of spectrum)severe end of spectrum)

Commoner in multipsCommoner in multips Variable presentationVariable presentation

– RUQ pain, epigastric pain, RUQ pain, epigastric pain, nausea + vomitingnausea + vomiting

– 85% hypertensive at 85% hypertensive at presentationpresentation

Present: 2/3 antepartum, Present: 2/3 antepartum, 1/3 postpartum1/3 postpartum– mid 2mid 2ndnd trimester to several trimester to several

days postnataldays postnatal


Differential diagnosis in Differential diagnosis in HELLPHELLP

Any liver problemsAny liver problems– Biliary colicBiliary colic– CholecystitisCholecystitis– HepatitisHepatitis

Gatroenteritis or Gatroenteritis or refluxreflux

PancreatitisPancreatitis ITP/ TTPITP/ TTP

Ureteric colicUreteric colic Renal calculusRenal calculus

Rare-if severe pain:Rare-if severe pain: Aortic dissectionAortic dissection MIMI


Management of HELLPManagement of HELLP

Treat as severe Treat as severe PETPET

StabiliseStabilise FluidsFluids AntihypertensivesAntihypertensives MgSO4MgSO4 Anti-thrombotic Anti-thrombotic

agentsagents Coagulation factors Coagulation factors

(if required)(if required)

Assess babyAssess baby– USSUSS– CTGCTG

(remember 20% risk (remember 20% risk of abruption)of abruption)

PLAN DELIVERY ASAPPLAN DELIVERY ASAP TRANSFER TO TRANSFER TO

TERTIARY CENTRE IF TERTIARY CENTRE IF REQUIREDREQUIRED

IOL or LSCSIOL or LSCS


Summary-PET, eclampsia, Summary-PET, eclampsia, HELLPHELLP

Serious disease with potential for Serious disease with potential for maternal and fetal mortalitymaternal and fetal mortality

Prevention not widespread ? Aspirin Prevention not widespread ? Aspirin for some ? Calcium for allfor some ? Calcium for all

Treatment depends on prevention of Treatment depends on prevention of complications and timing deliverycomplications and timing delivery

Senior involvement in severe casesSenior involvement in severe cases


THETHE

END END

pet/eclampsia george eliot hospital, nuneaton 1 pre-eclampsia and eclampsia dr suzy matts mrcog dept...

Documents