Case study anddiscussion

Pre-eclampsia and severe pre-eclampsiaNICE guideline August 2010 -> modified

in January 2011

Case study..

• Mrs. N• 18 years old, malay lady• G1p0 @ EDD + 8/7• ANC: uneventful• No past medical/surgical history• FHx father died of IHD

History..

• Patient was brought in via ambulance call at 8:30am on 5/6/2013

• c/o contraction pain since 6am presenting day, a/w headache, otherwise no blurring of vision/epigastric pain/vomitting

• No Pv bleeding, no LL, good FM

• On arrival:– BP: 165/114mmHg– PR: 75bpm– T: 37

• Patient alert, conscious• GCS 15/15

• Lungs auscultation: equal AE, clear• CVS: s1/s2, soft ejection systolic murmur at LSE

• p/a: – uterus term size, SFH: 38cm– Soft, not tense– Singleton, cephalic 3/5– EFW: 2.8 -3kg

• Bilateral LL no pedal oedema• Reflexes: normal, no clonus

• Urine albumin: nil

• Patient was given T nifedipine 10mg STAT and admitted to LR for BP stabilization

• Planned for bishop scoring after BP stabilized

• BP ½ hour after T nifedipine 10mg 140/70mmHg• CTG done : reactive• VE done:– v/v NAD– Os: 4cm, cx: effaced, soft, axial– St -2, MI, vx presentation– No cord/placenta felt

• Artificial rupture of membrane done after 2h in LR ( @ 10:30am) after BP stabilized due to persistent contraction of 3:10:25sec

• VE : v/v NAD– Os: 5cm, cx: 0.5cm, st: -1, MI, no cord/placenta

felt, Vx presentation– ARM done clear liquor seen

• Planned for hourly BP monitoring in labour and NRVE in 4H

• Informed by SN BP persistently range 160-170/86 – 109mmHg at 1:45pm

Attended pt in LR• Pt alert, conscious, GCS 15/15• Denies any IE sx• rpt BP: 161/98mmHg, PR: 82bpm• Iv labetalol 20mg STAT slow bolus given at

1:50pm• Rpt BP after 15mins: 134/79mmHg

• Was then attended PPH patient in LR• Was informed by HO at 2:30pm -> patient has

twitching of eyes • Attended STAT noted generalized tonic clonic seizure– Call for help (attended by specialist oncall and other MO

STAT)– Patient was put in LLP position with HF mask 15L/I– IV MgSo4 4gm loading dose was given– Fit aborted after administration of IV Mgso4 (5 mins)– Post ictal drowsiness

• CTG in progress: BFHR: 115bpm, no acceleration/deceleration, BTBV preserved

• BP post fit: 158/92mmHg• Urine albumin: nil

• VE done:– v/.v NAD– Os: 5cm, cx: effaced, st -2, MA clear liquor demonstrable– Caput 2+, moulding grade 1– No cord/placenta felt

• Currently already 4hours in active labour– Not on pitocin augmentation

• Started with IVI MgSO4 maintenance dose• Decided for EMLSCS for poor progress and

eclampsia

• Intra-operatively uneventful BP well controlled, no recurrence of fit

• IVI MgSO4 was resumed straight after LSCS

Lab investigations..

• FBC: Hb: 11gm/l, PLT: 216000, TWBC: 9470• PE profile: ur/CR: 2/44, UA: 206, ALT: 9.8, AST:

22.2• Coagulation: PT: 11.8, INR: 0.88• Urine feme: protein negative, leucocyte: nil

PRE-ECLAMPSIA AND SEVERE PRE-ECLAMPSIA

Definitions..• Chronic hypertension is hypertension that is present at the booking visit or before 20 weeks or if the

woman is already taking antihypertensive medication when referred to maternity services. It can be primary or secondary in aetiology.

• Gestational hypertension is new hypertension presenting after 20 weeks without significant proteinuria.

• Pre-eclampsia is new hypertension presenting after 20 weeks with significant proteinuria.

• Severe pre-eclampsia is pre-eclampsia with severe hypertension and/or with symptoms, and/or biochemical and/or haematological impairment.

• Eclampsia is a convulsive condition associated with pre-eclampsia.

• HELLP syndrome is haemolysis, elevated liver enzymes and low platelet count.

• Significant proteinuria is defined as urinary protein:creatinine ratio (PCR) > 30 mg/mmol or a validated 24-hour urine collection result shows > 300 mg protein (0.3gm)

Degrees of hypertension

Mild Hypertension

•SBP: 140 – 149 mmHg•DBP: 90–99 mmHg

Moderate Hypertension

•SBP: 150-159mmHg•DBP: 100-109mmHg

Severe Hypertension

•SBP: > 160mmHg•DBP: > 110mmHg

Risk of pre-eclampsia

• Nulliparity• Age 40 years or older• Pregnancy interval of more

than 10 years• Family history of pre-

eclampsia• Multiple pregnancy• BMI of 35 kg/m2 or more

High risk• Hypertensive disease during

previous pregnancy• Chronic kidney disease• Autoimmune disease such

as SLE or APLS• Type 1 or type 2 diabetes• Chronic hypertension

Moderate Risk

Symptoms of pre-eclampsia

• Severe headache• Problems with vision, such as blurring or

flashing before the eyes• Severe pain just below the ribs• Vomiting• Sudden swelling of the face, hands or feet.

Management of pre-eclampsia

• Admission to ward• To treat according to degree of hypertension

(moderate to severe hypertension)• 1st line therapy -> oral labetalol• Maintain – SBP: < 150mmHg– DBP: 80 – 100mmHg

• Alternative drugs – Methyldopa– Nifedipine

• Blood investigations:– Kidney function, electrolytes, full blood count,

transaminases, bilirubin– Not for repetition of quantification of proteinuria

• For CTG at diagnosis of severe hypertension or pre-eclampsia

• If decided for conservative– Growth scan + AFI– Umbilical artery doppler velocimetry

• No need for repeat CTG if fetal monitorings shows normal results

• Rpt CTG if:– Any reports of a change in fetal movement– Vaginal bleeding– Abdominal pain– Deterioration in maternal condition

• 2 weekly growth scan, AFI + doppler

Doppler monitoring..

• Mother with previous history of:– Severe pre-eclampsia– Pre-eclampsia that needed birth before 34 weeks– Pre-eclampsia with a baby whose birth weight was

less than the 10th centile– Intrauterine death– Placental abruption

Delivery..

• To be managed conservatively until 34 weeks• For early delivery ( < 34 weeks)– Severe hypertension develops refractory to

treatment– Maternal or fetal indications develop

– To complete course of corticosteroid prior to delivery– Discussion between O&G, neonatology and

anaesthesia teams

• For mild to moderate hypertension– Aim for delivery between 34 – 36/52 +6/7– depending on maternal and fetal conditions, risk

factors and availability of neonatal intensive care.

– Recommend birth within 24–48 hours for mild or moderate hypertension after 37+0 weeks with a/w pre-eclampsia

Intrapartum monitoring..

• Blood pressure– Hourly in women with mild or moderate hypertension– Continually in women with severe hypertension– Oral anti-hypertensive should be continued

• Haematological and biochemical monitoring

• If on epidural anaesthesia -> do not preload with IV fluid before established low-dose epidural analgesia

• No need for routinely limit the duration of the second stage of labour:– in women with stable mild or moderate

hypertension or– if blood pressure is controlled within target ranges

in women with severe hypertension.

• To offer operative birth only if have severe hypertension and failed with intial treatment

Medical management..Anticonvulsant• Drug of choice: magnesium sulphate• For delivery within 24hours after starting MgSO4

• To consider MgSO4 if:– Severe hypertension and proteinuria or– Mild or moderate hypertension and proteinuria with one or more of the

following:• Symptoms of severe headache• Problems with vision, such as blurring or flashing before the eyes• Severe pain just below the ribs or vomiting• Papilloedema• Signs of clonus (≥3 beats)• Liver tenderness• HELLP syndrome • Platelet count < 100 000• Abnormal liver enzymes (ALT or AST rising to above 70 iu/litre).

Administration of MgSO4..

• Loading dose -> IV MgSO4 4 gm over 5 - 10 minutes, – followed by an infusion of 1 g/hour maintained for

24 hours

• Recurrent seizures should be treated with a further dose of 2–4 g given over 5 minutes.

Antihypertensive• Drug of choice (acc to protocol)– LABETALOL (Oral or intravenous)– HYDRALAZINE (intravenous)– NIFEDIPINE (Oral)

• Aim of treatment– To ensure blood pressure falls (maintain SBP <

150mmHg, DBP: 80-100mmHg)– To identify adverse effects for both the woman

and the fetus– To modify treatment according to response.

Corticosteroid (for fetal lungs maturation)• For IM betamethasone* 12 mg for 2 doses (24

hours apart) in women between 24 and 34 weeks

• Consider giving IM betamethasone* 12 mg for 2 doses (24 hours apart) in women between 35 and 36 weeks

Fluid balance and volume expansion• Restrict volume to 80cc/hour -> unless there

are ongoing losses• Do not use volume expansion unless was

given IVI hydralazine concomitantly

Cesarean section VS IOL• According to the clinical circumstances and

the woman's preference

• Severe pre-eclampsia and needing ventilationLEVEL 3

• Step-down from level 3 or severe pre-eclampsia with any of the following complications:• Eclampsia• HELLP syndrome• haemorrhage• hyperkalaemia• severe oliguria• coagulation support• intravenous antihypertensive treatment• initial stabilisation of severe hypertension• evidence of cardiac failure• abnormal neurology

LEVEL 2

• Pre-eclampsia with mild or moderate hypertension• Ongoing conservative antenatal management of severe preterm

hypertension• Step-down treatment after the birth

LEVEL 1

Indications for referral to critical care levels

Post partum care..

Blood Pressure– At least 4x/day -> inpatient– At least once between day 3 and day 5 after birth– On alternate days until normal if blood pressure

was abnormal on days 3–5

– In women with pre-eclampsia who did not take antihypertensive treatment and have given birth, start antihypertensive treatment if blood pressure is 150/100 mmHg or higher

Cont..• In women with pre-eclampsia who took

antihypertensive treatment and have given birth, measure blood pressure:– at least 4x/day while the woman is an inpatient– every 1–2 days for up to 2 weeks after discharge and until is

off treatment and has no hypertension– To continue ANC antihypertensive treatment– To consider adjustment of dose if BP < 140/90 mmHg– To reduce antihypertensive treatment if BP < 130/80 mmHg.

– Women on methyldopa -> should be discontinued within 2 days of delivery

Discharge advice• Only discharge to community if:

– No symptoms of pre-eclampsia– BP with or without treatment, is 149/99 mmHg or lower– Blood test results are stable or improving

• measure platelet count, transaminases and serum creatinine 48–72 hours after birth or step-down

• do not repeat platelet count, transaminases or serum creatinine measurements if results are normal at 48–72 hours.

• Women with pre-eclampsia and still on anti-hpt treatment -> TCA 2 weeks for medical review in community clinic or hospital

• All women who have had pre-eclampsia ->TCA PNC for medical review 6–8 weeks post partum

• If hypertension persist after 6-8 weeks post partum refer for specialist assesment

• All women with pre-eclampsia and still have proteinuria (1+ or more) at 6–8 weeks after the birth for a further review at 3 months after the birth to assess kidney function and consider offering them a referral for specialist kidney assessment.

Care plan for discharge..

To includes all of the following:• Who will provide follow-up care, including

medical review if needed• Frequency of blood pressure monitoring• Thresholds for reducing or stopping treatment• Indications for referral to primary care for

blood pressure review• Self-monitoring for symptoms

Breastfeeding..Antihypertensive medications that is safe for breastfeeding

1. labetalol2. nifedipine3. enalapril4. captopril5. atenolol6. metoprolol

Has insufficient evidence on the safety in babies receiving breast milk

1. ARBs2. amlodipine3. ACE inhibitors other than

enalapril and captopril

Advice and follow-up care• Risk of recurrence of hypertensive disorders of pregnancy

– Gestational hypertension• RECURRENCE OF GH -> 16% - 47%• Pre-eclampsia -> 2% - 7%

– Pre-eclampsia• GH -> 13% - 53%• Pre-eclampsia up to 16%

– If cx with severe pre-eclampsia birth before 34/52 25%– If cx with severe pre-eclampsia birth before 28/52 55%

• Inter-pregnancy interval and recurrence of hypertensive disorders of pregnancy no additional risk of recurrence if up to 10 years

• Body mass index between 18.5–24.9 kg/m2

• Long-term risk of cardiovascular disease• Long-term risk of end-stage kidney disease• Thrombophilia and the risk of pre-eclampsia