Transcript 009 PIH, Eclampsia, HELLP Powerpoint

Severe Pre-eclampsia
Eclampsia
HELLP
Acute Fatty Liver of Pregnancy (AFLP)
Objectives
• Describe selected medical emergencies exclusive
to pregnancy
• Describe the serious complications related to
these diseases
• Formulate a plan for diagnosis and treatment of
these conditions
• Be aware that these conditions form a continuum
of disease with certain differences in presentation
Conditions Exclusive to Pregnancy
• Severe pre-eclampsia
• Eclampsia
• HELLP syndrome
• Acute fatty liver of pregnancy (AFLP)
Hypertensive Disorders of Pregnancy
6-8% of all
gestations
Pregnancy Induced
Hypertension
PIH
(no proteinuria)
Chronic Hypertension
(pre-existing or
undiagnosed prior to
pregnancy))
Preeclampsia
(PIH with proteinuria)
Severe
Preeclampsia
Eclampsia
HELLP
Syndrome
AFLP
Pre-eclampsia
• Classic Triad:
hypertension
(>140/90)
proteinuria
(>1+ or >0.3g/24hours)
generalized
oedema (least reliable)
• Hypertension and proteinuria must be
present on two occasions >6 hrs apart
• Rapid weight gain is supportive evidence
Risk Factors for Pre-eclampsia
• Nulliparity
• Chronic renal disease
• Maternal age <16 or
>40yrs
• Antiphospholipid
syndrome (APLS)
• Multiple pregnancy
• Diabetes mellitus
• Family history of preeclampsia or eclampsia
• Angiotensin gene T235
• Chronic (pre-existing)
hypertension
Prevention: of no proven benefit
• Correction of nutritional deficiencies:
 Magnesium
 Zinc
 Omega
3 fatty acids
• Alter prostacyclin / thromboxane balance:
 Low-dose
 (Note:
Aspirin
may be of some benefit in women with
previous early onset pre-eclampsia or eclampsia)
Severe Pre-eclampsia
Severe pre-eclampsia: symptoms, signs & diagnostic
criteria
Headaches
Visual Disturbances
Pulmonary Oedema
Hepatic Dysfunction
RUQ or Epigastric Pain
Oliguria
Elevated Creatinine
Proteinuria of 5 g or more in 24 hrs
Systolic BP > 160 to 180 mm Hg
Diastolic BP > 110 mm Hg
Thrombocytopaenia or haemolysis
Clinical Course of Neglected Severe Pre-eclampsia
Eyes
Arteriolar Spasm
Retinal Haemorrhage
Papilloedema
Transient Scotomata
Respiratory System
Pulmonary Oedema
ARDS
Liver
Subcapsular Haemorrhage
Hepatic Rupture
Haematopoietic System
HELLP Syndrome
DIC
CNS
Seizures
Intracranial Haemorrhage
CVA
Encephalopathy
Pancreas
Ischaemic Pancreatitis
Kidneys
Acute Renal Failure
Uteroplacental Circulation
IUGR
Abruption
Fetal Compromise
Fetal Demise
Management of Severe
Pre-eclampsia
• Admit to hospital with close maternal-fetal
assessment and monitoring
• Treatment goals:
lower
BP to prevent cerebral haemorrhage
prevent
seizures
• Plan delivery
• If maternal condition allows - consider steroids for
fetal lung maturation (<34 weeks)
Maternal & Fetal Evaluation
• 4 hourly BP, P & Temperature
• Record strict fluid balance
• Blood investigations: FBC (platelets), U&Es,
LFTs and uric acid; clotting screen,
• Urinary investigations: dipstix, [24hr collection
for protein/creatinine clearance]
• Assess fetal status - Scan [growth, Doppler,
BPP], CTG
Antihypertensive Medication
• Goal: maternal diastolic BP 90-100 mmHg
 NO
LOWER – to maintain placental blood flow
• Parenteral agents
 vasodilators
 beta
(eg IV hydralazine)
blockers (eg IV labetalol)
• Oral agents
 calcium
channel blockers (eg nifedipine)
Magnesium Sulphate
• Preferred anti-convulsant
• Slows neuromuscular conduction and decreases
CNS irritability
• No significant effects on blood pressure
• 4-6 gram IV load, followed by infusion of 1-3
grams / hour
• Can be monitored clinically (reflexes etc)
Magnesium Levels
mg/dl
Normal
1.3 to 2.6
Therapeutic
4 to 8
Loss of biceps/patellar reflex
8 to 10
Somnolence
10 to 12
Respiratory depression
12 to 17
Paralysis
15 to 17
Cardiac arrest
30 to 35
Antidote is calcium gluconate one gram IV over 3 minutes
MAGPIE TRIAL
PARTICIPANTS
• Large, multi-national RCT of MgSO4 vs placebo
for pre-eclampsia
• Entry criteria: BP140/90; protein 1+ (30mg/dl)
• Thus mild, moderate & severe pre-eclamptics
were included
Lancet 2002; 359: 1877-90
MAGPIE TRIAL
RESULTS
• Significant  risk of eclampsia
RR 0.58
• Trend to  maternal mortality
RR 0·55
• No difference in the risk of baby dying (12·7%, vs 12·4%)
• Significant  risk of placental abruption
RR 0·67
• This has lead to a change in UK practice with the
introduction of MgSO4 for treatment of severe preeclampsia
Lancet 2002; 359: 1877-90
Severe Pre-eclampsia
Delivery Decisions I
Significant maternal
or fetal compromise
No
If maternal condition has been stabilised
and gestation< 34 weeks:
Daily evaluation of maternal & fetal
conditions until delivery indicated
Consider oral anti-hypertensive drugs
Yes
Assess mode of delivery
Expedite delivery
Severe Pre-eclampsia
Delivery Decisions II
WHEN DECISION TO DELIVER HAS BEEN MADE
REVIEW MEDICATIONS:
• IV antihypertensives if: systolic > 160mmHg
diastolic > 110mmHg
MAP >125
• Commence MgSO4
Severe Preeclampsia
Delivery Decisions III
• Vaginal delivery preferred
• Consider Caesarean delivery for:
continuous seizures or other emergency
 obvious evidence of fetal compromise
 unfavourable cervix
 severe prematurity

• Anaesthesia

regional vs general (early involvement of obstetric
anaesthetist)
Post-partum Management
• Improvement usually rapid after delivery
• Risk of seizure greatest in first 24 hours
• Magnesium continued for 24 hrs
• Continue clinical monitoring of MgSO4 , BP,
urine output
• Watch for signs of fluid overload
Eclampsia
• Appearance of seizures in a patient (often with
pre-existing pre-eclampsia)
• 1 in 2000 pregnancies (developed countries)
• Aetiology uncertain
 cerebral
oedema, ischaemia possible causes
• In 20%, BP can be normal
• Can occur before, during or after delivery
 1/3
are post-delivery
Seizure Management
• Protect airway to minimize aspiration (ABCs)

nurse in appropriate environment (NOT A DARKENED ROOM)
• Prevent maternal injury
• Give MgSO4 to control the convulsions
• Avoid polypharmacy
• When stable, plan delivery
• Conservative management can be considered at <28
weeks with INTENSIVE maternal & fetal monitoring IN AN
APPROPRIATE UNIT (ie one with neonatal support)
“Why Mothers Die 1997-99”
• 15 confirmed deaths from pre-eclampsia/eclampsia
• 7 related to intracranial haemorrhage
• 3 from intra-abdominal haemorrhage
• 80% involved ‘substandard care’
Key recommendations / good practice
• Automated BP recording systems can seriously
UNDERESTIMATE BP in pre-eclampsia

BP values should be compared with those obtained by
conventional mercury sphygmomanometers
• Severe hypertension must be treated effectively
• Named obstetrician to lead decision-making with obstetric
anaesthetist (use regionally agreed guidelines)
• Early engagement of other specialists (eg ICU, haematology)
• Location in a single side-room may be inappropriate
(consider HDU etc)
HELLP Syndrome
• Atypical presentation of severe pre-eclampsia
• Acronym HELLP:
Haemolysis
Elevated
Low
Liver enzymes
Platelets
Clinical Presentation of HELLP
• Extremely variable
 usually
multiparous
• Common findings:
 RUQ
pain, epigastric pain, nausea, and vomiting
 85%
hypertensive
• Time of diagnosis
 mid-second
 2/3
trimester onwards
antepartum, 1/3 postpartum
Differential Diagnosis of HELLP
• Biliary colic, cholecystitis
• Hepatitis
• Gastro-oesophageal reflux
• Gastro-enteritis
• Pancreatitis
• Ureteric calculi or pyelonephritis
• ITP or TTP
Laboratory Findings in HELLP
• Haemolysis
 abnormal
peripheral smear
• Liver enzymes
 bilirubin
 ALT

 (>70 IU/L)
• Platelet count

<100 000 x 109/l
 can
be used to classify severity
Management of HELLP
• Similar to severe pre-eclampsia:
 stabilize
mother
 evaluate
fetus for compromise
 determine
 use
optimal timing/route of delivery
CEFM
 manage
BP and fluid status
• Women may be considered for MgSO4
HELLP: New Treatments
• If <32 weeks with platelets <100 000 x 109/l and falling:
give IV dexamethasone 10 mg 12hrly (48 – 72hrs)

evidence from small RCTs suggest the potential to prolong
pregnancy and possibly ‘cure’ HELLP
• Platelets for active bleeding or if <20 000 x 109/l

discuss with haematologist
• Plasmapheresis: limited success and not routinely used in
UK practice
Acute Fatty Liver of Pregnancy
• Rare (1 in 7 000 - 16 000 pregnancies)
• Presents in third trimester:
 vomiting
(76%), abdominal pain (43%)
 anorexia
(21%), jaundice (16%)
• May progress to liver failure, including ascities
and renal failure
• Differential includes HELLP, pre-eclampsia, acute
hepatitis, or toxin-induced liver damage
Diagnosis of AFLP
• ALT 
Bilirubin 
• PT & PTT 
Fibrinogen 
• Often significant hypoglycaemia (need IV glucose)
• Delivery is the most important part of treatment as
maternal mortality is up to 50% with conservative
management (also associated  perinatal mortality)
• Liver ultrasound may be suggestive
• Liver biopsy is diagnostic but rarely done
DIC
• Underlying cause can be difficult to detect
• May complicate any of the previous & other
conditions (eg abruption)
• Simultaneous activation of clotting system and
clot lysis
• Depletes clotting factors, causing bleeding
• Clots can lead to ischaemia
• Haemolysis can lead to significant anaemia
Diagnosis of DIC
• Venepuncture and IV sites ooze, easy bruising, petechiae
• Blood tests:
 APTT and PT
 Fibrin Degradation Products (FDPs) and ‘D-dimer’
 Fibrinogen
 Platelet count
• ‘Clot stability’ test – observe whole blood in plain tube:
 Clotting time or clot unstable and breaks down
Treatment of DIC
• Correction of underlying cause is the key!!
• Often related to associated pregnancy complication
• Expedite delivery (vaginal if appropriate)
• If cause uncertain, replace coagulation factors:
 discuss
with haematologist
 maintain
platelets >50 000 x 109/l
 maintain
fibrinogen (FFP or cryoprecipitate) >150mg/dl
 avoid
heparin if patient actively bleeding
Summary
• Be familiar with these serious medical
conditions specific to pregnancy
• Key to management is close clinical vigilance
with appropriate laboratory & imaging studies
• Clinical challenge is balancing maternal and
fetal well-being and mode/timing of delivery
• Consultation is of value in difficult cases