Severe Pre-eclampsiaEclampsia
HELLPAcute Fatty Liver of Pregnancy
(AFLP)
Severe Pre-eclampsiaEclampsia
HELLPAcute Fatty Liver of Pregnancy
(AFLP)
ObjectivesObjectives
• 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 PregnancyConditions Exclusive to Pregnancy
• Severe pre-eclampsia
• Eclampsia
• HELLP syndrome
• Acute fatty liver of pregnancy (AFLP)
Hypertensive Disorders of PregnancyHypertensive Disorders of Pregnancy
Pregnancy Induced Hypertension
PIH(no
proteinuria)
HELLP Syndrome
Chronic Hypertension (pre-
existing or undiagnosed prior
to pregnancy))
6-8% of all
gestations
Preeclampsia (PIH with
proteinuria)
EclampsiaSevere
Preeclampsia AFLP
Pre-eclampsiaPre-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-eclampsiaRisk Factors for Pre-eclampsia
• Nulliparity
• Maternal age <16 or >40yrs
• Multiple pregnancy
• Family history of pre-eclampsia or eclampsia
• Chronic (pre-existing) hypertension
• Chronic renal disease
• Antiphospholipid syndrome (APLS)
• Diabetes mellitus
• Angiotensin gene T235
Prevention: of no proven benefitPrevention: of no proven benefit
• Correction of nutritional deficiencies:
Magnesium
Zinc
Omega 3 fatty acids
• Alter prostacyclin / thromboxane balance:
Low-dose Aspirin
(Note: may be of some benefit in women with previous early onset pre-eclampsia or eclampsia)
Severe Pre-eclampsia
Severe Pre-eclampsia
Severe pre-eclampsia: symptoms, signs & diagnostic criteriaSevere pre-eclampsia: symptoms, signs & diagnostic criteria
HeadachesVisual Disturbances
Pulmonary Oedema
Hepatic DysfunctionRUQ or Epigastric Pain
OliguriaElevated Creatinine
Thrombocytopaenia or haemolysis
Proteinuria of 5 g or more in 24 hrs
Systolic BP > 160 to 180 mm HgDiastolic BP > 110 mm Hg
Clinical Course of Neglected Severe Pre-eclampsiaClinical Course of Neglected Severe Pre-eclampsia
EyesArteriolar SpasmRetinal HaemorrhagePapilloedemaTransient Scotomata
Respiratory SystemPulmonary OedemaARDS
LiverSubcapsular HaemorrhageHepatic Rupture
Haematopoietic SystemHELLP SyndromeDIC
CNSSeizuresIntracranial HaemorrhageCVAEncephalopathy
PancreasIschaemic Pancreatitis
KidneysAcute Renal Failure
Uteroplacental CirculationIUGRAbruptionFetal CompromiseFetal Demise
Management of Severe Pre-eclampsia
Management of Severe Pre-eclampsia
• Admit to hospital with close maternal-fetal assessment and monitoring
• Treatment goals:lower BP to prevent cerebral haemorrhageprevent seizures
• Plan delivery
• If maternal condition allows - consider steroids for fetal lung maturation (<34 weeks)
Maternal & Fetal EvaluationMaternal & 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 MedicationAntihypertensive Medication
• Goal: maternal diastolic BP 90-100 mmHg NO LOWER – to maintain placental blood flow
• Parenteral agents vasodilators (eg IV hydralazine)
beta blockers (eg IV labetalol)
• Oral agents calcium channel blockers (eg nifedipine)
Magnesium SulphateMagnesium 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 LevelsMagnesium Levels
Normal
Therapeutic
Loss of biceps/patellar reflex
Somnolence
Respiratory depression
Paralysis
Cardiac arrest
mg/dl
1.3 to 2.6
4 to 8
8 to 10
10 to 12
12 to 17
15 to 17
30 to 35
Antidote is calcium gluconate one gram IV over 3 minutes
MAGPIE TRIALMAGPIE 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 TRIALMAGPIE 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 pre-eclampsia
Lancet 2002; 359: 1877-90
Significant maternal or fetal compromise
If maternal condition has been stabilisedand gestation< 34 weeks:
Daily evaluation of maternal & fetal conditions until delivery indicated
Consider oral anti-hypertensive drugs
Yes Assess mode of delivery
Expedite delivery
No
Severe Pre-eclampsia Delivery Decisions ISevere Pre-eclampsia Delivery Decisions I
WHEN DECISION TO DELIVER HAS BEEN MADE
REVIEW MEDICATIONS:
• IV antihypertensives if: systolic > 160mmHg diastolic > 110mmHg MAP >125
• Commence MgSO4
Severe Pre-eclampsia Delivery Decisions IISevere Pre-eclampsia Delivery Decisions II
Severe Preeclampsia Delivery Decisions IIISevere 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 ManagementPost-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
EclampsiaEclampsia
• 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 ManagementSeizure 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”“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 practiceKey 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 SyndromeHELLP Syndrome
• Atypical presentation of severe pre-eclampsia
• Acronym HELLP:
Haemolysis
Elevated Liver enzymes
Low Platelets
Clinical Presentation of HELLPClinical Presentation of HELLP
• Extremely variable usually multiparous
• Common findings: RUQ pain, epigastric pain, nausea, and
vomiting
85% hypertensive
• Time of diagnosis mid-second trimester onwards
2/3 antepartum, 1/3 postpartum
Differential Diagnosis of HELLPDifferential Diagnosis of HELLP
• Biliary colic, cholecystitis
• Hepatitis
• Gastro-oesophageal reflux
• Gastro-enteritis
• Pancreatitis
• Ureteric calculi or pyelonephritis
• ITP or TTP
Laboratory Findings in HELLPLaboratory 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 HELLPManagement of HELLP
• Similar to severe pre-eclampsia: stabilize mother
evaluate fetus for compromise
determine optimal timing/route of delivery
use CEFM
manage BP and fluid status
• Women may be considered for MgSO4
HELLP: New TreatmentsHELLP: 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 PregnancyAcute 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 AFLPDiagnosis 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
DICDIC
• 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 DICDiagnosis 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 DICTreatment 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
SummarySummary
• 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