MANAGEMENT OF MANAGEMENT OF COMPLICATIONS OF PIH :COMPLICATIONS OF PIH :

AN OVERVIEWAN OVERVIEW

DR.VANDANA WALVEKARDR.VANDANA WALVEKARFormer Dean, Former Dean,

Nowrosjee Wadia Maternity Hospital,Nowrosjee Wadia Maternity Hospital,

Former President, Former President,

Mumbai Obs and Gyn society,Mumbai Obs and Gyn society,

Consultant, Consultant, Bhatia Hospital, MumbaiBhatia Hospital, Mumbai

PIHPIH

PIH can occur without warning at any time PIH can occur without warning at any time during pregnancy or early postpartum period.It during pregnancy or early postpartum period.It also occurs as a chronic form, gradually also occurs as a chronic form, gradually becoming worse with advancing pregnancybecoming worse with advancing pregnancy

In its mild form it causes NO significant In its mild form it causes NO significant deleterious effect on the mother and the baby deleterious effect on the mother and the baby BUT inn the severe form plays havoc in their BUT inn the severe form plays havoc in their lives with complicationslives with complications

PIHPIH What is more the complications are unpredictable!!!What is more the complications are unpredictable!!!

Am JOB 2006 Aug:Ganzewoot etalAm JOB 2006 Aug:Ganzewoot etal

216 women with cntrols with HELLP216 women with cntrols with HELLP

Adverse fetal outcome:g.age :ODratio 0.4Adverse fetal outcome:g.age :ODratio 0.4

Adverse mat outcome:parity :ODratio 0.4Adverse mat outcome:parity :ODratio 0.4

Hence prediction of clinical course and Hence prediction of clinical course and development of complications is NOT FEASIBLEdevelopment of complications is NOT FEASIBLE

PIH : COMPLICATIONSPIH : COMPLICATIONS Maternal complications: Obstetric:Maternal complications: Obstetric:

Abruptio placentae, Eclampsia, Preterm labour, Abruptio placentae, Eclampsia, Preterm labour, PPH,DIC and coagulopathy HELLPPPH,DIC and coagulopathy HELLP

Non Obstetric: acute pulm. Edema,CVA, blindness, Non Obstetric: acute pulm. Edema,CVA, blindness, ARF, acute pancreatitis, acuteARF, acute pancreatitis, acute

CholecystitisCholecystitis

Fetal coplications: IUGR, Prematurity, IUFD, Fetal coplications: IUGR, Prematurity, IUFD, neonatal/childhood neurological deficitsneonatal/childhood neurological deficits

PIH : PATHOPHYSIOLOGYPIH : PATHOPHYSIOLOGY

It is a multisystem disease with vasospasIt is a multisystem disease with vasospas

& coagulation defects begins with endothelial & coagulation defects begins with endothelial

dysfunction : platelet activation: release of dysfunction : platelet activation: release of

thromboxane A &serotonin: vasospasm: pl. thromboxane A &serotonin: vasospasm: pl.

aggregation: damage with coagulopathy aggregation: damage with coagulopathy

multiorgan failure: TERMINATES WITH DELIVERYmultiorgan failure: TERMINATES WITH DELIVERY

ABRIPTIO PLACENTAEABRIPTIO PLACENTAE Commonest, most often mixed APH, occ. Commonest, most often mixed APH, occ.

Concealed :USG usually confirms the diag. & Concealed :USG usually confirms the diag. & indicates severityindicates severity

MGT: depends on g.age, parity, inducibility with MGT: depends on g.age, parity, inducibility with Bishop’s score, fetal heart +/-Bishop’s score, fetal heart +/-

Hypertension prophylaxis, supportive mgt with Hypertension prophylaxis, supportive mgt with transfusion if needed, ARM/LSCS as delivery only transfusion if needed, ARM/LSCS as delivery only will sort the problemwill sort the problem

PPHPPH Simple, atonic: preterm labour,ut. Inertia, Simple, atonic: preterm labour,ut. Inertia,

incoordinate ut. Action, ass. with abruptioincoordinate ut. Action, ass. with abruptio

Usually responds to standard mgt. with oxytocics Usually responds to standard mgt. with oxytocics etc.etc.

2-5% severe needing surgical measures: B.Lynch 2-5% severe needing surgical measures: B.Lynch suture, stepwise devscularisation of uterine, suture, stepwise devscularisation of uterine, hysterectomy or int. iliac ligationhysterectomy or int. iliac ligation

Ass. With APH: couvelaire uterus: HELLPAss. With APH: couvelaire uterus: HELLP

ECLAMPSIAECLAMPSIA 5% approx. :ante, intra post partum epileps5% approx. :ante, intra post partum epileps

Mgt with magsulph Pritchard/modified Pritchard has Mgt with magsulph Pritchard/modified Pritchard has stood the test of time:RCTSstood the test of time:RCTS

Invest: PT, PTT, FDP, Fibrinogen, D-dimerInvest: PT, PTT, FDP, Fibrinogen, D-dimer

Mgt: supportive measures, IV 4-6gm Mgso4, foll by 4-6gm Mgt: supportive measures, IV 4-6gm Mgso4, foll by 4-6gm im 4-6hrly with close monitoring till under controlim 4-6hrly with close monitoring till under control

Induction/LSCS: g.age, FHS +/-,Bishop’s,Induction/LSCS: g.age, FHS +/-,Bishop’s,

Intercurrent ecl: R Bhatt: in rare casesIntercurrent ecl: R Bhatt: in rare cases

ECLAMPSIAECLAMPSIA ECLAMPSIA in UK - 2006ECLAMPSIA in UK - 2006

229 hospitals, 2205-2006 feb229 hospitals, 2205-2006 feb

Incidence: 2.7/10,000Incidence: 2.7/10,000

38% proteinuria seen only one week prior38% proteinuria seen only one week prior

99% treated with Mgso499% treated with Mgso4

NO mortalityNO mortality

Non eclampsia related compl :10%Non eclampsia related compl :10%

PNMR:59/10,000PNMR:59/10,000

help.. HELP.. HELLP Syndromehelp.. HELP.. HELLP Syndrome

Dr. Vandana Dr. Vandana WalvekarWalvekar

Dr. Vandana Dr. Vandana WalvekarWalvekar

Wein Stein : 1982Wein Stein : 1982

H = HemolysisH = Hemolysis

EL = Elevated liver enzymesEL = Elevated liver enzymes

LP = Low platelets in a women with pre- LP = Low platelets in a women with pre- eclampsia / eclampsiaeclampsia / eclampsia

Appears 24 wks. – post partum (1wk -33%)Appears 24 wks. – post partum (1wk -33%)

Maternal Mortality of 24-40%Maternal Mortality of 24-40%

Perinatal Mortality of 30-80%Perinatal Mortality of 30-80%

Classification – Mississippi, Classification – Mississippi, TennesseTennesse

I. I. < 50,000 /< 50,000 /l platelets, altered LFT l platelets, altered LFT microangiopathic anemia – highest MMR PNMRmicroangiopathic anemia – highest MMR PNMR

II. II. > 50,000 > 50,000 /1 platelets < 100,000//1 platelets < 100,000/l.l.

III. > 100,000 III. > 100,000 /1 platelets < 150,000/1 platelets < 150,000LFT-LDH > 600 I.U./l,LFT-LDH > 600 I.U./l,AST AST 70 I.U./l, ALT 70 I.U./l, ALT 40 I.U./l 40 I.U./l

Partial HELLP: one or two of the featuresPartial HELLP: one or two of the features

Considered a Variant Considered a Variant of P.E. & Eclampsiaof P.E. & Eclampsia

Prognosis:- Failure of platelet count to Prognosis:- Failure of platelet count to

with in 96 hrs. denotes multiorgan non with in 96 hrs. denotes multiorgan non

compensatory dysfunctioncompensatory dysfunction

Also occurs : Severe sepsis, Lung injury, Also occurs : Severe sepsis, Lung injury,

multiorgan failure with DICmultiorgan failure with DIC

HELLP – PathophysiologyHELLP – Pathophysiology

Vascular endothelial dysfunction Vascular endothelial dysfunction

Platelet aggregation Platelet aggregation fibrin fibrin

activation & consumption activation & consumption Selective Selective

organ (Liver) insufficiency organ (Liver) insufficiency clinical clinical

HELLPHELLP

Clinical SpectrumClinical Spectrum Disease of multiparaDisease of multipara tension > 150/90tension > 150/90 ProteinuriaProteinuria ConvulsionConvulsion Epigastric painEpigastric pain VomitingVomiting Abruptio placentaAbruptio placenta Retinal detachment with acute blindnessRetinal detachment with acute blindness HemolysisHemolysis Pt’s with ART techniques – donor egg, new partum more pronePt’s with ART techniques – donor egg, new partum more prone MSAFP & HCG more proneMSAFP & HCG more prone

Laboratory DiagnosisLaboratory Diagnosis

Platelets < 100,000/ulPlatelets < 100,000/ul

LDH >600 I.U./1LDH >600 I.U./1

AST >70 I.U.AST >70 I.U.

ALT > 40 I.u. ALT > 40 I.u.

Uric acid > 7.8mg %Uric acid > 7.8mg %

Creatinine > 1.0 mg%Creatinine > 1.0 mg%

Maternal Mortality : 25-40%Maternal Mortality : 25-40% Causes : Cardio pulm. failureCauses : Cardio pulm. failure

DICDIC

CVACVA

Hepatic ruptureHepatic rupture

Post caesarean shockPost caesarean shock

Multiorgan failureMultiorgan failure

Associated conditions – complementAssociated conditions – complement

Early disease can be only suspected as Early disease can be only suspected as

the diagnostic symptoms come too late the diagnostic symptoms come too late

in the course of the diseasesin the course of the diseases

Laboratory EvidenceLaboratory Evidence Peripheral smear : burr cellsPeripheral smear : burr cells

LDH (LDH (sensitive)sensitive)

S. Haptoglobins S. Haptoglobins early, sensitive early, sensitive

ThrombocytopeniaThrombocytopenia

prothrombin time, partial thromboplastin time, prothrombin time, partial thromboplastin time, Fibrinogen, Fibrinogen, FDP FDP

AST AST 70 IU/l70 IU/l

ALT ALT 40 I.u./l 40 I.u./l

S. creatinine S. creatinine

Management of HELLP SyndromeManagement of HELLP Syndrome(Univ. of Mississippi Medical Center)(Univ. of Mississippi Medical Center)

Anticipate the diseaseAnticipate the disease

Laboratory evidence to evaluate severity of maternal diseaseLaboratory evidence to evaluate severity of maternal disease

Fetal management: depends onFetal management: depends on

G.ageG.age

Severity of mat.disease Severity of mat.disease

≥≥ 34 – deliver within 24 hrs. irrespective of class of disease 34 – deliver within 24 hrs. irrespective of class of disease vag/abd. del.vag/abd. del.

24-34 – hospitalise, monitor, steroids : Dexa 10 mg 12 hrly till 24-34 – hospitalise, monitor, steroids : Dexa 10 mg 12 hrly till mat. Condition improvesmat. Condition improves

HELLP Management HELLP Management (contd.)(contd.)

Steroids : Fetal; Steroids : Fetal; lung maturity. Mat: platelet count stabilised, lung maturity. Mat: platelet count stabilised, AST/ALT AST/ALT Gain time for induction of labourGain time for induction of labour Gain time transfer to III institutionGain time transfer to III institution Vital to continue post partum to prevent rebound phenomenaVital to continue post partum to prevent rebound phenomena Nitric Oxide – reverse platelet destruction & promote vasodilationNitric Oxide – reverse platelet destruction & promote vasodilation Admin. Of FFP – provide other factors removal of angiopathic debrisAdmin. Of FFP – provide other factors removal of angiopathic debris Platelet transfusion: essential if < 50000 pt for immediate C.S., Platelet transfusion: essential if < 50000 pt for immediate C.S.,

bleeding from I.V. sites, vag del. Imminent, after delivery : for 24 hrs. bleeding from I.V. sites, vag del. Imminent, after delivery : for 24 hrs. till pt. Stabilise at till pt. Stabilise at 50,000 in C.S. 50,000 in C.S. 20,000 in vag.del. 20,000 in vag.del.

Refractory pts. Plasma change as a desperate measureRefractory pts. Plasma change as a desperate measure

Control of Control of Tension Tension To minimise AbruptioTo minimise Abruptio

Alpha-dopa/ LabetelolAlpha-dopa/ Labetelol

Nifedepine : sublingual /oral Nifedepine : sublingual /oral normalises platelet count, normalises platelet count, urine urine outputoutput

Control of convulsions: MgSOControl of convulsions: MgSO44 is the drug of choice 4-6gm iv foll. is the drug of choice 4-6gm iv foll.

by im 4-6gm every 4-6 hrs.by im 4-6gm every 4-6 hrs.

Monitoring is essentialMonitoring is essential

IV fluids to maintain output, restriction in cases of renal IV fluids to maintain output, restriction in cases of renal involvementinvolvement

Management of Labour & DeliveryManagement of Labour & Delivery Delivery is the only way deterioration can be stoppedDelivery is the only way deterioration can be stopped ≥≥ 34 wks. – expeditions delivery 68% LSCS rate34 wks. – expeditions delivery 68% LSCS rate ≤ ≤ 34 wks. –cortisone – induction of labour Dexamethazone 34 wks. –cortisone – induction of labour Dexamethazone

amelicrates the process & allows time for cervical ripeningamelicrates the process & allows time for cervical ripening LSCSLSCS

Spontaneous expulsion of placentaSpontaneous expulsion of placenta In situ repair of incisionIn situ repair of incision Mass closure of abd.wallMass closure of abd.wall Ascitic fluid loss to be compensatedAscitic fluid loss to be compensated Regional anaesthesia saferRegional anaesthesia safer Look for hepatic haemorrhageLook for hepatic haemorrhage

Post Partum HELLPPost Partum HELLP PE to be monitored till PE to be monitored till

Platelet count > 100,000Platelet count > 100,000 LDH LDH Diuresis Diuresis 100 ml/hr 100 ml/hr 150 150 100 BP 100 BP Clinical improvementClinical improvement

Post partum corticosteroidsPost partum corticosteroids ? D&C to remove decidual tissue? D&C to remove decidual tissue Hepatic complications: rupture-surgeryHepatic complications: rupture-surgery Recurrent risk: preeclampsia –42%, HELLP – 19-27%Recurrent risk: preeclampsia –42%, HELLP – 19-27% Higher risk in del. < 32 wksHigher risk in del. < 32 wks

HELLP:ASSORTED FACTSHELLP:ASSORTED FACTS Essentially: supportive mgt, seizure prophylaxis, BP Essentially: supportive mgt, seizure prophylaxis, BP

control, terminationcontrol, termination

Pulm. Edema: IV immunoglobulin viable Pulm. Edema: IV immunoglobulin viable

Refractory HELLP: pl.<30,000,ele. LFT, also need rpt. Refractory HELLP: pl.<30,000,ele. LFT, also need rpt. Transfusions for hematcrit maintenanceTransfusions for hematcrit maintenance

Hepatic imaging & liver biopsy DO NOT correlate the Hepatic imaging & liver biopsy DO NOT correlate the sverity of HELLPsverity of HELLP

Anasthesia: GA with sevoflurane without epidural/epiduralAnasthesia: GA with sevoflurane without epidural/epidural

CARDIOVASCULAR COMPLICATIONSCARDIOVASCULAR COMPLICATIONS Acute pulm. Edema, usually associated with eclampsia, acute Acute pulm. Edema, usually associated with eclampsia, acute

hypertensive crisis without convulsions, can occur hypertensive crisis without convulsions, can occur postpartumpostpartum

MGT: multidisciplinary, ICUMGT: multidisciplinary, ICU

Rapid digitalisation, diuretics, supportiveRapid digitalisation, diuretics, supportive

Not advisable to terminate unless pt. stable irresp. of g.age, Not advisable to terminate unless pt. stable irresp. of g.age, vag del preferredvag del preferred

Surgical mgt only if mandatorySurgical mgt only if mandatory

Fluid restriction at induction, (conentrated oxytocic admn) Fluid restriction at induction, (conentrated oxytocic admn) no data with misoprostolno data with misoprostol

PE AND FUTURE CARDIOVASCULAR RISKPE AND FUTURE CARDIOVASCULAR RISK

NEWSTEAD et NEWSTEAD et el:mar2007:Ex,Rev.cardiovascular el:mar2007:Ex,Rev.cardiovascular

therapytherapy

Pregnancy is a metabolic and vascular Pregnancy is a metabolic and vascular

“STRESS TEST” for the woman. Those who “STRESS TEST” for the woman. Those who

“FAIL” are at a risk of long term cardiovascular “FAIL” are at a risk of long term cardiovascular

complications ,obesity adds a further riskcomplications ,obesity adds a further risk

CEREBROVASCULAR ACCIDENTSCEREBROVASCULAR ACCIDENTS Usually asociated with eclampsiaUsually asociated with eclampsia Acute hypertensive crisis without convulsions: mged with MgSo4, Acute hypertensive crisis without convulsions: mged with MgSo4,

sublingual nifedepine, terminationsublingual nifedepine, termination VigilPE, GraciaP :RCT :mgt. of severePE VigilPE, GraciaP :RCT :mgt. of severePE IV Hydralazine (apresoline) or labetelolIV Hydralazine (apresoline) or labetelol 82 women SPE,HELLP:82 women SPE,HELLP: IV hydralazine5mg. Slow bolus every 20mts for 5 dosesIV hydralazine5mg. Slow bolus every 20mts for 5 doses IV labetelol20mg bolus:40mg if no hypotension in 20mts:foll by 80mg IV labetelol20mg bolus:40mg if no hypotension in 20mts:foll by 80mg

every 20mts till max 300mgevery 20mts till max 300mg Safe & effective in postpartum periodSafe & effective in postpartum period With intracranial hage: LSCS with decompression; Dai etal :nov2007, With intracranial hage: LSCS with decompression; Dai etal :nov2007,

cl. hypertensioncl. hypertension

FOOTPRINTS IN THE URINEFOOTPRINTS IN THE URINE Acute renal failure: with eclampsia or SPEAcute renal failure: with eclampsia or SPE

No positive clinical findings, anuria, No positive clinical findings, anuria,

hypertension, renal profile abnormal only after hypertension, renal profile abnormal only after

10-12 hrs10-12 hrs

Multidisciplinary approach, hemodialysis Multidisciplinary approach, hemodialysis

essental for reversal as anuria is prerenalessental for reversal as anuria is prerenal

VISUAL CALAMITIES ..ANDVISUAL CALAMITIES ..AND Blurring of vision &temp blindness are known and Blurring of vision &temp blindness are known and

are reversible totallyare reversible totally

Permanat blindness: rare: associated with SPE & Permanat blindness: rare: associated with SPE & HELLP : reports by Moseman etal OBGY,nov2007 HELLP : reports by Moseman etal OBGY,nov2007 vol100vol100

Acute pancreatitis, cholecystitis can occue due Acute pancreatitis, cholecystitis can occue due microvascular disturbances even with splanchnic microvascular disturbances even with splanchnic circulationcirculation

SEVERE PE WITH IUGRSEVERE PE WITH IUGR Expectant mgt of SPE with IUGR:AMJ Expectant mgt of SPE with IUGR:AMJ

mar2007,Hadad et almar2007,Hadad et al

239 pts, 24-33wks expectantly managed with 239 pts, 24-33wks expectantly managed with steriods till delsteriods till del

Maternal outcomes similar by way of labour and Maternal outcomes similar by way of labour and other complications to controlsother complications to controls

Fetal :higher death rath with severe IUGRFetal :higher death rath with severe IUGR

NEONATES AND PIH MOTHERNEONATES AND PIH MOTHER Ind j of pediatrics:july2007,vol 74, s. shivkumar: Ind j of pediatrics:july2007,vol 74, s. shivkumar:

Babies of PIH mothersBabies of PIH mothers

Thrombocytopenai:22%,higher in pretermThrombocytopenai:22%,higher in preterm

No correlation in mat & fetal pl countsNo correlation in mat & fetal pl counts

Neutropenia:well documentedNeutropenia:well documented

Nucleated RBCs :22% polycythemic in term IUGR: Nucleated RBCs :22% polycythemic in term IUGR: due to chronic asphxia: duration to produce due to chronic asphxia: duration to produce polycythemia not knkwn: polycythemia not knkwn: Philips et alPhilips et al

FUTURE THOUGHTSFUTURE THOUGHTS In this erratic, unpredictable entity it is posible thatIn this erratic, unpredictable entity it is posible that

Serum, urine InhibinA may provide a marker: Serum, urine InhibinA may provide a marker: HamaB HamaB et al AmJObGy Dec2006et al AmJObGy Dec2006

Plasmaferresis: in severe SPE, refractory HELLP, Plasmaferresis: in severe SPE, refractory HELLP, DICDIC

Aspirin early in pregnancy :evidence inconclusiveAspirin early in pregnancy :evidence inconclusive

COMMON PROBLEMCOMMON PROBLEM

UNPREDICTABLEUNPREDICTABLE

MULTIPLE MANAGEMENT MODALITIESMULTIPLE MANAGEMENT MODALITIES

CHALLENGE TO THE OBSTETRICIAN!!!CHALLENGE TO THE OBSTETRICIAN!!!

THANK YOUTHANK YOU