severe pre eclampsi

7/18/2019 Severe Pre Eclampsi

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SEVERE PRE-ECLAMPSIA

DEFINITIONS

• Pre-eclampsia: pregnancy induced hypertension with significant proteinuria +/- oedema

affecting virtually any organ system in the body

• Severe pre-eclampsia: Diastolic blood pressure >110 mmHg or systolic blood pressure

>160 mmHg on more than two occasions with significant proteinuria

RECOGNITION AND ASSESSMENT

Symptms

• Headache

• !isual disturbance

• "pigastric pain

• !omiting

Si!"s

• Hyperrefle#ia with clonus

• $bdominal tenderness % right upper &uadrant

• 'roteinuria of at least 1+ or >0() g in * hr with or without symptoms

• 'apilloedema



• ,iver tenderness

I"vesti!ati"s

Urine

• Dipstic measurement. proteinuria of at least 1+

• onfirm using a * hr collection

• >)00 mg protein or urinary protein/creatinine ratio >)0 mg/mmol with or without

symptoms

Blood

•

• 2f platelet count 3100 # 104/, perform clotting studies

• ,5

• $,5 or $5 rising or >70 28/,

• 89" and uric acid

• :roup 9 save

• ;apidly changing biochemical and haematological picture

IMMEDIATE MANAGEMENT

• $dmit all women with severe pre-eclampsia or eclampsia

• :ive high dependency care % see #i!$ %epe"%e"cy care guideline

• arefully e#plain problem and management to woman and birth partner

M&lti-%iscipli"ary team pla""i"!

• "nsure early involvement and liaison between senior obstetrician intensive care

specialists delivery suite <D= midwife co-ordinator and neonatologist in assessment

and management of women with suspected or proven severe pre-eclampsia and

eclampsia



M"itri"!

• tart high dependency care chart

Minimum requirement

• aternal pulse and ' % with woman rested and sitting at a ?@ angle every 1? min

until stabilised then every )0 min

• ensure appropriate cuff siAe used and placed at level of heart

• use multiple readings to confirm diagnosis

• use an automated machine that has been validated for use in pregnancy

• B#ygen saturations continually and recorded hourly % obstetric review if 346C

•;espiratory rate hourly

• 5emperature -hrly

• etal heart rate % continually by electronic fetal monitoring <"= % see Electr"ic

'etal m"itri"! guideline

Examine

• Bptic fundii for signs of haemorrhage and papilloedema

• $ssess for hyperrefle#ia and clonus

TREATMENT

• :ive antacid prophyla#is e(g( ranitidine 1?0 mg oral 6-hrly <if oral inappropriate ?0

mg 2 6-hrly=

• 2f fetus 3) wees gestation give betamethasone two 1* mg doses 2 1* or * hr

apart <depending on clinical situation= to promote fetal lung maturity



(l% press&re c"trl

The aim of anti-hypertensive therapy is to maintain systolic BP <16 mm!" and prevent

cere#ral haemorrha"e and hypertensive encephalopathy

$hen

• 2n women with a systolic blood pressure >160 mmHg or diastolic blood pressure

>110 mmHg begin antihypertensive treatment

!o%

• Bral and 2! labetalol oral nifedipine <unlicensed= and 2! hydralaAine are commonly

used agents of choice for severe hypertension % see Dr&! treatme"t re!ime" below

&otes

• onsider insertion of arterial line in woman who will be receiving continuous 2!

antihypertensive. close liaison with anaesthetist is essential

• $void rapid fall in blood pressure as this can potentiate fetal distress

• $im to eep blood pressure 31?0/E0%100 mmHg

Preve"ti" ' sei)&res

• $dminister magnesium sulphate prophyla#is % ee Ma!"esi&m s&lp$ate below



Fl&i% ma"a!eme"t

'mount of fluid

• $void fluid overload % limit total 2! input to 1 m,/g/hr. ma# E0 m,/hr

• include all drugs administered in the hourly volume input of fluid

• if o#ytocin re&uired use a reduced fluid o#ytocin regimen

• $lways use syringe driver or 2!$ to control delivery of fluids

Type of fluid

• 2f mared hypovolaemia due to haemorrhage <>?00 m,= haemolysis or D2 give

blood +/- blood products % discuss with haematologist

Monitorin"

• easure fluid input and output hourly

• insert oley indwelling catheter to measure urine output

• Fhen pre-eclampsia is complicated by pulmonary oedema persistent oliguria or

significant blood loss consider !' monitoring after discussion with anaesthetist

(li"uria

• During labour and after delivery oliguria is not uncommon

• renal failure is unusual in pre-eclampsia and is usually associated with additional

problems e(g( haemorrhage and sepsis

• give woman with severe pre-eclampsia controlled fluid and wait for natural diuresis

to occur appro#imately )6%E hr after delivery

• 2f oliguria 3100 m, over * consecutive hr periods chec 89" and auscultate chest

•

if no signs of fluid overload give *?0 m, colloid fluid challenge and assess response

• if oliguria persists senior review and consider furosemide and central venous

pressure <!'= monitoring

• if prolonged antenatal oliguria or anuria prepare for delivery



T$rm*em*lism

• :ive thromboprophyla#is <ee VTE + T$rm*prp$yla,is guideline=

DELIVER

Timi"! ' %elivery

• Bnce woman stable consultant obstetrician and anaesthetist mae decision to deliver(

,iaise with neonatology team

• 2f fetus premature and delivery can be delayed give betamethasone % two 1* mg

doses 2 1* or * hr apart <depending on clinical situation= to promote fetal lung

maturity( ;eassess benefits of continuing the pregnancy after * hr

M%e ' %elivery

• onsider fetal presentation and condition together with lielihood of success of

induction of labour

• after ) wees gestation with a cephalic presentation consider vaginal delivery

• in 3)* wees gestation prefer caesarean section

• 2f vaginal delivery planned plan short second stage with consideration of elective

operative vaginal delivery

&otes

• $n epidural is a useful method of controlling blood pressure and providing analgesia

but may be contraindicated in low platelet count

• 2f o#ytocin indicated for induction of labour or augmentation give 2! via a syringe

driver and administer a reduced fluid regime

Ma"a!i"! t$ir% sta!e ' la*&r

• anage third stage with ? units o#ytocin 2

)o not "ive er"ometrine or syntometrine in any form for prevention of haemorrha"e as this

can further increase #lood pressure



ECLAMPSIA

• Bne or more convulsions superimposed on pre-eclampsia

#ELLP SNDROME

• Haemolysis elevated liver enAymes and low platelets <H",,'= occurs in

appro#imately %1*C of women with severe pre-eclampsia( 2t is associated with a

high perinatal mortality

Symptms

• an present with vague symptoms which often delay diagnosis

• nausea

• vomiting

• epigastric pain and right upper-&uadrant pain

• $ uni&ue feature of H",,' syndrome is Gcoca-cola appearance of urine. small

amounts of dar blac urine are produced

Dia!"sis

• onfirmed by

• fragmented red cells on blood film

• platelet count 3100 # 104/,

• "levated $5 >7? 28/, significant and >1?0 28/, is associated with maternal

morbidity

• evere hypertension is not always a feature of H",,' syndrome and degree of

severity rarely reflects overall severity of the disease

Ma"a!eme"t

$s for severe pre-eclampsia plus

• "valuate severity

• Hourly



• onitor conscious level and loo for signs of confusion

• tabilise

• "arly blood transfusion % these women are often profoundly anaemic

•ontact haematologist early for advice about replacement of clotting factors

• orticosteroids recommended as they lead to a more rapid resolution of the

biochemical abnormalities but it is unclear if they reduce morbidity

• Deliver

• 'ostnatal recovery often more complicated with oliguria and a slow recovery of

biochemical parameters

POSTNATAL MANAGEMENT AND FOLLO.-/P

• 8p to C of convulsions occur postpartum especially at term( $ssess carefully and

continue high dependency care for a minimum of * hr

• ontinue antihypertensive medication after delivery

• 2f ' falls to 31)0/E0 mmHg reduce antihypertensive treatment

• .$ile i"-patie"t % measure ' at least times per day

• I' tra"s'erre% t cmm&"ity % measure ' every 1%* days for up to * wees until

antihypertensive treatment stopped and no hypertension( 2nclude medical care plan

for monitoring on discharge documentation

• 'ersisting hypertension and proteinuria at 6 wees can indicate renal disease

investigate further

• e aware of ris of late seiAures and review carefully before discharge

• Bffer follow-up to discuss events treatment and future pregnancy care

• Fll0-&p at 1 0ee2s

• Discuss events treatment and future pregnancy care

• hec ' and urine( 2nvestigate persisting hypertension and proteinuria at 6 wees as

may indicate renal disease investigate further



DR/G TREATMENT REGIMENS

LA(ETALOL

• eta-blocer with additional arteriolar vasodilating action

C"trai"%icati"s

• $sthma

• ardiogenic shoc

• $! loc

Ca&ti"s

• Heart failure

• Diabetes

Si%e e''ects

• 'ostural hypotension

• 5iredness

• Headache

• Feaness

• ;ashes

• 5ingling scalp

• Difficult micturation

• "pigastric pain

• Iausea vomiting



O*servati"s

• ontinuous pulse o#imetry

• 8rine output hourly

• ;espiratory rate hourly

• Deep tendon refle#es

C$ec2 ser&m ma!"esi&m levels

*top ma"nesium sulphate if+

•

8rine output 3100 m, in hr

• ;espiratory rate 31* breaths/min

• B#ygen saturation 340C

• 'atellar refle#es absent <not due to regional anaesthesia=

,. of ma"nesium is excreted in urine/ (li"uria can lead to toxicity/

'ntidote 0 1 m calcium "luconate 1. 23 over 1 min

severe pre eclampsi

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