Post on 19-Jan-2021
PRE ECLAMPSIA AND POSTNATAL CARE
Layla LavalleeResearch MidwifeNuffield Department of Primary Care Health SciencesUniversity of Oxford
OVERVIEW
Background
Importance of good postnatal care
Management
Discharge to the community
Future pregnancies
Long term health implications
BACKGROUNDDelivery doesn’t halt progression of disease immediately
PE can continue, worsen or present for the 1st time following delivery
Approximately 1/3 of women will continue to have HT during 1st week
Up to 28% of PE presents for the first time (66% following discharge)
32 - 44% of Eclamptic fits happen PN (most w/in 48 hours but have been occured up to 28 days PN)
Most hypertension and proteinuria resolves within first week:
Up to 57% by day 3
Up to 85% by day 7
*Prevalence probably underestimated*
WHY GOOD POSTNATAL CARE IS SO IMPORTANT
Findings from confidential enquiries into maternal deaths:
- PE related maternal deaths largely due to treatable pathology
- Substandard care occurred in the majority of cases (failure to recognise severity of disease and to act appropriately and quickly enough)
MBBRACE 2019 REPORT
6 PRE-ECLAMPSIA RELATED MATERNAL DEATHS
1 in antenatal period or on day of delivery
4 between 1 – 42 days following delivery
1 > 42 days after delivery
LACK OF AWARENESS
“DELIVERY IS NOT A CURE FOR PRE-ECLAMPSIA”
“The message I hope to express is to always trust your intuition and advocate for yourself. I was a part of the 5% of women who have experienced Postpartum Preeclampsia and HELLP and none of my health care providers would listen or took my symptoms seriously until it was too late. I often still wonder if they would have, if it would have gotten as bad as it did… I spent a long time angry about that”
(Natalie, symptoms dismissed as PND, later fitted and spent six days in ITU).
FAILURE TO SPOT THE DANGERS…
“A healthy low risk woman in her first pregnancy was delivered in a freestanding midwifery unit. Following delivery she developed a severe headache and moderate hypertension. Opiate analgesia was verbally prescribed. Over the following three hours she had severe hypertension but she was not transferred to the consultant unit until she had neurological signs. On arrival in the consultant unit her blood pressure was normal but she had lost airway control and CT scan performed shortly after her transfer showed a large intracranial bleed”.
MBBRACE, 2019
ON A HAPPIER NOTE…
UK trends show a significant decline in pre-eclampsia related deaths which are a testament to the high quality care UK women receive overall
UK TRENDS
2 deaths between 2012 – 2014 equates to < 1 woman/million or less than 1 death/year (Shennan, Green and Chappell, 2017)
GLOBAL COMPARISONS
(UK – 2%)
7.4% (Review to Action, 2018) 14% (WHO, 2014)
CAUSES OF POSTNATAL HYPERTENSION
Chronic, pre-existing hypertension – may have been previously undetected
Gestational Hypertension
Pre-eclampsia
Renal disease
Hyperthyroidism
Primary hyperaldosteronism
Pheochromocytoma (tumour of the adrenal gland)
OTHER CAUSES OF HT…Normal physiological changes
Pain/anxiety
Volume overload
Regional anaesthetic
Instrumental delivery
Delayed mobilisation
Medications NSAIDS – can cause vasoconstriction and sodium/water retention
Ergometrine
Decongestants e.g. Ephedrine, Phenylpropanolamine
SO WHAT DO WE DO?
AVOID SYNTOMETRINE“Two women presented so late in labour that their blood pressures were not measured before delivery. One of the women had had a normal blood pressure recording and normal urinalysis at the antenatal clinic the previous day. Both women received intramuscular syntometrine for third stage prophylaxis, and both were found subsequently to be hypertensive. In both cases, by coincidence, the blood pressures rose to maxima of 210/115 mm/Hg. One woman remained hypertensive despite intravenous hydralazine and experienced eclamptic seizures despite magnesium sulphate. She died from a large cerebral haemorrhage. The other woman had her hypertension treated aggressively, and improved for some time before becoming profoundly hypotensive. At laparotomy she was found to have a large haemoperitoneum from, in part, a tear of the liver capsule. She died, much later, of multi-organ failure in the intensive care unit. In both cases, the progress of pre-eclampsia was extremely rapid.”
Saving Mothers Lives report (2007)
LOW RISK WOMEN
Check and document BP within six hours of delivery
BP normal and no symptoms of PE
Diastolic > 90 with no symptoms of PE
Diastolic > 90 plus symptoms of PE
Severe or persistent headache with or w/out raised BP
No further action required
If no symptoms of PE repeat in 4 hours
• If normal then no further action
• If still > 90 then emergency action
Emergency action Emergency action
WHERE TO CARE FOR WOMEN Levels of Care
Level 1 (postnatal ward) Level 2 (HDU) Level 3 (ITU)
Pre-eclampsia with hypertension
Step-down treatment after birth
Eclampsia
HELLP
Haemorrhage
Hyperkalaemia
Severe Oliguria
Coagulation support
IV anti-HT treatment
Initial stabilisation of severe
hypertension
Evidence of cardiac failure
Abnormal neurology
Step-down treatment from level 3
Severe PE requiring ventilation
MANAGEMENT
Women with severe HT [>160/110]…
Measure blood pressure every 15-30 minutes until <160/110
Anti-hypertensives:
Labetalol (oral or IV)
Nifedipine (oral)
IV hydralizine
MAGNESIUM SULPHATECONSIDER GIVING IF ONE OR MORE OF THE FOLLOWING PRESENT…
Ongoing or recurrent severe headaches
Visual disturbances
Nausea/vomiting
Epigastric pain
Oliguria and severe hypertension
Progressive deterioration of bloods (rising creatinine and/or liver enzymes, falling platelets)
*Every postnatal ward should have an Eclampsia box*
MAGNESIUM SULPHATE REGIME
Loading dose
4g IV over 15 – 15 minutes followed by infusion of 1g/hour for 24 hours
Recurring fits
2 – 4g IV over 5 – 15 minutes
MONITORING BLOOD PRESSURE
Not medicated
At least 4 times/day while inpatient
At least once a day between day 3-5
If still high on days 3-5 then on alternate days until normal
Target BP < 140/90
If BP > 150/100 start medication and aim for a target of 135/85
Medicated
Min 4 times/day while inpatient
Every 1 -2 days for up to 2 wks until off treatment and/or no HT
Continue with anti-HT medication and aim for 135/85
Considering decreasing medication if BP < 140/90
Decrease medication if < 130/80
*Ask about severe headache and epigastric pain each time BP taken*
MEDICATION
Stop Methyldopa within two days – can increase risk of PN depression
BP may drop within the first 48 hours then increase day 3-6 so be very cautious reducing or stopping medication
Diuretics may be required for fluid overload
BEWARE SIGNS OF CEREBRAL PATHOLOGY…
Urgent senior review:
Altered consciousness
Agitation
Restlessness
Neuroimaging should be considered early in women multiple fits and those who do not become fully conscious within an hour of their fit.
ANTI-HYPERTENSIVES1st line
Ace inhibitors – Enalapril (preferred – once/day)
Captopril
For Black African/Caribbean women consider Ca channel blocker first
Second Line
Combination of ACE inhibitors and Calcium channel blockers (eg Nifedipine, Amlodipine)
If Nifedipine and Enalapril not effective can try Beta Blockers such as Atenolol or Labetalol (preferably Atenolol as OD versus 3 times/day)
BREASTFEEDINGContinue to promote breastfeeding.
Medications can get into BM in very small amounts but unlikely to have an effect.
Potential risks: hypoglycaemia, hypothermia, hypotension, bradycardia.
Consider monitoring baby’s BP if any concerns especially premature and look out for drowsiness, lethargy, pallor, cold peripheries or poor feeding.
Diuretics and Angiotensin 2 receptor blockers (e.g. Losartan) should be avoided in women who want to breastfeed as they can reduce the milk supply.
Women who aren’t breastfeeding should be treated according to NICE guidelines for HT in adults.
NSAIDS
Avoid or use with cautionCan:
Increase BP
Antagonise some anti-HT meds
Exacerbate or cause renal problems
URINE OUTPUT AND FLUID RESTRICTION
Fluid overload can lead to pulmonary oedema
Monitor output hourly and limit maintenance fluid to 80 mls/hr with severe PE and MGSO4 unless ongoing fluid losses
Observe for SOB, low sats, reduced urine output (< 100 mls/4 hours)
HAEMATOLOGICAL AND BIOCHEMICAL MONITORINGIn women with mild/mod HT …
Check PCR, Platelets, Liver enzymes, Serum creatinine and Electrolytes 48 -72 hours after birth (or stepdown from critical care)
If normal then no need for further testing if abnormal then repeat as clinically indicated until normal.
VTE – ASSESSMENT AND PROPHYLAXIS
Assess daily - PE can increase risk of VTE
Compression stockings
Use of heparin depends on platelet count, renal/liver function and BP control so may be contraindicated
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EMOTIONAL SUPPORT
Increased risk of postnatal depression
May experience grief, anger, fear, anxiety
Separation from baby
May find it hard to care for baby depending on how unwell she is
Don’t forget the partner
Debriefing
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DEBRIEFINGAll women with severe PE should be offered de-briefing session with senior Obstetrician covering:
Screening for anti-phospholipid syndrome if PE < 34 weeks.
Estimates of risk for future pregnancies
Management plan for future pregnancy
Information on where to get immediate and ongoing support: APEC www.apec.or.uk
Tommy’s (pregnancy and birth related problems) www.tommy’s.org
SANDS (Stillbirth and NND) www.uk.sands.org
Implications for future health
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DISCHARGE TO COMMUNITY
When no symptoms of PET
BP controlled with or without medication
Bloods stable or improving
Most women can be discharged by day 5
teds
POSTNATAL CARE PLAN
Upon discharge women should have written care plan outlining:
Who will provide f/u care including medical review if needed
Frequency of BP checks – if self-monitoring instructions on what to do with readings
Threshold for titrating medication
Indications for referral to primary care for blood pressure review
*All hypertension needs follow up monitoring – even if resolved*
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“A woman had raised blood pressure in labour and was given a single dose of oral therapy. She went home shortly after the birth, without
treatment and had no postnatal checks of her blood pressure. She had a cerebral haemorrhage at home”
(MBBRACE, 2019)
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” Any woman treated with antihypertensives in the antenatal or intrapartum period, even if only a single dose, requires additional postnatal blood pressure checks and continuing preventive antihypertensive treatment until it is certain that the hypertension was solely related to pregnancy and has completely resolved. There is a risk of ‘rebound hypertension’ and so there is a need to have repeated checks of the blood pressure at home. Every woman who has had hypertension in pregnancy should have a documented plan for postnatal blood pressure surveillance and antihypertensive treatment and this plan should be included in the postnatal discharge notes and communicated to the woman’s general practitioner and community midwife”.
MBBRACE, 2019
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SYMPTOMSAll women should be advised on symptoms to look out for
Can be easily overlooked or attributed to other factors
“…Four days after being discharged I had severe swelling on my limbs and genital area, as well as an unbearable headache (which was HBP, but I did not know then), nausea and vomiting. I took a nap thinking that would cure the headache, yet when I woke up at feeding time for my baby, I realized I was so confused and had altered consciousness to the point that I could not get off the bed because my brain was doing other movements with my limbs. After that I do not remember anything and my husband claims that is when I went into seizures. I had continuous seizures and was in the ICU 11 days… It’s been 7 years since the episode yet my husband and I are still traumatized and scared to try for another”.
(Testimonial from Pre-eclampsia Foundation website)
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FOLLOW UP Offer a medication review with GP two weeks after transfer to community care
Offer all women a medical review with GP or specialist 6 - 8 weeks after the birth.
Six week check should include:
Proteinuria check – if present offer further r/v at 3 months to assess kidney function (12-17% of severe PE associated with underlying renal disease).
Relative risk of kidney disease raised but absolute risk is low for women with no proteinuria or HT at six weeks and no further f/u required
Discussion regarding contraception, future pregnancies, future CVD risks
FUTURE PREGNANCIESIf planning another pregnancy soon then need to consider medications
Will need to see midwife/GP asap in next pregnancy and take 75 –150 mg of aspirin daily from 12 weeks
Will also need referral to obstetrician early on to make a plan for care
Overall risk to next pregnancy approximately 1:5 but will vary individually based on severity of PE in this pregnancy, gestation at delivery and presence of other risk factors
Maintaining a healthy weight can reduce risk of PE and an interval of > 10 years between pregnancies can increase risk
FUTURE RISKS
Type of hypertension in previous or current pregnancy
Prevalence of hypertensive
disorder in future pregnancy
Any hypertension in pregnancy
Pre-eclampsia Gestational hypertension
Any hypertension Approximately 21%1:5 women
Approximately 20%1:5 women
Approximately 22%1:5 women
Pre-eclampsia Approximately 14%1:7 women
Up to 16% (1:6)28 - 34 wks: 33% (1:3)34 – 37 wks: 23% (1:4)
Approximately 7%1:14 women
Gestational hypertension
Approximately 9%1:11 women
Approximately 6 – 12%Up to 1:8 women
Between 11 – 15 %Up to 1:7 women
Chronic hypertension
N/A Approximately 2%Up to 1:50 women
Approximately 3%Up to 1:34 women
FUTURE CVD RISKS
PE significantly increases the risk of CVD in later life – the more severe the PE the greater the risk
Children of affected pregnancies more likely to have:
Hypertension in childhood and adolescence
Hypertension and stroke as adults
Lifestyle interventions and tighter control of BP following delivery could mitigate risks and women should be advised to discuss this with their GP at the six week check
FUTURE CVD RISKS
Pre-eclampsia
Major adverse CV event 1.5 - 3 times higher
Cardiovascular mortality 2 times higher
Stroke 2 – 3 times higher
Hypertension 2 - 5 times higher
MAIN POINTS…Pre-eclampsia can worsen or present for the first time following delivery
Early recognition, management and escalation of care are key
Avoid Syntometrine, NSAIDS and Methyldopa
All women with HT (even if resolved) BP require further monitoring upon discharge
Aspirin from 12 weeks in future pregnancies
Advise women of future pregnancy and CVD risks and how these can be mitigated
ONE LAST POINT… 2014 report by RCM highlighted the impact poor staffing on postnatal care provision:
Staffing levels main factor influencing number of postnatal visits not the needs of women
Length of hospital stay and number of postnatal visits have decreased significantly over the years with little evaluation of its impact
Of women surveyed 3.4% reported receiving no postnatal care, 14.1% had only one visit
Most MW’s reported not having enough time to convey all PN information they need to
REFERENCESAction on Pre-eclampsia - Supporting familes affected by Pre-eclampsia [Internet]. Action on Pre-eclampsia. [cited 2020 Jan 16]. Available from: https://action-on-pre-eclampsia.org.uk/
Bramham K, Nelson-Piercy C, Brown MJ, Chappell LC. Postpartum management of hypertension. BMJ. 2013 Feb 25;346:f894.
Building capacity to to review and prevent maternal deaths: Report from nine maternal mortality review committees. [Internet]. [cited 2020 Feb 6]. Available from: https://reviewtoaction.org/Report_from_Nine_MMRCs
Cairns Alexandra E., Tucker Katherine L., Leeson Paul, Mackillop Lucy H., Santos Mauro, Velardo Carmelo, et al. Self-Management of Postnatal Hypertension. Hypertension. 2018 Aug 1;72(2):425–32.
Lazdam M, Davis EF, Lewandowski AJ, Worton SA, Kenworthy Y, Kelly B, et al. Prevention of Vascular Dysfunction after Preeclampsia: A Potential Long-Term Outcome Measure and an Emerging Goal for Treatment. J Pregnancy [Internet]. 2012 [cited 2020 Jan 17];2012. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3235810/
Lewis, Gwyneth Editor Centre for Maternal and Child Enquiries Saving mothers’ lives : reviewing maternal deaths to make motherhood safer: 2006–08 : the eighth report on Confidential Enquiries into Maternal Deaths in the United Kingdom. BJOG ; 118 (Suppl. 1): 1–203 London : CMACE, 2011
Recommendations | Postnatal care up to 8 weeks after birth | Guidance | NICE [Internet]. [cited 2020 Feb 10]. Available from: https://www.nice.org.uk/guidance/cg37/chapter/1-Recommendations
REFERENCES
Recommendations | Hypertension in pregnancy: diagnosis and management | Guidance | NICE [Internet]. [cited 2020 Jan 16]. Confidential Enquiry into Maternal Deaths | MBRRACE-UK | NPEU [Internet]. [cited 2020 Jan 16]. Available from: https://www.npeu.ox.ac.uk/mbrrace-uk/reports/confidential-enquiry-into-maternal-deaths(can access past confidential enquiry reports from this page)
Royal College of Midwives. Pressure Points: the case for better post-natal care, 2014.
Say L, Chou D, Gemmill A, Tunçalp Ö, Moller A-B, Daniels J, et al. Global causes of maternal death: a WHO systematic analysis. The Lancet Global Health. 2014 Jun 1;2(6):e323–33.
Shennan AH, Green M, Chappell LC. Maternal deaths in the UK: pre-eclampsia deaths are avoidable. The Lancet. 2017 Feb 11;389(10069):582–4.)
Sibai BM. Etiology and management of postpartum hypertension-preeclampsia. American Journal of Obstetrics & Gynecology. 2012 Jun 1;206(6):470–5.
Website. 2014 Preeclampsia Awareness Survey Highlights Need for Education [Internet]. Preeclampsia Foundation Official Site. 2014 [cited 2020 Jan 16]. Available from: https://www.preeclampsia.org/the-news/44-press-releases/366-2014-preeclampsia-awareness-survey-highlights-need-for-education