Pre-eclampsia and Eclampsia

Quality Education for a Healthier Scotland

Multidisciplinary

Pre-eclampsia and Eclampsia

Promoting multiprofessional education and development in

Scottish maternity care


Multidisciplinary

Background

• Deaths from pre-eclampsia and eclampsia have increased from 18 in 2003-2005, to 19 in 2006-2008

• PET/eclampsia is the second most common cause of direct maternal death (rate of 0.83: 100,000 maternities)


MultidisciplinaryDisease Incidence

• Hypertension complicates 10 -15% of all pregnancies.

• Pre-eclampsia (hypertension, impaired renal function and fluid retention) occurs in 4-10% of women in their first pregnancy.

• In the UK, the incidence of eclampsia is down from 4.9 to 2.7 per 10,000 maternities (UKOSS 2007).


MultidisciplinaryHypertension• Hypertension in pregnancy is defined as a

diastolic pressure greater than 90 mmHg.• Severe hypertension is a diastolic pressure

>110 mmHg, a systolic pressure >160 mmHg or a mean arterial pressure >125 mmHg.

(CEMD, 2004; Sibai et al., 2005)

• the mean arterial pressure is calculated thus: diastolic blood pressure + 1/3 pulse pressure [Diastolic BP + 1/3 (Systolic BP – Diastolic BP)]


MultidisciplinarySystolic Pressure• Saving Mothers’ Lives 2006-2008• Reported inadequate treatment of systolic

hypertension of >150-160mm/Hg directly resulted in fatal intracranial haemorrhage


Multidisciplinary

Pre-eclampsia: Risk Factors

• age ≥40 years• primigravida • previous pre-

eclampsia• FH on maternal side• multiple pregnancy• central obesity (BMI)• molar pregnancy• previous severe

IUGR

• migraine• renal disease• connective tissue

disease• chronic hypertension• diabetes• thrombophilia• time between

pregnancies (<6 months and >5 years)(Duckitt & Harrington, 2005; Poon et al.,

2010)


MultidisciplinaryDiagnosisUsually asymptomatic and detected at

antenatal review (elevated BP and proteinuria)

Symptoms tend to be non-specific:rapidly progressive oedema

nausea and vomiting

epigastric pain

headache

visual disturbances

Blood tests may show:reduced platelets, elevated urate (normal range is gestation dependent) urea & creatinine, LFT abnormalities, DIC


MultidisciplinaryMaternal Complications of PET• Placental abruption (1-4%)• DIC/HELLP syndrome (10-20%)• Pulmonary oedema/aspiration (2-5%)• Acute renal failure (1-5%)• Eclampsia (<1%)• Liver failure/rupture/haemorrhage (<1%)• Stroke (rare, but the most common cause of

maternal death)• Death

(Sibai et al., Lancet 2005)


MultidisciplinaryMaternal Complications of PET


Multidisciplinary

Maternal Complications of PET


MultidisciplinaryMaternal Complications of PET


Multidisciplinary

Cause of death 1985-87

1988-90 1991-93

1994-96

1997-99

2000-02 2003-05 2006-08

Cerebral 11 14 5 7 7 9 12 14

Pulmonary 11 10 11 8 2 1 0 0

Hepatic 1 1 0 3 2 0 2 3

Other 3 2 4 2 5 4 4 2

TOTAL 27 27 20 20 16 14 18 19

Maternal Mortality and PET


MultidisciplinaryAntihypertensive Medication

• Should be given when the systolic BP is >150 mmHg or the diastolic BP is >110 mmHg (CEMD, 2011)

• Chronic hypertensionoral methyldopa oral labetaloloral nifedipine (oral hydralazine)

• Acute hypertensionintravenous labetaloloral nifedipineintravenous hydralazine

The drugs of choice will depend on local guidelines and protocols


Multidisciplinary

Fulminating Pre-eclampsia

• Manage in appropriate surroundings

• Involve senior clinicians and have protocols: communication and documentation is crucial

1. Control blood pressure (see flow chart)

2. Monitor fluid balance3. Commence seizure prophylaxis

(MgSO4)

4. Arrange delivery


MultidisciplinaryFluid Balance

• Involve anaesthetic colleagues if possible• Start fluid balance chart (input-output)• Insert a urinary catheter• Replace blood loss from delivery

Restrict maintenance input to 1 ml/kg/hr, to a maximum of 85 ml/hr (inclusive of all infusions)

• A urine output of > 100 ml in 4 hours should be achieved

• CVP monitoring requires expertise and should be regarded as an adjunct to clinical assessment

• Assess regularly for clinical signs of pulmonary oedema


Multidisciplinary

Intrapartum Management

• Delivery is the only cure for PET• Timing can be difficult if preterm• Mode of delivery - parity, gestation,

Bishop score, presentation, severity of disease

• Platelet count and (?) coagulation screen before siting epidural or spinal

• Avoid ergometrine/Syntometrine for 3rd stage

• Postpartum thromboprophylaxis.


Multidisciplinary

Seizure Prophylaxis

The Magpie Trial (Lancet 2002: 359:1877–90)

• Women allocated magnesium sulphate had a 58% lower risk of eclampsia (95% CI 40-71), than those allocated placebo (40, 0.8% vs 96, 1.9%; 11 fewer women with eclampsia per 1000 women)

• Magnesium treatment did not improve perinatal morbidity or mortality.


Multidisciplinary

Eclampsia: Management• Seizure starts• Call for help• Arrival of staff• STATE ECLAMPTIC FIT• Correct pt positioning• Airway management• Delivery of oxygen• Intravenous access• Pharmacological

intervention

• Monitoring• Oxygen saturation• BP• ECG• Blood glucose• CTG• Renal function

(catheter)• Mg Toxicity

• Delivery plan

‘Simulation training resulted in enhanced performance with higher rates of completion for basic tasks, shorter times to administration of magnesium sulfate and improved teamwork’’ Ellis et al., 2008


MultidisciplinaryECLAMPSIA BOX


MultidisciplinarySummary• Pre-eclampsia is common

• Risk factors should be sought at booking and reviewed throughout pregnancy

• Always check urine for protein at every visit

• Anihypertensive medication should be given when the blood pressure is: systolic >150 mmHg, diastolic >110 mHg or mean arterial pressure >125 mmHg

• In the management of fulminating pre-eclampsia: control blood pressure, monitor fluid balance, consider seizure prophylaxis and arrange delivery


MultidisciplinaryCase studyCritically appraise this patient’s management:A 41 year old primigravida, whose BMI was 36, booked for antenatal care with her midwife in a rural and remote antenatal clinic at 12 weeks’ gestation. Her ‘booking’ BP was 100/50 mmHg. At her final antenatal check with her midwife (39 weeks’ gestation), her BP was 136/86 mmHg. Urinalysis was not performed because she had failed to bring a specimen. Arrangements were made to review her at term+8 days.

Risk assessment – what risk factors for pre-eclampsia did this lady have?

Discuss her last antenatal clinic appointment.


Multidisciplinary

She presented to her local antenatal clinic several days later with headache, epigastric pain and a BP of 162/104 mmHg. She had ++++ proteinuria.

Discuss how and where this woman should be managed.


Multidisciplinary

She was transferred the the nearest consultant-led maternity unit where the hypertension (160/102) was confirmed. ‘BP bloods’ were sent by the FY2 doctor, who gave her oral labetalol 200mg and admitted her to an antenatal ward. (Discuss this management.)


Multidisciplinary

She subsequently had an eclampticseizure.

How should an eclamptic seizure bemanaged?


Multidisciplinary

She was in fact treated with i.v. hydralazine and an i.v. bolus of Diazemuls and underwent caesarean section for fetal distress. After delivery, her BP was poorly controlled with a maximum pressure of 174/116 mmHg.

(Discuss)


Multidisciplinary

Her blood pressure rose to 180/120 mmHg despite combined therapy with i.v. labetalol and hydralazine, and shortly afterwards she became unresponsive. She was then seen by a consultant obstetrician for the first time since admission. A CT scan showed an intracranial haemorrhage, from which she subsequently died.

(Discuss)


Multidisciplinary

Any Questions?


MultidisciplinarySummary• Pre-eclampsia is common

• Risk factors should be sought at booking and reviewed throughout pregnancy

• Always check urine for protein at every visit

• Anihypertensive medication should be given when the blood pressure is: systolic >150 mmHg, diastolic >110 mmHg or mean arterial pressure >125 mmHg

• In the management of fulminating pre-eclampsia: control blood pressure, monitor fluid balance, consider seizure prophylaxis and arrange delivery

Pre-eclampsia and Eclampsia

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