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