Pre-eclampsia and eclampsia

Lisa Nasis

Case 1 Ms HV

29 yo primigravidaPresented to LMO at 36/40 with 2/52 hx

of generalised pruritus and diarrhoea Otherwise well No jaundice/rash; normal BP; urine negative

Past Medical Hx Depression on Sertraline Gestation DM at 28/40 - diet controlled

Case 1FBE

Hb 133

WCC 6.9

Plt 82

UECNa 136/K 4.4/Ur 4.6/Cr 71

LFTs

Bili 21

GGT 9

ALT 337

AST 158

ALP 229

Total Protein 63

Albumin 34

Case 1

Reviewed by LMO Pruritus improving, ongoing diarrhoea BP 122/75 Urine negative for protein No liver tenderness Oedema to shins

Case 1

3334Albumin

6263Total Protein

235229ALP

211158AST

433337ALT

109GGT

2521Bilirubin

8182Plt

6.26.9WCC

132133Hb

7/104/10

Case 1

Referred by LMO to Angliss O & G - admitted

Planned for delivery to prevent development of further complications

Anaesthetic department felt patient too high risk - required transfer

Case 1

Transferred to BHH 8/10 O/E

BP 120/80Oedema hands/legsAbdomen soft non-tenderHyperreflexia present

LUSCS planned

Case 1

32APTT

0.9INR

484419ALT

236222ALP

2317Bilirubin

8770Plt

8/10 12007/10

Case 1

LUSCS 8/10 Spinal

L3/4 27 g pencil point needle Clear CSF first pass 2.2 ml x 0.5 % heavy bupivacaine + 15 mcg fentanyl

Mild nausea post spinal Metaraminol/ephedrine/fluids

Case 1

Day 1 post-op Reports feeling‘twitchy’/’jittery’

OE normotensive, urine clearhyperreflexic

Felt to be ‘not true HELLP but in spectrum of pre-eclampsia’

Rx - clonazepam, not MgSO4

Case 1

Further ix Rheum/haem screen Abdo u/s NAD Discharged home 13/10 for LMO follow up

and r/v of LFTs

Case 2 Ms KL

Maternal Code Blue Birralee Green Team …

Case 2

30 yo female post ictal after 2 x tonic clonic seizures1st seizure lasted ~ 2 minGiven diazepam 5 mg iv after

second seizure startedSecond seizure lasted ~ 1 min

Case 2

No seizure activity nowBreathing spontaneouslyGCS 11BP 230/90HR 100BSL 5.4

Case 2 Further history..

G7P4 Day 2 post NVD at 33+6/40 T/f from Bairnesdale 4/7 ago with threatened

premature labour, ?choriamnionitis Rx = Celestone, cephazolin, nifedipine 20 mg Spontaneous labour 15/9 - delivery of liveborn

female

Case 2

PMHx Cholestasis of pregnancy Hepatitis C positive Smoker/marijuana use PHx IVDU Depression PHx of 3 x seizures a/w IVDU and sleep

deprivation - never investigated

Case 2

293193ALP

4342AST

163132GGT

16Bilirubin

12/9/086/8/08

3732ALT

Case 2

Management MgSO4 loaded 2.47g x 2 Remained drowsy, no further seizures BP 114/69, HR 111 Transferred to ICU for further monitoring

Case 2

ICU care Patient teary/agitated, refused MgSO4

infusion Monitored for ~ 6 hours D/c to ward

Case 2

Neurology r/v ? Eclampsia ? Seizure 2o to sleep deprivation ? Posterior encephalopathy

MRI - normal

Case 2

Discharged to Sale HospitalFollow up arranged

Seizure clinic Liver clinic

Management guidelines - Pre-eclampsia and eclampsiaANZCA Obstetric SIGDefinitionsDiagnosisHypertensionSeizuresFluidsLabour AnalgesiaAnaesthesia for caesarean

Definitions

Australasian Society of the Study of Hypertension in Pregnancy Pre-eclampsia: Hypertension arising after 20

weeks gestation with subsequent resolution of the disease by three months post partum, whereSBP ≥ 140 mmHg and or DBP ≥ 90 mmHgPLUS one or more of…

Brown et al. Aust N Z Obstet Gynaecol, 2000

Definitions

PLUS one or more of Proteinuria > 0.3g/24 hours Renal impairment Liver disease Neurological problems Haematological disturbance Fetal growth restriction

(hyperuricaemia)

Definitions

Liver tenderness, N & V, epigastric pain, severe LFT derangement

Mildly elevated LFTsGIT

Seizures, headache, visual disturbance, papilloedema, clonus

-CNS

√ +/- severe HT SBP ≥ 160 mmHg; DBP ≥ 110 mmHg

√HT

Severe pre-eclampsiaMild pre-eclampsia

Definitions

Pulmonary oedema-CVS/Resp

Fetal/placental compromise

-Uterofetal

•Proteinuria > 5 g/24h•3+ on dipstick•Urine output < 500ml/24h

•Proteinuria 0.3g/24h•1+ on dipstick

Renal

Platelets ≤ 100Haemolysis, DIC

Platelets ≤ 150 Haem

Severe pre-eclampsiaMild pre-eclampsia

Definitions

HELLPA severe form of pre-eclampsia

Haemolysis - elevated LDHElevated liver transaminasesPlatelet count < 100

Differential DiagnosisAcute fatty liver/cholestasis of pregnancyRenal diseaseVasculitisHaemolytic uraemic syndromeThrombotic thrombocytopenic purpuraDrug use eg cocaine, amphetaminesEarly onset > 20 weeks gestation - molar

pregnancy, multiple pregnancy, fetal abnormality

Reduction of high blood pressure

Non-severe hypertension BP 140-159/90-109 mmHg Recommended lowering to 140-150/90-100 mmHg Safe agents

Methyldopa, labetalol, nifedipine, metoprolol, propanolol

Not recommendedAtenolol - fetal growth restriction

ContraindicatedACEIs and ATIIRBs - teratogenic

Abalos et al, Cochrane Database Syst Rev 2007

Reduction of high blood pressure

Severe hypertension BP ≥160/110 Lower to 140-150/90-100 by 10-20 mmHg every

10-20 minutes Continuous fetal heart rate monitoring until BP

stable Specific agents

Hydralazine, labetalol, nifedipineAvoid labetalol in severe asthmaAvoid ketanserin, nimodipine, MgSO4, diazoxideSNP - last resort only

Magee et al. BMJ, 2003

Duley et al. Cochrane Database Syst Rev, 2006

Seizures - prevention

Severe pre-eclampsia MgSO4 recommended as prophylaxis

Risk of seizures ↓by 50%, NNT = 50

Mild pre-eclampsia Controversial - NNT = 100, SE ++ ‘Consider’ use of MgSO4

Duley et al, Cochrane Database Syst Rev, 2003

Seizures - treatment

MgSO4 Reduces mortality cf diazepam Superior to diazepam, phenytoin, lytic

cocktail in reducing risk of recurrence Reduces morbidity related to ICU stay cf

phenytoin

Duley et al, Cochrane Database Syst Rev, 2003 and 2000

Haematological Complications

Corticosteroids for HELLP syndrome Dexamethasone 10 mg iv shown to increase

platelet count however no improvement in outcome

Matchaba et al, Cochrane Database Syst Rev, 2004

Intravenous Fluids

Volume expansion - no advantages compared with no plasma volume expansion

IV fluid administration to increase plasma volume or treat oliguria in pts with normal renal function and stable creatinine levels not recommended

Duley et al, Cochrane Database Syst Rev, 1999

Regional blockade

Platelet count > 75 in absence of other coagulation abnormalities not expected to be a/w increased risk of complications of regional anaesthesia

Orlikowski et al, Br J Anaesth., 1996

Labour analgesia

Epidural recommended Reduces pain-mediated hypertensive responses Option for extension of block if caesarean required

Anaesthesia for caesarean

Regional anaesthesia preferred Single shot spinal, CSE, EVE - similar benefits

Hypotension less common in pre-eclampsia compared to healthy women Treat with vasopressors rather than fluids

Use of adrenaline containing LA is safe

General anaesthesia

Indications coagulopathy, pulmonary oedema,

eclampsia Post eclamptic period

GA if evidence of cerebral oedema or decreased conscious state

Regional ok if normal conscious state, no neurological deficit

General anaesthesia

Avoid hypertensive response to intubation Alfentanil, fentanyl, MgSO4, lignocaine,

esmolol Use technique with which clinician is most

familiar

Note MgSO4 potentiates NDMRs

Oxytocic agents

Post partum haemorrhageErgometrine, Syntometrine not

recommended as a/w hypertensive crises and death

Post partum management

Analgesia Caution with NSAIDS in pts with renal

impairment, intravascular volume depletion

ThromboprophylaxisDuration of MgSO4 infusion

24/24

OR Clinical assessment

Summary

Hypertension should be lowered to 140-150/90-100 mmHg using labetalol, nifedipine or hydralazine

MgSO4 is first line for treatment of seizures and should be used for prophylaxis in severe preeclampsia

IV fluid management should be monitored closely

Summary

Risk of haematoma a/w regional anaesthesia with platelet count > 75 is very low

Regional anaesthesia is preferred anaesthetic for caesarean section

When GA required measures should be taken to ablate the intubation response