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THE MANAGEMENT OF SEVERE PET/ECLAMPSIA

The document provides guidelines for the management of severe preeclampsia and eclampsia. It defines preeclampsia and eclampsia and describes criteria for severe disease. It recommends close maternal monitoring of blood pressure, labs, urine output and fetal wellbeing. It provides guidance on controlling blood pressure with antihypertensive drugs like labetalol, nifedipine and hydralazine. The goal is to prolong the pregnancy and deliver at the optimal time while preventing maternal and fetal complications.

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THE MANAGEMENT OF SEVERE PET/ECLAMPSIA Prof.Aboubakr elnashar Benha university Hospital, Egypt ABOUBAKR ELNASHAR Introduction ABOUBAKR ELNASHAR
ABOUBAKR ELNASHAR ❑Eclampsia (E): convulsions superimposed on PET. ❑Preeclampsia (PET): PIH in association with proteinuria (> 0.3 g/24 h) ± oedema ❑Severe PET ▪ DBP ≥ 110 mmHg on 2 occasions or ▪ SBP ≥ 170 mmHg on 2 occasions and that, together with significant proteinuria (1 g/litre) ▪ DBP ≥ 100 mmHg on 2 occasions & significant proteinuria with at least 2 S or S of imminent E. ❑HELLP syndrome: ▪ Variant of severe PET ▪ Haemolysis, Elevated liver enzymes, Low platelet count ABOUBAKR ELNASHAR
1. DEFINITION ❑Syndrome of new onset of Hypertension and either Proteinuria or End organ dysfunction after 20 w in a previously normotensive woman (ACOG, 2013) ABOUBAKR ELNASHAR ❑Proteinuria: ▪No longer ▪Required alone in diagnosis ▪Useful in: ▪classifying PET as severe ▪deciding whether to induce {amount not shown to predict either maternal or fetal outcomes} (ACOG, 2013) ▪Heavy (5 g/24 h) has been eliminated as a criterion for diagnosing severe PET ▪Testing may be discontinued once significant proteinuria has been demonstrated ABOUBAKR ELNASHAR
❑Diagnosis of PET (ACOG , 2015) New-onset hypertension without proteinuria plus 1 of the following: 1. Platelet count below 100,000/μL 2. Serum creatinine level above 1.1 mg/dL 3. Doubling of serum creatinine in the absence of other renal disease 4. Liver transaminase levels at least twice the normal 5. Pulmonary edema 6. Cerebral or visual symptoms ABOUBAKR ELNASHAR William, 2016 ABOUBAKR ELNASHAR
❑Clinical features of severe PET ▪ In addition to hypertension & proteinuria: ▪ Severe headache ▪ Visual disturbance ▪ Papilloedema ▪ Liver tenderness ▪ Epigastric pain ▪ Vomiting ▪ Signs of clonus ▪ Platelet count <100 x 10 6 /l ▪ Abnormal liver enzymes (ALT or AST≥ 70 iu/l) ▪ HELLP syndrome. ABOUBAKR ELNASHAR ❑ Maternal assessment 1. Symptoms: 1. Convulsions, abdominal pain or general malaise: PET should be considered: BP& urine analysis. 2. Symptoms are important components of worsening disease, particularly headache& abdominal pain. ABOUBAKR ELNASHAR
2. Signs: 1. Increasing oedema: Not in itself a sign that should determine management. 2. Maternal tendon reflexes: ▪ Assess Mg toxicity ▪ Assess risk of convulsion. 3. Continuous oxygen saturation monitoring with a pulse oximeter: ▪ Valuable ▪ {give early signs of pulmonary oedema}. ABOUBAKR ELNASHAR ❑Measurement of blood pressure 1. Patient: ▪ Rested ▪ Sitting at a 45-degree angle. 2. BP cuff: ▪ appropriate size ▪ placed at the level of the heart. 3. Readings: ▪ Multiple readings {confirm the diagnosis}. ▪ Korotkoff phase 5 for DBP. 4. The method: Automated: used with caution {underestimate particularly SBP} ABOUBAKR ELNASHAR
❑High blood pressure: ▪≥140 mm Hg systolic or ≥90 mm Hg diastolic on 2 occasions, 4 h apart after20 w ▪Either ▪high systolic or ▪high diastolic is sufficient ▪Systolic BP: ▪as important as diastolic blood pressure in diagnosis ▪Persistent, severe (≥ 160 mmHg) should be treated promptly. ABOUBAKR ELNASHAR ❑Measurement of proteinuria 1. Visual dipstick assessment: ▪ 2+ dipstick ▪ 1+ = 0.3 g/l ▪ 2+ = 1 g/l ▪ 3+ = 3 g/l. ▪ Poor predictive value ▪ False negative as well as false positive rates. ABOUBAKR ELNASHAR
2. 24-h protein urine collection. ▪High false positive rates with dipsticks: confirm significant proteinuria, unless the clinical urgency dictates immediate delivery. ▪Inconvenient ▪Sometimes inaccurate {improper collection}. ▪Excellent correlation with ratio of protein to creatinine concentrations in a random urine sample ABOUBAKR ELNASHAR 3 . Spot protein creatinine ratio ±valid alternative. 0.03 g/mmol equivalent to 0.3 g/24 h. ABOUBAKR ELNASHAR
▪ Creatinine excretion/d ▪ 15-20mg/Kg= 1000-1500mg ▪ constant throughout the day regardless of changes in urine flow rate. ▪ Protein excretion/d: < 100 - 150mg. ▪ Normal protein-to-creatinine ratio: 100-150mg protein/ 1000- 1500mg creatinine= < 0.1 ▪ Protein-to creatinine ratio in a random sample (in mg/mg) is roughly equal to 24-hour urine protein excretion in grams/day ▪ Reasonable “rule-out” test for detecting proteinuria of 0.3 g/day or more in hypertensive pregnancy.ABOUBAKR ELNASHAR ACOG, 2013 Proteinuria ▪≥300 mg/dL on a 24-h urine ▪PCR: ≥0.3 or ▪Protein dipstick reading of >1 if quantitative analysis is not available ABOUBAKR ELNASHAR
I. Maternal monitoring II. Foetal assessment III.Control BP IV.Prevention of seizures V. Control of seizures VI. Fluid balance VII.Delivery VIII. Postparum ABOUBAKR ELNASHAR I. Maternal monitoring 1. BP: /15 m until the woman is stabilised and then /30 m in the initial phase of assessment. /4-h if a conservative management plan and the woman is stable and asymptomatic. 2. CBC, liver function, renal function tests. ▪ Repeated at least daily when the results are normal ▪ more often if the clinical condition changes or if there are abnormalities. ABOUBAKR ELNASHAR
3. Clotting studies ▪ not required if the platelet count >100 x 10 6 /l. 4. Input and output chart. ▪ A catheter with an hourly urometer in the acute situation, especially in the immediate postpartum period. ABOUBAKR ELNASHAR ▪Uric acid: rise ▪ correlates with poorer outcome for both mother and baby. ▪ confirms the diagnosis of PET ▪ levels should not be used for clinical decision- making. ▪Creatinine ▪ elevated early in the disease process: underlying renal disease should be suspected. ▪ In severe disease: rise: worsening outcome ABOUBAKR ELNASHAR
▪Platelet count <100x10 6 : worsening disease coagulation abnormality consideration for delivery. ▪Platelet volume may be of benefit but are as yet unproven. ABOUBAKR ELNASHAR ▪AST >75 iu/l or ALT >70 iu/l ▪ Significant ▪ >150 iu/l: increased maternal morbidity ▪Diagnosis of HELLP syndrome 1. Haemolysis: LDH levels, or blood film (fragmented red cells). 2. Platelet count: <100 x 10 6 ABOUBAKR ELNASHAR
II. Foetal assessment 1. In the acute setting: CTG: assess fetal wellbeing at that time but does not give any predictive information. 2. In labour: continuous electronic fetal monitoring. ABOUBAKR ELNASHAR 3. In Conservative management: Serial assessment will allow timing of delivery to be optimised. 1. US a. fetal size: IUGR30% of PET usually asymmetrical: AC is the best for assessment. b. liquor volume. ▪ Reduced: placental insufficiency and IUGR. ▪ Serial estimations: detect fetal compromise. 2. Umbilical artery Doppler: ▪ Absent or reversed-end diastolic flow ▪ improves neonatal outcome ▪ used to follow pregnancies and optimise delivery. ABOUBAKR ELNASHAR
3. CTG: ▪ Repeated regularly and easily ▪ No need of expensive equipment or highly skilled personnel. ABOUBAKR ELNASHAR III. Control BP Antihypertensive treatment ▪ Indications: 1. SBP> 160 mmHg or DBP>110 mmHg. 2. SBP <160 plus ▪ severe disease ▪ heavy proteinuria or ▪ disordered liver or haematological test) {alarming rises in BP may be anticipated}. ABOUBAKR ELNASHAR
3. DBP between 100 mmHg and 110 mmHg Continuing debate {treatment a. Reduction of severe hypertensive crises b. Reduction in the need for further antihypertensive therapy c. Small reduction in infant birth weight. d. Prolongation of pregnancy of an average of 15 days}. ABOUBAKR ELNASHAR ❑Indication of antihypertensive: ❑BP: more than 160/110 mm Hg (ACOG, 2013) ❑SBP: over 170 mm Hg. (WHO) ABOUBAKR ELNASHAR
6. MANAGEMENT I. Antihypertensive ❑There is an increasing trend toward tighter blood pressure control ❑keeping ▪SBP: below 150 mm Hg ▪DBP: 80-100 mm Hg ❑First-line treatment ▪labetalol and hydralazine for acute and severe (ACOG, 2013) ▪Labetalol [NICE, 2012] ABOUBAKR ELNASHAR ▪Drugs: •Acute, severe: ▪Nifedipine: oral not sublingually ▪ IR cap:10 mg initial; repeat after 30 m if necessary ▪ IR cap: 10-30 mg tid; not to exceed 120-180 mg/d ABOUBAKR ELNASHAR
▪ Hydralazine ▪ IV: 5 mg over 5 min, repeat /20 min until DBP 95 mmHg, No more than 4 doses. If not give Labetalol or Nifidipine. ▪ Maintenance: 10 mg/h ▪ Add 2ml NS to reconstitute 20 mg hydralazine. Withdraw 0.5 ml hydralazine solution and add 9.5 ml NS to give total 10 ml solution. ABOUBAKR ELNASHAR ▪Labetalol: ▪ IV: 20 mg; subsequent doses of 40, 80, 80 mg IV at 20-min intervals. Maintenance: 40 mg/h ▪ Oral: 100 mg BID ABOUBAKR ELNASHAR
ABOUBAKR ELNASHAR ABOUBAKR ELNASHAR
▪ Chronic, moderate ▪ Nifedipine: SR tab: 30-60 mg qd; not to exceed 90-120 mg/d ▪ Hydralazine: Oral: 25 mg tds ▪ Labetalol: ▪ 100 mg bid ▪ should be avoided in asthma. ▪ Methyldopa ▪ was the most commonly used therapies in UK. ▪ safe in long term follow-up of the delivered babies ▪ some studies have suggested some benefits of labetalol. ABOUBAKR ELNASHAR ▪Atenolol: increase in IUGR. ▪ACE inhibitors and ARBs: ▪contraindicated ▪{unacceptable fetal adverse effects}. ▪Diuretics ▪ relatively contraindicated for hypertension ▪ should be reserved for pulmonary oedema. ABOUBAKR ELNASHAR
IV. Prevention of seizures ▪Indications: Mg S should be considered for women with PET for whom there is concern about the risk of E. ▪ Severe PET: ▪ Once a delivery decision has been made and in the immediate postpartum period. ▪ When conservative management of a woman with severe hypertension and a premature fetus is made it would be reasonable not to treat until the decision to deliver has been made. ABOUBAKR ELNASHAR ▪If Mg So is given: 1. It should be continued for 24 h following delivery or 24 h after the last seizure, whichever is the later, unless there is a clinical reason to continue. 2. Regular assessment of: a. Urine output, b. Maternal reflexes, c. Respiratory rate d. Oxygen saturation . ABOUBAKR ELNASHAR
V. Control of seizures I. 1. Do not leave the patient alone. 2. Prevent maternal injury during the convulsion. 3. Call for help and place a code blue call- Medical Emergency call. 4. Initiate resuscitation. 5. Turn the patient into left lateral position when able to do so. 6. Inform consultant obstetrician&anesthetist on call. ABOUBAKR ELNASHAR II. AIRWAY 1. Assess and maintain patency, using oral suction if necessary. 2. Insert a plastic oral airway if possible 3. Administer oxygen therapy via face mask. III. BREATHING 1. Assess respiratory rate and ambubag using facial mask/laryngeal mask or endotracheal tube if necessary. ABOUBAKR ELNASHAR
IV. CIRCULATION 1. Evaluate Pulse and B P. If absent, initiate CPR. 2. Secure IV access as soon as possible with main line infusion, with three-way tap attached Hartmann's Solution very slow rate, as fluid intake will be restricted to 1 ml/kg/h 3. Pulse oximetry is helpful. ABOUBAKR ELNASHAR V. Mg SO4 ▪Therapy of choice to control seizures. ▪Loading dose: 4 g infusion pump over 5–10 min ▪Maintainance: 1 g/h for 24 h after the last seizure. ▪Recurrent seizures Further bolus of 2 g Mg SO4 or an increase in the infusion rate to 1.5 g or 2.0 g/h. ABOUBAKR ELNASHAR
▪Prepare loading dose Add 4g (8ml) of 50% MgS04 to 12ml of NS. Administer slowly IV over 10 m. ▪ Prepare Maintenance dose ▪ Add 50g (100 ml) of 50% MgS04 to 400ml of NS (withdraw 100mls from 500ml bag of NS, prior to adding MgS04). ▪ Administer IV via volumetric pump at 10ml/h =1g/hour. ABOUBAKR ELNASHAR VI. Once stabilized ▪Plans should be made to deliver the woman ▪No particular hurry and a delay of several hours to make sure the correct care is in hand is acceptable, assuming that there is no acute fetal concern such as a fetal bradycardia. ▪The woman’s condition will always take priority over the fetal condition. ABOUBAKR ELNASHAR
VI. Fluid balance 1. Fluid restriction is advisable {reduce the risk of fluid overload in the intrapartum and postpartum periods} Total fluids should be limited to 80 ml/h or 1 ml/kg/h {a. pulmonary oedema has been a significant cause of maternal death. b. No evidence of the benefit of fluid expansion c. fluid restriction regimen is associated with good maternal outcome. d. No evidence that maintenance of a specific urine output is important to prevent renal failure, which is rare.}ABOUBAKR ELNASHAR 2. The regime of fluid restriction should be maintained until there is a postpartum diuresis, as oliguria is common with severe pre-eclampsia. 3. If there is associated maternal hge, fluid balance is more difficult and fluid restriction is inappropriate. ABOUBAKR ELNASHAR
VII. Delivery ▪When: •once the woman is stable and with appropriate senior personnel present. •If the fetus is <34 w and delivery can be deferred: corticosteroids should be given, although after 24 h the benefits of conservative management should be reassessed. •Conservative management at very early gestations may improve the perinatal outcome but must be carefully balanced with maternal wellbeing. ABOUBAKR ELNASHAR ▪ Fetal indications ▪ Severe intrauterine growth restriction ▪ Nonreassuring fetal surveillance ▪ Oligohydramnios ▪ Maternal indications ▪ Gestational age of 38 weeks or greater* ▪ Platelet count below 100 × 10 3 per mm 3 (100 × 10 9 per L) ▪ Progressive deterioration of hepatic function ▪ Progressive deterioration of renal function ▪ Suspected placental abruption ▪ Persistent severe headache or visual changes ▪ Persistent severe epigastric pain, nausea, or vomiting ABOUBAKR ELNASHAR
▪How? •Depend on 1. presentation 2. fetal condition 3. likelihood of success of induction of labour •>34 w with a cephalic presentation: ▪ vaginal delivery should be considered. ▪ Discuss the mode of delivery with the mother. ▪ Vaginal Pg will increase the chance of success. ▪ Anti-hypertensive treatment should be continued throughout assessment and labour. •<32 w: CS is more likely as success of induction is reduced ABOUBAKR ELNASHAR ▪Anaesthesia ▪In the absence of contraindications, all of the following are acceptable for women undergoing CS: ▪Epidural ▪Spinal ▪Combined spinal-epidural, and ▪General anaesthesia. (A) ▪Regional anaesthesia for women on LMWH: ▪ 12 h after a prophylactic dose ▪24 h after a therapeutic dose. (B) ABOUBAKR ELNASHAR
▪The third stage: •5 u IM Syntocinon or 5 u IV Syntocinon given slowly. •Ergometrine or Syntometrine should not be given for prevention of hge {can further increase the blood pressure}. ABOUBAKR ELNASHAR VIII. Postpartum management 1. a. Women who develop hypertension or symptoms of PE postnatally (headaches, visual disturbances, n and v or epigastric pain): referred for a specialist opinion and investigation to exclude PE. b. Women who deliver with severe PET (or E): close observation postnatally for 4 days or more c. Careful review to ensure improving clinical signs is needed before discharge. ABOUBAKR ELNASHAR
2. Anti-hypertensive •Continued as dictated by BP. •BP should not exceed 160/110 mmHg •Reduction in anti-hypertensive therapy: in stepwise fashion. •Avoid alpha methyldopa •In breastfeeding: labetalol, atenolol, nifedipine and enalapril can be given ABOUBAKR ELNASHAR 3. Follow-up and final diagnosis 1. An assessment of BP and proteinuria at the 6 w. If hypertension or proteinuria persists then further investigation is recommended. 2. Preconceptional counselling ABOUBAKR ELNASHAR
ABOUBAKR ELNASHAR Thank you ABOUBAKR ELNASHAR
1)fluid balance in moderately and severely oliguric preeclampsia and HELLP To prevent fluid depletion(prerenal failure) And fluid overload (pulm edema) 2-Eclampsia 26 w controlled can pregenancy be continued or must be terminated 3-vaginal delivery in severe preeclampsia& eclampsia 4-DD between HELLP and AFL 5- Diagnosis and management of DIC and hemolysis in severe preeclampsia and HELLP 6- Absence of protinuria can exclude preeclampsia ABOUBAKR ELNASHAR hepatic steatosis, but the liver may appear normal (as the fat is microvesicul ar). CT may show decreased attenuation suggestive of fatty infiltration. ABOUBAKR ELNASHAR
❑C.P: may be asymptomatic or associated with massive haemorrhage depending on the degree. ❑Diagnosis ↑FDPs (these may be elevated post delivery) ↑Soluble fibrin complexes ↓Fibrinogen (fibrinogen concentration is normally elevated in mid- and late pregnancy so a level <2 g/L is highly significant) ↓Platelets Prolongation of clotting times (thrombin time, APTT, prothrombin time). ABOUBAKR ELNASHAR ❑Management treatment of the underlying cause and treatment of haemorrhage and coagulopathy. 1. Treatment of the cause This usually necessitates delivery of the fetus and emptying of the uterus. Pregnancy may be prolonged in cases of mild DIC associated with PET at early gestational ages, but such conservative management necessitates very careful monitoring. 2. Treatment of massive bleeding according to predefined and agreed protocols in close collaboration with haematology and anaesthetic staff. . Adequate monitoring with a central venous pressure line and urinary catheter is essential. ABOUBAKR ELNASHAR
▪ Treatment of coagulopathy: ▪ FFP, which contains all the coagulation factors ▪ Red cells (only needed to replace losses) ▪ Platelet concentrates (may be given to a bleeding patient if the platelet count is <80×10 9 /L) ▪ Cryoprecipitate or recombinant fibrinogen. Use may be considered if there is haemorrhage and the fibrinogen concentration is <1 g/L. ▪ Recombinant factor VIIa is a powerful but expensive pro- haemostatic tool that may be potentially useful in obste hge. ▪ The coagulation disturbance usually resolves within 24 to 48 hs after delivery, although thrombocytopenia may persist for up to a week postpartum. ABOUBAKR ELNASHAR ▪ What is the accurate method to measure blood pressure in pregnant woman ? •· What are measures to predict pre- eclampsia ? •· Has low molecular wt. heparin a role in improving the outcome of pregnancy in pre- cclampsia ? •· What types of tocolysis can be taken in pre- eclampsia ? •· What is the post – operative protocol for pre- eclamptic patient for - Fluids - Anti hypertensives - Analgesics - Antibiotics ABOUBAKR ELNASHAR
I. Preconceptional Risk Factors Rates of preeclampsia depend on: severity of underlying complications& combinations of risk factors. Risk % Risk factors 15-40 Chronic hypertension/renal disease 10-35 Pre gestational DM 10-20 Connective tissue disease (lupus, rheumatoid arthritis) 10-40 Thrombophilia (acquired or congenital) 10-15 Obesity/insulin resistance 10-20 Age older than 40 y 10-35 Limited sperm exposure 10-15 Family history of preeclampsia/ cardiovascular disease 1.5 fold Woman born as SFGA 2-3 fold Adverse outcome in a previous pregnancy: IUGR, ab placentae,IUFD ABOUBAKR ELNASHAR II. Pregnancy-Related Factors Regular antenatal care is mandatory for the prevention& early detection of PE. ▪Risk factors: Magnitude of risk depends on the number of factors ✓Hydrops/hydropic degeneration of the placenta ✓Multifetal gestation ✓Unexplained FGR ✓Gestational hypertension ✓UTI ✓Periodontal infection ▪Markers ✓Biophysical ✓Biochemical ABOUBAKR ELNASHAR
I. Biophysical •Mean arterial pressure •(2D BP+S BP)/3 •Better predictor of PE than S& D BP (BMJ 200817;336:111; Meta-analysis of 34 RCT) 2 nd trimester MA BP ≥ 90 mm Hg had +ve LR 3.5 and –ve LR 0.46 •BP remains the cornerstone of early diagnosis although it has limitations: measurement errors associated with sphygmomanometer effect of maternal posture on BP in pregnant women}. ABOUBAKR ELNASHAR •Repeated routine urinalysis throughout pregnancy NOT useful for predicting PE (JAMA 2003: 12;289(10):1220) ABOUBAKR ELNASHAR
Uterine artery Doppler ultrasound •}impaired trophoblastic invasion of the spiral arteries: reduction in uteroplacental blood flow} •High pulsatility index and/or Notch in 1 st & 2 nd trimesters: poor predictor of PE (Papgeorghiou & Leslie, 2007) Uterine artery Doppler plus biochemical markers •Promising results •Current data do not support this combination for routine screening for PE (Barton& Sibai, 2008). ABOUBAKR ELNASHAR • Diastolic Notch in uterine artery waveform ABOUBAKR ELNASHAR
The Roll over test Not of value in predicting PE (Mahomed &Lasiende,1990) ABOUBAKR ELNASHAR II. Biochemical Markers Angiogenic factors before & after the onset of PE (Barton& Sibai, 2008). Serum placental growth factor: reduced Soluble fms-like tyrosine kinase: elevated Endoglin: elevated ABOUBAKR ELNASHAR
•Currently: There is no clinically useful screening test to predict PE (WHO, 2004) ABOUBAKR ELNASHAR Regular antenatal care is mandatory for the prevention& early detection of PE. For prevention of PE Bed rest Reduction of job stress High dietary fiber intake Low dose aspirin Low dose aspirin/heparin Ca supplementation ABOUBAKR ELNASHAR

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