11_Eclampsia and preeclampsia real.pptxf

Explanation about induction of labor

1. HYPERTENSIVE DISEASES IN PREGNANCY Basic Obstetrics - 202 4 DR. David Brewen Conteh

2. Causes for maternal death Hypertension also contributes to maternal deaths through Haemorrhage as it is a major risk factor for Abruption and PPH O bstet r ic H em o rr h a g e 40% H y pe r tens ion 16% A n emia 13% O bs t r uc ted L a b or 4% S e p s is 11% Other 16% C a u se s o f m a te r n a l d e a t h , J a n - De c 201 6 ( n = 668 )

3. Hypertension in pregnancy - classification Chronic hypertension Pregnancy induced hypertension (PIH) Pre-eclampsia Eclampsia

4. What is the prevalence? 10%

5. Who is at risk? Pre-eclampsia in previous pregnancy Women with Chronic hypertension Women with Diabetes mellitus Mother had pre-eclampsia Obesity (BMI > 30) Primipara Older women > 40 years Multiple pregnancies Twins Triplets Smoking RR 8,4 RR 5 , 1 RR 3. 7 RR 2. 9 RR 2. 8 RR 2 . 1 RR 1 ,5 RR 2.8 RR 8-9 RR 0,5 (risk reduced)

6. What is the cause of pre-eclampsia?

7. Pathophysiology

8. The role of the placenta Placental insufficiency  FGR / IUFD

9. Systolic blood pressure > 140 mmHg and/or Diastolic blood pressure > 90 mmHg – On 2 readings > 4hours apart (not always practical) Definition of hypertension

10. Management of PIH and Chronic Hypertension Control BP – aim 140/90 - 150/100 mmHg Warn/educate the patient and family of complications of hypertension signs and symptoms of pre-eclampsia Monitor BP and urine dip regularly Consider induction after 37 weeks Especially if poor BP control, poorly compliant patient or other pregnancy concerns

11. Drug Management of Hypertension in pregnancy Emphasize need for ongoing treatment Ensure regular monitoring Options: Methyl Dopa 250mg BD to 1g TDS Labetalol 100mg BD to 400mg TDS Nifedipine MR 10 - 40mg BD Oral hydralazine 25mg BD to 50mg BD NOT Furosemide, Bendrofluazide, Diazepam, ACE-I Aim for BP 140/90 – 150/100

12. Treatment of refractory hypertension in pregnancy If BP ≥ 160/100 mmHg despite treatment AND GA > 34 weeks  Consider induction Very high risk of stroke, hepatic rupture, renal failure, seizure, abruption, FGR and IUFD W h y ?

13. Definition of pre-eclampsia Systolic blood pressure > 140 mmHg and/or Diastolic blood pressure > 90 mmHg AND Proteinuria > 1+ If < 20 weeks of pregnancy: Likely to be chronic hypertension If also proteinuria likely to be chronic renal damage

14. Treatment of mild pre-eclampsia before 37 weeks (preterm) Definition of mild PET: BP >140/90 and 1+ protein with no signs or symptoms of severe PET Control blood pressure 140/90 – 150/100 mmHg Inform her and the family about danger signs!! Regular monitoring Consider admission – Admit if she lives far away or not reliable for followup

15. Treatment of mild pre-eclampsia after 37 weeks (term) Induce labour Monitor for worsening condition and complication Control BP – aim for 140/90 – 150/100 mmHg

16. Definition: Severe Pre-eclampsia Systolic BP Diastolic BP 160 mmHg and/or 1 1 mmHg and Proteinuria > 3+ 140 mmHg and/or 90 mmHg and Sy m p t oms of severe PET OR

17. Signs/Symptoms of severe PET

18. Severe Headache Nausea and vomiting Severe swelling of face Blurred vision Pulmonary Oedema Epigastric pain/RUQ pain Hyperreflexia and clonus >2 beats Oliguria IUFD, severe IUGR Signs/Symptoms of severe PET

19. Management of Severe PET Admit to hospital Treatment goals: Lower BP to prevent cerebral hemorrhage Prevent seizures (with MgS04) Aim to deliver within 24 hours < 24 weeks 24 – 34 wks  deliver within 24 hours  Steroids for fetal lung maturation  deliver after 24 hours (if stable)  deliver within 24 hours > 34 weeks Do not delay IOL or C/S if unstable

20. Severe Pre-eclampsia: Acute Treatment of BP If BP >160/110 then treatment is urgent Options include: Nifedipine (standard release) 10-20mg Works within 15 minutes Hydralazine 5mg i.v. or Labetalol 10mg i.v. Works within 15 minutes Important: Always monitor the patient for response and recurrence Be prepared for hypotension – give 500ml rapid RL with first dose unless already received fluid

21. Severe Pre-eclampsia: Longterm Treatment of BP Remember it is important to give the patient a long acting medicine to prevent recurrence of raised BP Options include: Hydralazine i.v. infusion (if patient unconscious) Nifedipine MR 20 – 40mg BD Labetalol 200 – 400mg TDS (Methyl Dopa has a long onset time - give only if no alternative available = 1g TDS)

22. Preeclampsia - Complications Abruptio placentae (with DIC) Renal insufficiency or failure HELLP syndrome (Haemolysis, Elevated Liver enzymes and Low Platelet count) Intracranial haemorrhage Disseminated intravascular coagulation (DIC) Adverse fetal outcome (IUFD, asphyxia, neonatal death) Maternal death

23. Magnesium Sulphate (MgSO4) Preferred anti-convulsant Slows neuromuscular conduction and decreases CNS irritability No significant effects on blood pressure

24. The intramuscular MgSO4 regimen M A INTE N A N C E THERAPY Deep i.m. injection, 5 g every 4 hours. Continue for 24 hours after last convulsion or delivery Magnesium sulphate 4g INTRAVENOUS Slow i.v. injection over a period of more than 10 minutes Magnesium sulphate 10g INTRAMUSCULAR Magnesium sulphate 5g INTRAMUSCULAR Deep i.m. injection, 5g in each buttock (+1ml lidocaine 1%) LOADING DOSE

25. Monitoring on MgS04 Hourly: – BP – aim 140/90 – 150/100 – RR – >16 Tendon reflexes – present Pulse and FHR 4-hourly Urine output – should be >100ml Temperature VE as indicated if in labour

26. Magnesium Toxicity Loss of biceps/patellar reflex Somnolence Respiratory depression Paralysis Cardiac arrest Antidote is calcium gluconate 1 g in 10ml i.v. given over 10 minutes (slowly!) S i gns of i n creasing Toxicity

27. Magnesium Toxicity Be aware of the following signs: Respiratory arrest Stop MgSO4 treatment Intubate and ensure ventilation Calcium gluconate 1g i.v. Respiratory depression Stop MgSO4 treatment Oxygen by mask Calcium gluconate 1g i.v. Absent patellar reflexes - If respiration rate normal, withhold further MgSO4 until reflexes re-emerge Urine output < 100 ml in 4h - If no respiratory or patellar signs reduce dose by half (i.m. 2.5g). Consider discontinuing if urine output still <100ml

28. Fluid Management Record strict input / output Fluid input max 150 ml/h (including oral intake) Beware risk of pulmonary and cerebral oedema Check chest for fluid as part of your assessment Review for other signs of worsening oedema – e.g. facial oedema, corneal oedema, ascites

29. Other Investigations Hb and Blood grouping Malaria: RDT +/- smear Blood sugar – if convulsion or signs of liver involvement (jaundice) USS to assess fetal size/presentation* Clotting time (bed-side or lab-based) Platelets* Kidney and liver function* * If available

30. Severe Preeclampsia Delivery Decisions Vaginal delivery preferred Consider Caesarean delivery for: obvious evidence of fetal compromise (unfavourable cervix) Eclampsia or unstable patient and delivery not likely <12h Pulmonary oedema HELLP (but beware coagulopathy) Severe uncontrolled BP despite appropriate treatment

31. Resemble grand mal seizures of epilepsy initially self-limiting May recur in rapid sequence May eventually be followed by coma Risk increases in severe pre-eclampsia but can occur rarely on background of normal BP Remember! Convulsions may occur: before delivery during delivery after delivery (48%)

32. Epilepsy Cerebral Malaria Head injury Cerebrovascular incident Intoxication Menigitis Encephalitis Hypertensive encephalopathy Hypoglycaemia Seizure – differential diagnosis

33. What to do?

34. ABC Call for Help Airway: left lateral tilt, head lift, chin tilt Breathing: Oxygen, RR, Sats, Check Chest Circulation: IV-line, BP, Pulse Prepare MgSO4 Disability: Evaluate consciousness Check FHR

35. Management of Eclampsia Prevent new seizures - give MgSO4 Lower BP to prevent cerebral hemorrhage Plan delivery within 12 hours

36. Post-partum Management NEVER LEAVE THE PATIENT ALONE Improvement usually rapid after delivery Risk of seizure greatest in first 24 hours MgSO4 continued for 24 hours after last seizure or delivery Continue monitoring of MgSO4, BP, urine output Watch for signs of fluid overload

37. Life threatening complications can still occur after delivery Consider referral of a woman who has: Oliguria (<400ml/24h that persists 48h after delivery) Liver Failure Coagulation failure Severe jaundice Persistent hypoglycaemia Persistent coma Post partum care