Obstetrics: Management of Pre Eclampsia.

Important question in Obstetrics is Management of pre eclampsia, identifying impending signs and management ( medical & surgical ) of pre eclampsia with complications

1. Management of Pre Eclampsia Harita Prakash Reddy Final year MBBS AIMS, Mandya

2. Management Objectives Stabilisation of hypertension and prevention of progression to severe pre- eclampsia, HELLP syndrome or eclampsia Prevention of complications To prevent eclampsia Delivery of healthy baby in optimal time Restoration of health of mother in postpartum period.

3. Women without severe features can be managed in OPD/ Day Care Center/ Hospital—> Daily fetal Kick Chart USG -> fetal growth every 3 weekday Daily maternal BP monitoring Weekly CBC, Liver Enzymes, serum Creatinine Evaluation of maternal signs & symptoms -> progression of disease With severe features -> hospitalisation until delivery Additional to initial management ( same as that of PE without complications) BP stabilisation with drug therapy ideally to be < 160/110 mmHg Fetal monitoring -> Daily NST, twice weekly BPP, USG with Doppler study of umbilical artery every 2 weeks Ominous symptoms education-> headache, visual disturbances, vomiting, epigastric pain or scanty urine. Definitive treatment is delivery of foetus

4. HOSPITAL MANAGEMENT REST : Increases renal blood flow -> diuresis Increases uterine blood flow -> improves placental perfusion-> decreases BP DIET : should contain 100 G protein, low salt intake. MEDICATION : DIURETICS : to be used cautiously as it can diminish placental perfusion + electrolyte imbalance indication : Cardiac failure Pulmonary edema Fluid retention associated with anti hypertensive therapy ( dioxide group) Massive edema

5. Commonly used diuretic is Furosemide (LASIX) 40 mg orally OD after breakfast for 5 days. Mechanism of Action :

6. ANTIHYPERTENSIVES : Indications : DBP > 105 - 110 mm Hg persistently or SBP > 160 mmHg + associated with proteinuria Severe preeclampsia-> bring down BP during pregnancy and labour. Prevent stroke LABETALOL : competitive, selective Alpha 1 receptor, non selective Beta 2 blocker Partial Beta 2 agonistic activity -> vasodilation Onset : 5 - 10 mins Duration : 3 - 6 hrs Half life : 5 - 8 hrs

7. Dosage : 100 mg TID or QID orally -> without severe features 10 - 20 mg IV in 20 mins ( max dose is 300mg IV, maintenance dose : 40 mg/h) -> with severe features PE

8. MOA:

9. Contraindication : Sinus bradycardia Cardiogenic shock Cardiac failure Asthma

10. HYDRALAZINE : directly acting smooth muscle relaxant, causes vasodilation in primarily arterioles. Onset : 10 - 20 mins Duration : 3 - 9 hrs Half life : 1 - 4 hrs Dosage : 10 -25 mg BID orally ( non severe PE) 5mg IV or IM followed by 10 mg doses at 15 to 20 min intervals upto 3 doses -> severe PE

11. MOA :

12. Contraindication : Hypersensitivity SLE Thyrotoxicosis ( severe tachycardia + Heart failure + high Cardiac output) Myocardial insufficiency ( eg: pericarditis) Cor pulmonale Adverse effects : Hypotension Tachycardia Arrhythmias Neonatal thrombocytopenia

13. NIFEDIPINE : it is a Calcium channel blocker Onset : 20 mins Duration : 8 hours Half life : conventional -> 1.7 hrs Extended release -> 7 hrs Dosage : 10 - 20 mg BID orally -> non severe PE 10 mg orally followed by 20 mg doses at 20 mins, 2 times

14. MOA:

15. Contraindication: Simultaneous usage of MgSO4 can cause synergistic effect One month of MI Unstable angina Ventricular outflow obstruction Adverse effects : Hypotension Flushing Headache Abnormal FHR tracing Reflex tachycardia -> use Beta blocker to treat

16. Depending upon response to treatment patients are grouped into : Women with PE/GH without severe features at <= 34 weeks : management is continued with follow up in OPD/ Day care center Women with PE/GH with severe features at <= 34 weeks : hospitalisation + close maternal and fetal monitoring + delivery at or beyond 34 weeks ( after stabilisation & corticosteroids administered-> <= 34 weeks Corticosteroids are administered for fetal lung maturation <= 34 weeks as it reduces : Respiratory Distress Syndrome Intraventricular Hemorrhage in newborn Necrotizing enterocolitis Maternal thrombocytopenia

17. MAGNESIUM SULFATE : recommended for Antepartum, intrapartum, postpartum for Seizure prophylaxis in women with PE with severe features , imminent eclampsia Onset : immediate Duration : 30 mins

18. METHODS OF DELIVERY : C-section : Indication : Urgent termination of pregnancy & cervix is unripe & closed Severe pre eclampsia Complicating factors : elderly primigravida, malpresentation Note : Regional anaesthesia is preferred due to risk of aspiration, failed intubation, stroke. Platelet count should be > 70 X 10^9 /L to avoid coagulopathy.

19. Induction of Labour : Ripe Cervix -> surgical induction by low rupture of membrane to curtail labour duration in 1st stage, Forceps & Ventouse in 2nd stage Unripe Cervix -> PGE2 gel 500 mcg Intracervical or 1-2 mg in posterior fornix to make cervix ripe -> low rupture of membranes Fetal monitoring -> FHS Cardiotocograhy BP & Urine output monitoring hourly basis Prophylactic MgSO4 is started with severe features of PE Antihypertensive drugs continued

20. POSTPARTUM MANAGEMENT: Monitoring for 48 hrs ( for convulsion risk) Continue Antihypertensive therapy ( >150/ > 100 mmHg) Nifedipine-> every 6 hrs orally till BP normalises Furosemide -> 20mg/5days MgSO4 for atleast 24 hrs ( neuroprotective) Avoid Methyldopa -> Postpartum depression risk.

21. Acute Fulminant Pre Eclampsia Clinical entity where onset of pre eclamptic manifestations are acute or there is rapid deterioration in established case of preeclampsia eclampsia with severe hypertension over short period of time. Management : Sedation by Midazolam 1-2 mg IV repeat 5-10 mins / Diazepam 10 mg IV Prophylactic MgSO4 before transfer from PHC or point of care to higher center. First line Antihypertensive-> labetalol (IV), Hydralazine( IV) started + BP, Urine output, Proteinuria, haematological parameters should be monitored OBSTETRIC MANAGEMENT: Maternal interest should be considered In pregnancies > 37 weeks or when condition doesn’t improve (6 -8 hrs) delivery to be conducted irrespective of gestation Termination or delivery done done by Low rupture of membrane aided by Oxytocin or C section based on Cervix (ripe/unripe)

22. REFERENCE: DC Dutta textbook of Obstetrics- 9th edition William’s Obstetrics - 26th edition Slideshare “ECLAMPSIA” by Basavaraj Hukkeri