SEVERE PRE-ECLAMPSIA - Mwanyika-1.pptx

eclampsia

1. HYPERTENSIVE DISORDERS IN PREGNANCY Mwanyika M.P- MD, Mmed (OBGY)

2. INTRODUCTION Hypertension is a raise in BP>/=140/90measured 2times with at least 6hours interval Gestational hypertension is a raise in BP>/=140/90 which occurs for the first time in pregnancyafter 20weeks of gestation ,without protenuria . Pre- eclampsia is gestational hypertention with protenuria of more than 300mg in a 24 hour urine collection or persistent 1+ ( 30mg/ dL ) on dipstick

3. INTRODUCTION Severe pre e clampsia is the elevation of BP (in pregnant women) above 160/110mmHg with protenuria accompanied by blurring of vision , vomiting, epigastric pain and severe and persistent headache . Eclampsia is pre eclampsia complicated with convulsions and or coma Chronic hypertension is a known hypertension before pregnancy or diagnosed before 20wks of pregnancy or persistence of hypertension beyond 12 weeks postpartum

4. Superimposed pre eclampsia / eclampsia occurrence of proteinuria in a woman with chronic hypertension

5. RISK FACTORS Primigravida : Young or elderly Family history : Hypertension, pre-eclampsia Placental abnormalities : – Hyperplacentosis Increased placental tissue for gestational age 􀂃 Resulting from Hydatiform moles, twin pregnancies, etc. Obesity : BMI >35 kg/M2, Insulin resistance. Pre-existing vascular disease New paternity . Thrombophilias Renal diseases

6. Classification of Pre-Eclampsia-1 Mild–Moderate Pre- Eclampsia May be asymptomatic BP is raised but is below 160/110 mmHg Protein in urine is 1+ or less, less than 5 grams in a 24 hour urine collection No symptoms of severe pre- eclampsia

7. Classification of Pre-Eclampsia-2 Severe Pre- Eclampsia Pre- eclampsia with any of the following features (but with no convulsion) Severe persistent headache, visual disturbances, epigastric / right upper abdominal pain BP is above 160/110 mmHg Protein in urine is 3+ or above Hyperreflexia Respiratory distress (pulmonary oedema ) Oligohydramnios Intra-Uterine Growth Restrictions/Retardation (IUGR )

8. Oliguria/anuria Acute renal failure (Oliguria with less than 500mL per 24 hours) HELLP syndrome Pulmonary oedema or cyanosis / generalised edema Concerning abdominal pain Impaired liver function test findings Thrombocytopenia

9. MANAGEMENT-1 Mild–Moderate Pre- Eclampsia before 37 Weeks of GA Manage as outpatient if patient is compliant and can be followed closely Provide antihypertensives : Aldomet , etc. Rest at home Monitor foetal well-being Foetal movements, ultrasound (USS), etc. Deliver at 37weeks Patients presenting with pre- eclampsia prior to 34 weeks of gestational age (GA) should be given a course of steroids.

10. MANAGEMENT-2 FOR SEVERE P./ECLAMPSIA PRINCIPLES OF MANAGEMENT ARE: Maintain : airway, breathing & circulation Oxygen administration 8–10 L/min or Ventilatory support C ontrol BP Prevent/arrest convulsions Do investigations Decide on delivery, If convulsions have occurred d eliver by 6-8 hours- Treatment with steroids for lung maturity?? Prevention of complications or injury Postpartum care (intensive)

11. Note : Patients with severe pre- eclampsia / eclampsia should be managed in the hospital by a doctor.

12. INVESTIGATIONS Urine for albumin test Full blood count to all admitted patients Serum urea and creatinine to all patients Liver function test to all patients Serum magnesium level Malaria test (BS/MRDT) Obstetric USS (if needed)

13. MgSO4 Reg imens of MgSO4 for the management of severe pre-eclampsia and eclampsia Regimen Loading dose Maintenance dose Intramuscular (Pritchard) 4 gm IV(20%) over 3–5 min followed by 10 gm deep IM (5 gm in each buttock) 5 gm IM 4 hourly in alternate buttock Intravenous ( Zuspan or Sibai ) 4–6 gm IV(20%) over 15–20 min 1–2 gm / hr IV infusion (50%)

14. MgSO4 DILUTIONS 1% Solution= 1g/100ml 20% solution=20g/100ml=1g/5ml=2g/10ml 50% solution=50g/100ml=1g/2ml=5g/10ml 1 Ampoule of MgSO4; 5g in 10ml= 1g/2ml = 50% solution Loading dose; -------------------------------  4g of 20% MgSO4 8ml of 50% MgSO4 (4g) + 12ml NS  4g in 20ml solution= 4/20 x100= 20% MgSO4  IV slowly for 15min Maintenance dose 1 g of 50% MgSO4 hourly for 24hrs from the last fit or delivery (depending on what comes LAST)

15. MgSO4 IN CASE THE PATIENT FITS AFTER THE LOADING DOSE, GIVE ANOTHER LOADING DOSE OF 2G OF 20% MGSO4 AND CONTINUE WITH YOUR MAINTENANCE DOSE . Continue with and Magnesium for at least 24 hours post-delivery, and Aldoment orally until BP is back to normal.

16. MgSO4 SERUM MAGNESIUM LEVELS NORMAL RANGE; 0.66—1.07mmol/L   EFFECT mmol/L mEq/L Mg/dl 2------3.5 4----7 5------9 Therapeutic level >3.5----5 >7---10 >9-----12 Loss of patellar reflexes >5----12.5 >10----25 >12----30 Respiration paralysis >12.5 >25 >30 Cardiac arrest

17. MgSO4 Monitoring of patient on MgSO4 Respirtory rate> 16 b/min Patellar reflex should be present Urine output of at least 30ml/ hr

18. MgSO4 Si gns of Mg toxicity Absent patellar reflexes  Stop MgSO4 until the reflexes return  Give antidote Calcium gluconate Respiratory depression  Give oxygen by mask  Stop MgSO4  Maintain airway

19. ANTI-HYPERTENSIVES DRUG MODE OF ACTION DOSE Methyl- dopa Central and peripheral anti-adrenergic action 250–500 mg tid or qid Labetalol Adrenoceptor antagonist (α and β blockers) 100 mg tid or qid Nifedipine Calcium channel blocker 10–20 mg bid Hydralazine Vascular smooth muscle relaxant 10–25 mg bid

20. WHEN TO DELIVER???? MODE OF DELIVERY ????

21. Complications of Pre-Eclampsia-1 Pre- eclampsia can produce complications in many different systems . • Cardiovascular System o Haematological changes – HELLP syndrome may lead to DIC. • Kidneys-o Acute renal failure-AKI ( oliguria/anuria ) • Brain o Cerebral oedema o Infarction, cerebral haemorrhage o Blindness, possibly due to retinal artery vasospasms and retinal detachment o Coma – may be a result of CVA

22. Complications of Pre-Eclampsia-2 • Respiratory o Pulmonary oedema and cyanosis • Reduced utero-placental perfusion o May be due to increased vasospasms and perfusion and acute artherosis • Foetal complications o Intrauterine growth restriction, foetal distress, intrauterine foetal death

23. Key Points Severe pre- eclampsia and eclampsia are dangerous medical conditions, requiring referral to the hospital level. • Manage minor hypertensive problems during pregnancy to prevent progression into eclampsia . • In severe cases, control convulsions and BP, maintain fluid balance, deliver the mother at whatever gestation age, and keep records.