Preeclampsia: an overview Is there a LAO word for pre-clampsia? What word do you use? french éclampsie? Family Medicine Specialist CME Improving Quality of Care for Everyone November 4 – 6, 2013 Savannakhet, Lao PDR Eliana Castillo MD University of Calgary

Outline What is pre-eclampsia? Why do we care about pre-eclampsia? How does pre-eclampsia arise? What are the priorities in care for women with pre-eclampsia?

Outline What are the priorities in care for women with pre-eclampsia? Diagnosis, assessment and surveillance Blood pressure management Seizure prevention and management Delivery & fluids Postpartum care

Case 1 24 y G1P0 28 weeks presents to hospital with severe headache and mild shortness of breath x 4 hours BP on arrival 140/100 Fundal Height: small for gestational age Urine dip++ protein

Case 2 24 y G1P0 36 weeks presents to hospital with severe headache and vaginal bleeding and abdominal pain BP on arrival 140/95 Fundal Height: small for gestational age Urine dip: no protein

What is her clinical diagnosis?

What is Pre-eclampsia? Definition – Hypertension and Significant proteinuria sBP ≥140mmHg and/or dBP ≥90mmHg AND ≥++ dipstick proteinuria OR ≥300mg protein/24 hours OR ≥30mg protein/mmol creatinine on spot urinary protein:creatinine ratio

What is Pre-eclampsia? Hypertension + Proteinuria This traditional definition does not fully recognise the SYSTEMIC nature of pre- eclampsia

Pre-eclampsia is more than hypertension & proteinuria Both Cases have pre-eclampsia Case 1: htn, proteinuria, end-organ damage (severe headache and maybe developing pulmonary edema) Case 2: htn, small baby = placental disease, end-organ damage (severe headache and maybe having abruption)

Pre-eclampsia is more than hypertension & proteinuria Maternal symptoms & laboratory abnormalities Encephalopathy, pulmonary edema, HELLP etc Both Cases have pre-eclampsia Case 1: htn, proteinuria, end-organ damage (severe headache and maybe developing pulmonary edema) Case 2: htn, small baby = placental disease, end-organ damage (severe headache and maybe having abruption) Placental Disease Growth retardation/fetal demise

Case 1 24 y G1P0 28 weeks presents to hospital with severe headache and mild shortness of breath x 4 hours BP on arrival 140/100 Fundal Height: small for gestational age Urine dip++ protein

Case 2 24 y G1P0 36 weeks presents to hospital with severe headache and vaginal bleeding and abdominal pain BP on arrival 140/95 Fundal Height: small for gestational age Urine dip: no protein

Spectrum severity Maternal death Eclampsia Pulmonary Edema Acute Renal Failure Placental Abruption Fetal Demise

Why do we care about pre-eclampsia? Worldwide pre-eclampsia causes 70,000 – 80,000 maternal deaths per year 500,000 stillbirths and neonatal deaths per year In total: 1600 deaths/day >99% of these deaths occur in countries like Lao PDR That translates into the death of one mother every seven minutes 1600 deaths/day is equivalent to 4 x 747 jets carrying each 400 people crashing every day and losing every soul

What does this mean to Lao PDR? Using data from Dr. Sychareun and the Lao reproductive health survey 2005

Why do we care about pre-eclampsia? Lao PDR 44,000 live births per year ~450 maternal deaths/100,000 live births At least 7,000-14,000 pregnant women will have hypertension in pregnancy Lao PDR 240 maternal deaths/year from pre-eclampsia Most women will die at home

How does pre-eclampsia arise?

How does pre-eclampsia arise? immune factors genetic factors co-morbidities inadequate placentation endothelial activation

How does pre-eclampsia arise? inadequate placentation causes endothelial activation

Pre-eclampsia: lethal complications endothelial activation at different organs account for the multiple organ involvement

How would you manage this patient?

Outline What are the priorities in care for women with pre-eclampsia? Diagnosis, assessment and surveillance Blood pressure management Seizure prevention and management Delivery & fluids Postpartum care

Diagnosis, assessment and surveillance Surveillance and timed delivery WORK to decrease the number of deaths from pre-eclampsia! Standardized Surveillance

Diagnosis, assessment and surveillance How to identify women at greatest (and least) risk of adverse outcomes? Expectant management vs aggressive therapy Place of care – Community vs 1st level clinic vs hospital – Local/regional/referral centres It is very important to to identify women at greatest (and least) risk of adverse outcomes? Why? Because you can decide if she needs aggressive therapy (being delivered) NOW vs Expectant management (can wait). But also it decides place of Place of care – Community vs 1st level clinic vs hospital – Local/regional/referral centres

Diagnosis, assessment and surveillance miniPIERS: symptom & sign prediction tool Parity GA at admission Systolic blood pressure Dipstick proteinuria Symptoms of: Chest pain/dyspnoea Headache/visual disturbances Epigastric pain Vaginal bleeding with abdominal pain Example of a pre-eclampsia prediction tool that has been proved to help identify WHO are the women at “high risk” of developing the “lethal” complications that need delivery within 48 hours +/- transfer to higher level of care Payne et al. PLOS Med (in press)

How would you manage this patient? Blood pressure management

Blood pressure management Severe systolic hypertension MOST important risk factor for maternal stroke

Blood pressure management Severe Hypertension (>160/110 mmHg) Lower BP by 10% per hour Continuous fetal monitoring with viable fetus Agent Dosage Nifedipine 5-10 mg capsule bitten or swallowed every 30 minutes 10 mg PA tablet every 45 min to a maximum of 80 mg/day Labetalol 20 mg IV; repeat 20-80 mg IV every 30 min to a maximum of 300mg (alternative: continuous infussion 1-2 mg/min) Hydralazine 2-5 mg IM/IV; repeat every 30 min in doses up to 10mg to a maximum of 30 mg (the switch to oral) Magee, L.A., et al. How to manage hypertension in pregnancy effectively. British Journal of Clinical Pharmacology 2011 72(3):394-401

How would you manage this patient? Seizure Prevention

Seizure Prevention & Management MgSO4 4g IV + 10g IM loading dose & 5g IM q4h 4g IV loading dose & 1g/hr IV recurrent seizure(s) treated with additional 2–4 g iv loading dose(s)

How would you manage this patient? Timing of Delivery

Timing of Delivery Remote from term Expectant management until compelled to deliver (maternal or fetal reasons) Antenatal steroids for lungs betamethasone12 mg IM/day 2 doses dexamethasone 6mg IM q12h 4 doses MgSO4 for fetal neuroprotection ≤31+6 weeks For women with imminent preterm birth (≤ 31+6 weeks), antenatal magnesium sulphate administration should be considered for fetalneuroprotection Magee, L et al SOGC Clinical Practice Guideline. Magnesium sulphate for fetal neuroprotection JOGC, 2011. 33(5):516-29.

Timing of Delivery Induction of labour should be advised for women with gestational hypertension and a diastolic blood pressure of 95mmHg or higher or mild pre- eclampsia at a gestational age beyond 37 weeks IOL reduces risk of – severe hypertension – HELLP syndrome – Caesarean section if ≥37+0 For women with imminent preterm birth (≤ 31+6 weeks), antenatal magnesium sulphate administration should be considered for fetalneuroprotection Koopmans, CM et al Induction of labour versus expectant monitoring for gestational hypertension or mild pre-eclampsia after 36 weeks' gestation (HYPITAT): a multicentre, open-label randomised controlled trial. Lancet, 2009. 374(9694): 979-88

How would you manage this patient? Fluid Management

Fluid Management Pulmonary edema: leading cause of pre-eclampsia-related maternal mortality and morbidity Generally iatrogenic Women with severe pre-eclampsia Total intake (all routes): 80ml/hr Tolerate urine output as low as 15ml/hr

How would you manage this patient? Timing of Delivery

Postpartum Care Liver, renal, and coagulation function will deteriorate transiently postpartum, particularly after early-onset preeclampsia BP rises day 3-5postpartum = stroke risk Eclampsia up to 2-3 weeks postpartum Risk of blood clots (rebound of hypercoagulability) Eclampsia risk persists up to 2-3 weeks postpartum

What do you tell her about risk in future pregnancies and her long term health?

Future Risk CV Disease

Case 1: Apply what you learned today 24 y G1P0 28 weeks presents to hospital with severe headache and shortness of breath x 4 hours BP on arrival 140/100 Fundal Height: small for gestational age Urine dip++ protein Apply miniPIERS in small group discussion: is she at hight risk of developing a severe or potentially lethal complication in the next 24-48h? YES What to do? -does she need to be referred? -what needs to be done? steroids IM 1st dose and ?MgSO4 for neonatal brain protection

Case 1a: Apply what you learned 24 y G1P0 28 weeks presents to hospital with severe headache and shortness of breath x 4 hours BP on arrival 160/100 Fundal Height: small for gestational age Urine dip++ protein Apply miniPIERS in small group discussion: is she at hight risk of developing a severe or potentially lethal complication in the next 24-48h? YES What to do? -does she need to be referred? -what needs to be done NOW? bring her BP down: nifedipine po now, steroids IM 1st dose and ?MgSO4 for MATERNAL -prevent seizure- and neonatal brain protection

Case 2: Apply what you learned today 24 y G1P0 36 weeks presents to hospital with severe headache, vaginal bleeding and abdominal pain BP on arrival 140/95 Fundal Height: small for gestational age Urine dip: no protein Apply miniPIERS in small group discussion: is she at hight risk of developing a severe or potentially lethal complication in the next 24-48h? YES What to do? -does she need to be referred? YES if not a facility that can handle abruption -what needs to be done NOW? bring her BP down: MgSO4 IM for MATERNAL -prevent seizure-

Case 1, 1a, 2: Apply what you learned Apply miniPIERS: is she at hight risk of developing a severe complication in the next 24-48h? YES What needs to be done now? Refer Treat BP IM steroids IM MgSO4 Apply miniPIERS in small group discussion: is she at hight risk of developing a severe or potentially lethal complication in the next 24-48h? YES What to do? -does she need to be referred? -what needs to be done NOW? bring her BP down: nifedipine po now, steroids IM 1st dose and ?MgSO4 for MATERNAL -prevent seizure- and neonatal brain protection

Pre-eclampsia Quality Improvement Three main modifiable reasons why women and their fetuses/newborns die due to pregnancy complications: delays by the woman herself in recognizing the seriousness of her condition delays in her being assessed and then transported to a center capable of providing effective and life-saving interventions delays in the health facility in providing those interventions

Pre-eclampsia Quality Improvement What can you change in the next year to help women in cases 1 and case 2? Can you work with women, midwives, birth attendants in your community to raise awareness of pre-eclampsia manifestations?

Pre-eclampsia Quality Improvement What can you change in the next year to help women in cases 1 and case 2? Can you establish a program to apply 2001 WHO guidelines to do a blood pressure check in the second antenatal visit in addition to testing for proteinuria in nulliparous women or in women with previous preeclampsia?

Pre-eclampsia Quality Improvement Can you provide the 2 treatments for pre-eclampsia that are poorly accessed in countries like Lao PDR? IM magnesium sulfate(MgSO4) to treat or prevent eclampsia oral antihypertensive medication to lower maternal BP to reduce the risk of stroke

Questions? Comments?