1. 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

2. 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?

3. 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

4. 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

5. 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

6. What is her clinical diagnosis?

7. 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

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

9. 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)

10. 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

11. 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

12. 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

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

14. 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

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

16. 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

17. How does pre-eclampsia arise?

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

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

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

21. How would you manage this patient?

22. 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

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

24. 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

25. 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)

26. How would you manage this patient?
Blood pressure management

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

28. 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 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 (3):

29. How would you manage this patient?
Seizure Prevention

30. 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)

31. How would you manage this patient?
Timing of Delivery

32. 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, (5):

33. 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, (9694):

34. How would you manage this patient?
Fluid Management

35. 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

36. How would you manage this patient?
Timing of Delivery

37. 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

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

39. Future Risk CV Disease

40. 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

41. 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

42. 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-

43. 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

44. 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

45. 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?

46. 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 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?

47. 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

48. Questions? Comments?