1. Quality Education for a Healthier Scotland Multidisciplinary Pre-eclampsia and Eclampsia Promoting multiprofessional education and development in Scottish maternity care

2. Quality Education for a Healthier Scotland Multidisciplinary Background Deaths from pre-eclampsia and eclampsia have increased from 18 in 2003-2005, to 19 in 2006- 2008 PET/eclampsia is the second most common cause of direct maternal death (rate of 0.83: 100,000 maternities )

3. Quality Education for a Healthier Scotland Multidisciplinary Disease Incidence Hypertension complicates 10 -15% of all pregnancies. Pre-eclampsia (hypertension, impaired renal function and fluid retention) occurs in 4-10% of women in their first pregnancy. In the UK, the incidence of eclampsia is down from 4.9 to 2.7 per 10,000 maternities (UKOSS 2007).

4. Quality Education for a Healthier Scotland Multidisciplinary Hypertension Hypertension in pregnancy is defined as a diastolic pressure greater than 90 mmHg. Severe hypertension is a diastolic pressure >110 mmHg, a systolic pressure >160 mmHg or a mean arterial pressure >125 mmHg. (CEMD, 2004; Sibai et al., 2005) the mean arterial pressure is calculated thus: diastolic blood pressure + 1/3 pulse pressure [Diastolic BP + 1/3 (Systolic BP – Diastolic BP)]

5. Quality Education for a Healthier Scotland Multidisciplinary Systolic Pressure Saving Mothers’ Lives 2006-2008 Reported inadequate treatment of systolic hypertension of >150-160mm/Hg directly resulted in fatal intracranial haemorrhage

6. Quality Education for a Healthier Scotland Multidisciplinary Pre-eclampsia: Risk Factors age ≥40 years primigravida previous pre-eclampsia FH on maternal side multiple pregnancy central obesity (BMI) molar pregnancy previous severe IUGR migraine renal disease connective tissue disease chronic hypertension diabetes thrombophilia time between pregnancies ( 5 years) (Duckitt & Harrington, 2005; Poon et al., 2010)

7. Quality Education for a Healthier Scotland Multidisciplinary Diagnosis Usually asymptomatic and detected at antenatal review (elevated BP and proteinuria) Symptoms tend to be non-specific: rapidly progressive oedema nausea and vomiting epigastric pain headache visual disturbances Blood tests may show: reduced platelets, elevated urate (normal range is gestation dependent) urea & creatinine, LFT abnormalities, DIC

8. Quality Education for a Healthier Scotland Multidisciplinary Maternal Complications of PET Placental abruption (1-4%) DIC/HELLP syndrome (10-20%) Pulmonary oedema/aspiration (2-5%) Acute renal failure (1-5%) Eclampsia (<1%) Liver failure/rupture/haemorrhage (<1%) Stroke (rare, but the most common cause of maternal death) Death (Sibai et al., Lancet 2005)

9. Quality Education for a Healthier Scotland Multidisciplinary Maternal Complications of PET

10. Quality Education for a Healthier Scotland Multidisciplinary Maternal Complications of PET

11. Quality Education for a Healthier Scotland Multidisciplinary Maternal Complications of PET

12. Quality Education for a Healthier Scotland Multidisciplinary Maternal Complications of PET

13. Quality Education for a Healthier Scotland Multidisciplinary Cause of death1985- 87 1988-901991- 93 1994- 96 1997- 99 2000-022003-052006-08 Cerebral 111457791214 Pulmonary 11101182100 Hepatic 11032023 Other 32425442 TOTAL 27 20 16141819 Maternal Mortality and PET

14. Quality Education for a Healthier Scotland Multidisciplinary Antihypertensive Medication Should be given when the systolic BP is >150 mmHg or the diastolic BP is >110 mmHg (CEMD, 2011) Chronic hypertension oral methyldopa oral labetalol oral nifedipine(oral hydralazine) Acute hypertension intravenous labetalol oral nifedipine intravenous hydralazine The drugs of choice will depend on local guidelines and protocols

15. Quality Education for a Healthier Scotland Multidisciplinary Fulminating Pre-eclampsia Manage in appropriate surroundings Involve senior clinicians and have protocols: communication and documentation is crucial 1.Control blood pressure (see flow chart) 2.Monitor fluid balance 3.Commence seizure prophylaxis (MgSO 4 ) 4.Arrange delivery

16. Quality Education for a Healthier Scotland Multidisciplinary Fluid Balance Involve anaesthetic colleagues if possible Start fluid balance chart (input-output) Insert a urinary catheter Replace blood loss from delivery Restrict maintenance input to 1 ml/kg/hr, to a maximum of 85 ml/hr (inclusive of all infusions) A urine output of > 100 ml in 4 hours should be achieved CVP monitoring requires expertise and should be regarded as an adjunct to clinical assessment Assess regularly for clinical signs of pulmonary oedema

17. Quality Education for a Healthier Scotland Multidisciplinary Intrapartum Management Delivery is the only cure for PET Timing can be difficult if preterm Mode of delivery - parity, gestation, Bishop score, presentation, severity of disease Platelet count and (?) coagulation screen before siting epidural or spinal Avoid ergometrine/Syntometrine for 3rd stage Postpartum thromboprophylaxis.

18. Quality Education for a Healthier Scotland Multidisciplinary Seizure Prophylaxis The Magpie Trial (Lancet 2002: 359:1877–90) Women allocated magnesium sulphate had a 58% lower risk of eclampsia (95% CI 40-71), than those allocated placebo (40, 0.8% vs 96, 1.9%; 11 fewer women with eclampsia per 1000 women) Magnesium treatment did not improve perinatal morbidity or mortality.

19. Quality Education for a Healthier Scotland Multidisciplinary Eclampsia: Management Seizure starts Call for help Arrival of staff STATE ECLAMPTIC FIT Correct pt positioning Airway management Delivery of oxygen Intravenous access Pharmacological intervention Monitoring Oxygen saturation BP ECG Blood glucose CTG Renal function (catheter) Mg Toxicity Delivery plan ‘Simulation training resulted in enhanced performance with higher rates of completion for basic tasks, shorter times to administration of magnesium sulfate and improved teamwork’’ Ellis et al., 2008

20. Quality Education for a Healthier Scotland Multidisciplinary ECLAMPSIA BOX

21. Quality Education for a Healthier Scotland Multidisciplinary Summary Pre-eclampsia is common Risk factors should be sought at booking and reviewed throughout pregnancy Always check urine for protein at every visit Anihypertensive medication should be given when the blood pressure is: systolic >150 mmHg, diastolic >110 mHg or mean arterial pressure >125 mmHg In the management of fulminating pre-eclampsia: control blood pressure, monitor fluid balance, consider seizure prophylaxis and arrange delivery

22. Quality Education for a Healthier Scotland Multidisciplinary Case study Critically appraise this patient’s management: A 41 year old primigravida, whose BMI was 36, booked for antenatal care with her midwife in a rural and remote antenatal clinic at 12 weeks’ gestation. Her ‘booking’ BP was 100/50 mmHg. At her final antenatal check with her midwife (39 weeks’ gestation), her BP was 136/86 mmHg. Urinalysis was not performed because she had failed to bring a specimen. Arrangements were made to review her at term+8 days. Risk assessment – what risk factors for pre-eclampsia did this lady have? Discuss her last antenatal clinic appointment.

23. Quality Education for a Healthier Scotland Multidisciplinary She presented to her local antenatal clinic several days later with headache, epigastric pain and a BP of 162/104 mmHg. She had ++++ proteinuria. Discuss how and where this woman should be managed.

24. Quality Education for a Healthier Scotland Multidisciplinary She was transferred the the nearest consultant-led maternity unit where the hypertension (160/102) was confirmed. ‘BP bloods’ were sent by the FY2 doctor, who gave her oral labetalol 200mg and admitted her to an antenatal ward. (Discuss this management.)

25. Quality Education for a Healthier Scotland Multidisciplinary She subsequently had an eclamptic seizure. How should an eclamptic seizure be managed?

26. Quality Education for a Healthier Scotland Multidisciplinary She was in fact treated with i.v. hydralazine and an i.v. bolus of Diazemuls and underwent caesarean section for fetal distress. After delivery, her BP was poorly controlled with a maximum pressure of 174/116 mmHg. (Discuss)

27. Quality Education for a Healthier Scotland Multidisciplinary Her blood pressure rose to 180/120 mmHg despite combined therapy with i.v. labetalol and hydralazine, and shortly afterwards she became unresponsive. She was then seen by a consultant obstetrician for the first time since admission. A CT scan showed an intracranial haemorrhage, from which she subsequently died. (Discuss)

28. Quality Education for a Healthier Scotland Multidisciplinary Any Questions?

29. Quality Education for a Healthier Scotland Multidisciplinary Summary Pre-eclampsia is common Risk factors should be sought at booking and reviewed throughout pregnancy Always check urine for protein at every visit Anihypertensive medication should be given when the blood pressure is: systolic >150 mmHg, diastolic >110 mmHg or mean arterial pressure >125 mmHg In the management of fulminating pre-eclampsia: control blood pressure, monitor fluid balance, consider seizure prophylaxis and arrange delivery