Obstetric Emergencies

Front 1

Define hypertension in pregnancy

Back 1

Largest cause of death - intracranial haemorrhage secondary to uncontrolled hypertension indicating a failure in antihypertensive therapy

Systolic hypertension poses the greatest risk of death and high pressures (>160mmhg) should be treated as a medical emergency

Mild: BP 140-149/90-99

Moderate: BP 150-159/100-109

Severe: BP >160/110

Front 2

What is essential/chronic hypertension?

Back 2

• Hypertension diagnosed before pregnancy or <20/40 wks
  
• Continues during pregnancy
• No proteinuria

Front 3

What is gestational hypertension?

Back 3

• New diagnosis of hypertension in pregnancy >20/40wks
• Sometimes called pregnancy-induced hypertension
• no significant proteinuria

Front 4

What are the definitions are pre-eclampsia?

Back 4

Pre eclampsia: New hypertension >20/40wks and significant proteinuria

Severe pre eclampsia: pre eclampsia with severe hypertension +/- symptoms +/- biochemical or haematological impairment

Eclampsia: Convulsive condition associated with pre eclampsia

Front 5

What are the symptoms and signs of pre-eclampsia?

Back 5

• Headache - if sufficient severity, pre eclampsia until proven otherwise
• Visual disturbance - blurring/flashing
• Severe pain, particularly epigastric pain >20wks gestation is pre eclampsia until proven otherwise
• RUQ +/- vomiting
• Oedema
• >/=3 beats of clonus
• liver tenderness
• HELLP syndrome
• Falling platelet count
• Abnormal liver enzymes
• Abnormal renal function

Front 6

What are the maternal complications of pre eclampsia?

Back 6

• Intracranial haemorrhage - leading cause of death from severe PET in UK
• placental abruption and DIC
• eclampsia
• HELLP syndrome - haemolysis, elevated liver enzymes and low platelets
• Renal failure
• Pulmonary oedema
• Acute respiratory arrest

Front 7

What are the fetal complications of pre-eclampsia?

Back 7

• Intrauterine growth restriction
  
• Oligohydramnios
• Hypoxia from placental insufficiency
• Placental abruption
• Premature delivery
• Placental abruption
• Premature delivery

Front 8

What are the risks for pre eclampsia?

Back 8

High risk:

• Hypertensive disease in previous pregnancy
• CKD
• Autoimmune disease such as SLE or antiphospholipid syndrome
• type 1/2 diabetes
• Chronic hypertension

Moderate risk

• First pregnancy
• maternal age >40y
• BMI >35 at first visit
• Family history pre eclampsia
• multiple pregnancy

Women with 2 x moderate risk or 1 x high risk are advised to take 75mg aspirin from 12 wks to delivery

Front 9

How would you manage hypertension in pregnancy?

Back 9

Moderate pre-clampsia:

• oral labetalol if systolic BP reaches 150-160mmhg

Severe pre-eclampsia (systolic >180mmhg)

• Oral/IV labetalol
• Oral nifedipine
• IV hydralazine

aim to lower the systolic BP to <150mmhg

Front 10

What is the HDU management of pre eclampsia?

Back 10

• Managed on labour ward
  
• Observations (IV access, urine output, BP every 15mins if on treatment and 30min when stabilised
• Should be reviewed at least 4 hourly by obstetrician
• Continuous CTG if not delivered
• HDU chart (adapted MOEWS)
• Strict fluid balance: Input 1ml/kg/hr OR 80ml/hr. Hour;y urine output measurements (>100ml/4 hrs). If oral intake is adequate, IV replacement is not necessary. Do not preload with IV fluids if epidural is needed

Front 11

What is eclampsia and its management?

Back 11

One or more convulsion in association with pre eclampsia. However, most in UK will not have established hypertension or proteinuria prior to seizure.

Magnesium sulphate is drug of choice for management of eclamptic seizure which reduces cerebral vasospasm (less recurrent seizures compared with diazepam and phenytoin)

Can also prevent eclampsia. Do not use diazepam, phenytoin or lytic cocktail as an alternative to MgSO4. Consider magnesium sulphate for primary prophylaxis in women with severe pre eclampsia where birth is planned within the next 24h, or secondary prophylaxis after eclamptic fit. It should be continued for 24hrs from time of commencement or for 24hrs after delivery.

Magnesium sulphate requires hourly urine measurements as it is excreted by the kidneys and therefore the risk of toxicity is higher with oliguria. Hourly deep tendon reflexes and hourly respiratory rate

Third stage: syntocinon should be the routine oxytocic for active management of the 3rd stage in any woman with concerns that BP may be an issue.

Antenatal: beware headaches and epigastric pain - Pre eclampsia until proven otherwise. Measure BP and urinalysis. Assessment of risk in antenatal period - consider aspirin

Front 12

What are the signs for magnesium sulphate toxicity?

Back 12

• Loss of deep tendon reflexes
• Respiratory depression
• Respiratory arrest
• Cardiac arrest

Front 13

What is the emergency management for magnesium sulphate toxicity?

Back 13

1. Call for help
   
2. stop magnesium sulphate
3. start BLS
4. give IV calcium gluconate 1g (10ml of 10%)
5. Intubate early and ventilate until respiration resumes

Front 14

Whats are the long term implications of pre eclampsia?

Back 14

Increased risk of hypertension and its complications in future life

Increased risk of pre eclampsia in future pregnancies