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Case 2 ALSO(UK) –June 2007. Case Presentation BP. History. 19 year old G1 P0+0 39 weeks - antenatal care outside your area Contractions 3-4 in 10 minutes Pregnancy uncomplicated - except 1st trimester UTI Excessive weight gain during pregnancy Recent generalized oedema

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Case 2 ALSO(UK) –June 2007


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case presentation bp
Case Presentation BP

History

19 year old G1 P0+0

39 weeks - antenatal care outside your area

Contractions 3-4 in 10 minutes

Pregnancy uncomplicated - except 1st trimester UTI

Excessive weight gain during pregnancy

Recent generalized oedema

PMH etc – nil of note

on examination

Case Presentation BP

On Examination

Facial & generalised oedema +++

Admission BP = 164/102 (repeat 160/100)

Urine = +++ protein

VE :Cervix = 4 cm dilated, 100% effaced,

station ‘0’, membranes intact

- contractions 3-4 in 10 mins,

- baseline FHR = 140bpm

- normal variability, no decelerations

slide4

Case Presentation BP

What concerns you about with this situation?

  • likely to have severe pre-eclampsia

 both fetal & maternal risks such as

      • risk of ECLAMPSIA
      • intracranial haemorrhage
      • risk of pulmonary oedema (iatrogenic fluid overload)
      • hepatorenal failure
slide5

Case Presentation BP

How would you calculate the MAP?

  • Diastolic + [1/3 the difference between systolic and diastolic]

2. [Systolic + twice the diastolic] then divide by 3

slide6

Case Presentation BP

What lab investigations would you order?

Full Blood Count

(Coagulation)

Group & Save for X-match

Urea, Creatinine & Electrolytes

Liver Function Tests

Urate

MSU (inc Gram Stain)

slide7

Case Presentation BP

What other data do you need at this point?

  • her handheld antenatal records
slide8

Case Presentation BP

Would you give antihypertensive and/or magnesium sulphate at this point?

  • Antihypertensives – probably not at this stage as MAP<125 (actually 120) & asymptomatic. However, persistent systolic BP >160mmHg should be treated
  • Magnesium Sulphate – most units would start MgSO4 at this stage (ref MAGPIE study)

…. IN THIS CASE, NEITHER IS GIVEN…..

30 minutes later

Case Presentation BP

30 minutes later…

While awaiting laboratory results, you are called urgently to delivery suite

The patient has a grand mal seizure that lasts about 1 minute

CTG shows a fetal bradycardia of 80 bpm

after the seizure

slide10

Case Presentation BP

What would you do at this point?

CALL FOR HELP +++++

INITIATE BASIC ABCs

remember left lateral tilt!!

‘A’ – airway can’t be inserted during a fit

‘C’ – includes x2 large bore cannulae

Initiate unit ‘Eclampsia protocol’

DO NOT NURSE IN THE DARK!!

Give loading dose MgSO4(…what dose?)

Foley catheter/fluid balance ( rate IV fluid?)

Keep NBM – review need to treat BP

slide11

Case Presentation BP

Would you use diazepam to shorten the fit?

  • NO – most fits are self-limiting
  • avoids ‘polypharmacy’
  • diazepam kept for recurrent fits or when MgSO4 unavailable (e.g. pre-hospital care)
slide12

Case Presentation BP

What is the significance of the fetal

bradycardia?

  • occurs frequently during aneclamptic fit
  • proceeding to immediate LSCS because of the bradycardia MAY ENDANGER THE MOTHER’S LIFE
  • stabilise the mother - ‘Resuscitating the mother will resuscitate the fetus’
slide13

Case Presentation BP

How would you deliver when stable - LSCS versus induction with vaginal delivery?

Labour induction can usually be considered if:

  • gestation >32 weeks
  • cervix reasonably favourable (i.e. delivery likely within 12 hours) – cervix is often favourable in pre-eclampsia
  • fetal condition stable (i.e. no severe IUGR)
after the seizure

Case Presentation BP

After the seizure...

Meticulous attention to fluid balance -

intake / output assessed hourly

  • 4g loading dose MgSO4 then infusion at 1-2 g/hr
  • Total IV fluids limited to 80-85ml/hr or 1 ml/kg/hr
  • Foley catheter
slide15

Case Presentation BP

Fetal bradycardia recovers with control of seizures, oxygen and left lateral positioning

Contracting 4-5 in 10; lasting 60-90 seconds

ARM - meconium-staining

FHR = 160bpm with decreased variability

Consultant Anaesthetist / Obstetrician and theatre aware of situation

BP = 180/110 (what is the MAP now ?)

133

slide16

Case Presentation BP

What would you do next?

  • Control Blood Pressure
  • Analgesia as appropriate
slide17

Case Presentation BP

Are you worried about her blood pressure?

YES – in this case, BP>180/110 and/or MAP>125 puts maternal CNS at risk (intracranial haemorrhage)

slide18

Case Presentation BP

How would you control the blood pressure?

  • can you name 2 drugs you could consider using?
      • SL Nifedepine
      • IV hydralazine (bolus +/- infusion)
slide19

Case Presentation BP

Will the MgSO4 itself lower the BP?

NO – it is primarily for seizure prophylaxis

slide20

Case Presentation BP

What are the signs of magnesium toxicity?

IN ORDER

loss of reflexes

somnolence

respiratory depression

paralysis

finally cardiac arrest

slide21

Case Presentation BP

What is the antidote for magnesium toxicity?

Calcium gluconate 1g IV over 3 minutes

(10mls 10% calcium gluconate)

slide22

Case Presentation BP

What action should be taken for absent reflexes?

Stop MgSO4 until reflexes return

slide23

Case Presentation BP

What action should be taken for

respiratory depression / somnolence?

  • Stop MgSO4
  • Give O2
  • Recovery position (as reduced level of consciousness)
  • Monitor closely
case presentation bp1
Case Presentation BP

What action should be taken for

respiratory arrest?

  • Initiate BLS
  • Intubate/ventilate immediately
  • Stop MgSO4
  • I.V. calcium gluconate
slide25

Case Presentation BP

What action should be taken for cardiac arrest?

  • Initiate Basic Life Support

Airway

Breathing - ventilate

Circulation – CPR

  • Stop MgSO4
  • I.V. calcium gluconate
  • If antenatal  immediate Caesarean Section
the blood results return

Case Presentation BP

The blood results return…

Observations BP 140/95

Pulse - 90bpm

Resp rate - 12/min

Temp - 37.8°C

Urine output 30ml over past hour

Blood results Hb 12.0g/dl

WBC 21x109

Platelets 185x109

Coagulation normal / LFTs Normal

Magnesium level is therapeutic

slide27

Case Presentation BP

The patient has another grand mal seizure

What would you do next?

  • general supportive measures (ABCs)
  • second bolus MgSO4 (2g) should be given even if levels are therapeutic, as long as no signs of toxicity
  • consider another neuroleptic or GA if seizures continue despite second bolus
slide28

Case Presentation BP

Would you deliver – if so how?

  • once stable, delivery by urgent LSCS may be appropriate after this 2nd fit (assuming vaginal delivery is not imminent)
slide29

Case Presentation BP

Is she septic ?

(T = 37.8°C WCC = 21 x 109)

NO -  WCC and pyrexia are more likely related to the grand mal fit

Should antibiotics be started ?

NO - unless there are other overt signs of infection

slide30

Case Presentation BP

Does she have HELLP syndrome?

NO – HELLP typically presents with:

Haemolysis

Elevated Liver enzymes (ALT/AST)

Low Platelets

the delivery and then

Case Presentation BP

The delivery… and then?
  • VE confirms cervix 7cm dilated
  • Oxytocin augmentation
  • Normal delivery within 1 hour
  • Healthy 3.8kg baby boy
  • Apgars = 6 (1 min) + 9 (5 min)
  • Placenta delivered & appears intact
  • No uterine atony or perineal trauma
post delivery

Case Presentation BP

Post-delivery

When would you discontinue MgSO4?

  • continue for minimum 24 hours post-delivery (possibly 48 hours if recovery is protracted)
  • More than 40% of all eclampsia occurs post-delivery
post delivery1

Case Presentation BP

Post-delivery

If uterine atony occurs, what drugs would you use?

  • oxytocin 5-10 units (slow IV bolus) + IV infusion
  • prostaglandins - misoprostol 600-800 mikrograms (PR)
  • ERGOMETRINE - usually avoided because of unpredictable BP ‘spikes’, BUT MAY BE NECESSARY IN INTRACTABLE, SEVERE ATONIC BLEEDING
final question

Case Presentation BP

Final question….

Would you have changed treatment of initial fit given a history of grand mal epilepsy?

  • NO – still give MgSO4because of possibility of eclampsia
  • remember the old adage – “every fit in mid/late pregnancy is an eclamptic fit until proven otherwise”