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Preeclampsia: an overview

Preeclampsia: an overview. 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?

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Preeclampsia: an overview

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  1. Preeclampsia: an overview • 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

  10. Pre-eclampsia is more than hypertension & proteinuria Maternal symptoms & laboratory abnormalities Encephalopathy, pulmonary edema, HELLP etc 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

  15. What does this mean to Lao PDR?

  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 co-morbidities genetic factors inadequate placentation endothelial activation

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

  20. Pre-eclampsia: lethal complications

  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 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

  25. Diagnosis, assessment and surveillance • Parity • GA at admission • Systolic blood pressure • Dipstick proteinuria • Symptoms of: • Chest pain/dyspnoea • Headache/visual disturbances • Epigastric pain • Vaginal bleeding with abdominal pain miniPIERS: symptom & sign prediction tool 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 Magee, L.A., et al. How to manage hypertension in pregnancy effectively. British Journal of Clinical Pharmacology 2011 72(3):394-401

  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 Magee, L et al SOGC Clinical Practice Guideline. Magnesium sulphate for fetal neuroprotection JOGC, 2011. 33(5):516-29.

  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 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

  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)

  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

  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

  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

  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

  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 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?

  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?

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