Case 2 ALSO(UK) –June 2007

1. Case 2ALSO(UK) –June 2007

2. 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

3. 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

4. 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

5. 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

6. 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)

7. Case Presentation BP What other data do you need at this point? • her handheld antenatal records

8. 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…..

9. 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

10. 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

11. 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)

12. 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’

13. 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)

14. 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

15. 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

16. Case Presentation BP What would you do next? • Control Blood Pressure • Analgesia as appropriate

17. 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)

18. 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)

19. Case Presentation BP Will the MgSO4 itself lower the BP? NO – it is primarily for seizure prophylaxis

20. Case Presentation BP What are the signs of magnesium toxicity? IN ORDER loss of reflexes somnolence respiratory depression paralysis finally cardiac arrest

21. Case Presentation BP What is the antidote for magnesium toxicity? Calcium gluconate 1g IV over 3 minutes (10mls 10% calcium gluconate)

22. Case Presentation BP What action should be taken for absent reflexes? Stop MgSO4 until reflexes return

23. 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

24. Case Presentation BP What action should be taken for respiratory arrest? • Initiate BLS • Intubate/ventilate immediately • Stop MgSO4 • I.V. calcium gluconate

25. 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

26. 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

27. 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

28. 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)

29. 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

30. Case Presentation BP Does she have HELLP syndrome? NO – HELLP typically presents with: Haemolysis Elevated Liver enzymes (ALT/AST) Low Platelets

31. 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

32. 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

33. 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

34. 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”