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  ECLAMPSIA / PRE ECLAMPSIA   A dangerous multiorgan disease of pregnancy, concerning hypertension . There are three levels: -   Pregnancy Induced Hypertension - Raised Blood Pressure after the point of viability   Severe Hypertension - two BP readings (15 mins + apart) > 170 systolic or >110 diastolic or >125 MAP   Pre eclampsia - More severe form, coupled with proteinuria with or without oedema or epigastric pain or visual disturbances   Eclampsia - More severe, coupled with seizures and/or coma   Severe Pre eclampsia affects 1% of all pregnancies. Eclampsia affects 4.9 per 1000 maternities . (38% antenatally, 18% intrapartum period, 44% postnatally). Causes  of Pre eclampsia / Eclampsia   There is no known cause  of this disease. However theories are listed below    Genetic disposition    Immunological disorder    Abnormal placental implantation    Platelet activation    Coagulation abnormalities    Cardiovascular system not adapting to pregnancy   Risk factors       Nulliparity    >40 years old    multiple pregnancy    family history    renal disease    chronic hypertension    diabetes     previous pre-eclampsia (with same partner) Signs  of Pre eclampsia    BP >160/180 mmHg systolic or > 110 mmHg diastolic (or >30 mmHg rise from booking BP)    Proteinuria      serum creatinine      urine output  –  ogliuria <500mls a day    Pulmonary oedema    Thrombocytopaenia (reduced platelets)    Hepatic dysfunction     IUGR    Headaches    Visual disturbances    Epigastric pain    Seizures (in Eclampsia)   Symptoms / Effects  of Severe Pre eclampsia    Severe Hypertension AND one or more out of     ++ proteinuria on dipstick (or >1g on 24 hour collection)    <100mls urine in 4 hours (or creatinine >100)    CNS signs  –  altered consciousness, increased muscle tone    Flashing lights, blurred vision    Persistent headaches    Epigastric pain    LFT raised (alanine aminotransferase (ALT) > 50 iu/L)   Symptoms / Effects  of Eclampsia    Convulsion between viability and 10 days postpartum which has no other known cause    Usually preceded by Pre eclampsia or CNS excitability    Usually within 48 hours of delivery   Symptoms / Effects  of HELLP Syndrome , a severe variant of pre eclampsia   H aemolysis Red Blood Cells are damaged as they pass through blood vessels with a damaged endothelium tissue and fibrin deposits   E levated L iver Enzymes Fibrin is deposited in the hepatic sinusoids, creating liver damage and elevated enzymes   L ow P latelets There is a decrease in the life span of the platelets and wide aggregation   Management  of Severe Hypertension    Try to keep BP in region of 140-150 / 90-100    Compare BP with manual sphygmometer (or take with if different)    Use 4th karotkoff sound for diastolic    Avoid sharp drop in BP    Continuous CTG up to 1 hour after BP stable following treatment    Labetalol is first drug of choice    Monitor Fluid Balance hourly  –   total of 85mls per hour in  Too little = renal failure    Too much = pleural effusion    Don’t forget fluid leaks into the extra vascular space    Start 24 hour urine collection    Take bloods    FBC    Urates and electrolytes    Liver Function Test    Clotting (including platelets)     Group and Save  Repeat U&Es and LFT bloods every 6  –  12 hours   Management  of severe pre eclampsia  antenally    Should be in consultant led unit with NICU facilities    Inform relevant staff     Consultant Obstetrician    On call Anaesthetist    Senior Midwife    SCBU / Neonatologist    Mode and Timing of Delivery must be considered    Delay to stabilise woman or to give steroids to mature fetal lungs    Transfer to an area where 1 to 1 care can be given    Labour ward or other high dependency area    Site two large bore venflons    Take bloods    FBC    Urates and electrolytes    Liver Function Test    Clotting (including platelets)    Group and Save  Repeat bloods every 6  –  12 hours    Monitor Mother (at this level until 24 hours after delivery)    Monitor Fluid Balance    Too little = renal failure    Too much = pleural effusion    Don’t forget fluid leaks into the extra vascular space    Catheterise    Indwelling catheter with hourly measurement bag    Send sample for culture  Start 24 hour urine collection    Pulse oximeter & Sats continuously    Blood Pressure every 15 minutes (30 if stable)    Temperature hourly    Dipstick for urine hourly    Monitor fetus    CTG for at least 1 hour 3* daily    If non-reassuring then continuous    Ultrasound scan    Growth and liquor volume    Umbilical Cord Doppler Flow    Deliver    Induce labour    Caesarean Section      Management  of Eclampsia    Call for help    Senior obstetrician    Obstetrician to assist (potential caesarean section)    Anaesthetist    ODP    Senior midwife    Scribe    Paediatrician (if antenatal)    Inform SCBU (if antenatal)    Notify Haematologist    Porter    Turn onto left lateral    Remove pillows    Aspirate material from mouth    Give facial oxygen (10L)    Insert guedal airway (when/if possible)    Give magnesium sulphate    4  –  6g loading dose IV over 15-20 minutes    2g IV for secondary fit    1-3g/hr for maintenance    Cannot use at same time as nifedipine    Diazepam PR (if magnesium fails or no IV access)    Then site IV access if none    Catheterise    Indwelling catheter with hourly measurement bag    Consider delivery (if antenatal)    Monitor mother hourly while on magnesium sulphate    Knee jerk (stop if absent)    Respiratory (stop if <10breaths a minute)    Urine output (reduce to 0.5g/hr if <30mls)    Give antidote to magnesium sulphate    Calcium Gulgonate 10mls of 10% (1g) IV over 3 minutes    Blood levels should be 2-4mmols/l for therapeutic levels    5mmols/l loss of knee jerk reflex, weakness, blurred vision, slurred speech    7.5mmols/l muscle paralysis & respiratory arrest    12mmols/l cardiac arrest   Bloods (order with vaccutainer system as preservatives can affect results)   Blue - Clotting Screen   Yellow - U&Es and LFT   Purple - FBC   Pink - Group & Save  

Tulipmania

Jul 23, 2017
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