Magnesium Sulphate in Obstetric Care

Severe Hypertension & Eclampsia

• This presentation covers diagnosis and management of hypertensive disorders in pregnancy, including severe hypertension, pre-eclampsia, and eclampsia.
• Recaps diagnosis and management strategies for hypertensive disorders of pregnancy.
• Details emergency management for severe hypertension, severe pre-eclampsia, and eclampsia.
• Includes updates from the 2019 NICE guideline on hypertension in pregnancy and MBRRACE-UK reports and recommendations (2019 & 2023).
• Highlights human factors considerations.

Scope of Problem

• One in ten pregnant women experience high blood pressure.
• Up to 6% of UK pregnancies are affected by pre-eclampsia.

Case Study

• A woman, at 30 weeks pregnant, presented with 3+ proteinuria. Blood pressure was not recorded. At 32 weeks, she reported feeling unwell and reduced fetal movement. BP was recorded at 210/140 with 3+ proteinuria. She was treated with nifedipine and transferred.
• Critical care was not provided immediately.
• Blood pressure was not recorded for three hours later.
• No MOEWS chart was completed.
• She died from an intracranial hemorrhage.
• Recommendations include baseline antenatal care with routine BP checks, appropriate escalation using IWEWS charts, and seeking senior support if concerns arise about patient care.

Maternal Mortality

• Maternal mortality remains low (0.3/100,000) but is four times higher than in 2012 (MBRRACE 2022).
• Causes of maternal deaths include COVID-19, cardiac disease, sepsis, neurological conditions, other indirect causes, hemorrhage, early pregnancy deaths, pre-eclampsia, amniotic fluid embolism, malignancies, anesthesia, and psychiatric disorders.

MBRRACE-UK 1997-2020 Data

• Causes of death related to pre-eclampsia between 1997 and 2020 are detailed, showing frequencies for intracranial hemorrhage, eclampsia/cerebral oedema, pulmonary oedema, hepatic rupture, hepatic necrosis/HELLP, and AFLP.

MBRRACE-UK 2018-2020 Data

• Eight women died from hypertensive disorders during or up to six weeks after their pregnancies.
• Two women died following intracranial hemorrhage in association with HELLP syndrome.
• Two died of acute fatty liver of pregnancy, and two died of eclamptic seizures.
• Two died from pulmonary edema (neither death was associated with intravenous fluid administration).
• The care of three women who died was potentially impacted by pandemic-related issues.

MBRRACE-UK 2019 Data

• 6 women died from hypertensive disorders between 2015-2017.
• Improved care could have made a difference in their outcomes.
• Comnencing aspirin from 12 weeks is important for eligible women.

Indications for Aspirin from 12 Weeks

• High Risk factor: Hypertensive disorder in previous pregnancy, chronic kidney disease, autoimmune disease (e.g., SLE or antiphospholipid syndrome), type 1 or type 2 diabetes, or chronic hypertension.
• Moderate risk factors (two or more): Primip, age 40 or older, pregnancy interval >10 years, BMI of 35 or more at booking, family history of pre-eclampsia, or multi-fetal pregnancy.

Definitions (Essential/Chronic Hypertension, Gestational Hypertension, Pre-eclampsia, Severe Pre-eclampsia, Eclampsia)

• Clear definitions are provided for each term regarding blood pressure levels and proteinuria.

Pre-eclampsia Signs and Symptoms

• Common pre-eclampsia symptoms include frontal headache, visual disturbances (blurring or flashing), vomiting and epigastric pain, sudden swelling of face, hands, or feet, reduced fetal movements, and abdominal pain with or without vaginal bleeding.

Maternal and Fetal Complications

• Presents a range of possible maternal and fetal complications associated with preeclampsia, including intracranial hemorrhage, placental abruption and DIC, eclampsia, HELLP syndrome (hemolysis, elevated liver enzymes, low platelets), renal failure, pulmonary oedema, and acute respiratory arrest; fetal complications include restricted growth, oligohydramnios, hypoxia from placental insufficiency, abruption, and preterm birth.

Intracranial Haemorrhage

• Still rare in pregnancy but for every 100 women who experience a hemorrhage, 96 will have a blood pressure >160/110 mm Hg.
• BP of 160/110 mm Hg in a pregnant or postpartum woman is considered an emergency.

Managing Severe Gestational Hypertension

• Treatment protocols and monitoring guidelines for severe gestational hypertension (BP ≥ 160/110) are provided, including admission, treatment stabilization, blood pressure monitoring, urine testing, and other tests.
• Detailed information on the management of the disease during pregnancy are provided.
• Guidance on the management of severe pre-eclampsia is provided.

Managing Severe Pre-eclampsia

• Provides a checklist for managing severe pre-eclampsia, including preparation, assessment, stabilization, monitoring, and planning.

Eclampsia Emergency Box

• Essential items for managing eclampsia in an emergency setting are listed.

Stabilizing Eclampsia

• Steps to stabilize patient condition, including blood pressure control and seizure prevention.

Magnesium Sulphate

• Magnesium Sulphate regimens for loading and maintenance doses, as well as administration guidelines are provided.

Postnatal Care

• Postnatal considerations for management of gestational hypertension, including continuing medication and reducing dosage if appropriate.
• Information for patients experiencing hypertensive disorders during pregnancy are provided.

Postnatal Considerations

• Postnatal care considerations for women with gestational hypertension/pre-eclampsia.

Key Learning Points

• Important takeaways regarding the management and recognition of severe pre-eclampsia and eclampsia, including BP measurement strategies, the critical role of specialists, the importance of aspirin for high-risk women, and causes of death related to hypertensive disorders
• Emphasizing the need for clear communication between the staff and use of standard tools in the procedure.

Key Clinical Points

• Emphasizing the importance of accurate BP measurement, considering VTE, and recognizing headaches as a potential warning sign.

This quiz covers the use of Magnesium Sulphate for primary prophylaxis in eclampsia, including its loading and maintenance doses, monitoring parameters, and responses to toxicity. Test your knowledge on maternal care and the latest practices regarding hypertensive disorders in pregnancy.