PROMPT Annual Update - Severe Hypertension & Eclampsia PDF

Severe hypertension & eclampsia Heather Helen September 2024 Session objectives Recap on diagnosis and management of hypertensive disorders of pregnancy Emergency management of severe hypertension, severe pre- eclampsia and eclampsia Updates from the 2019 NICE guideline – hypertension...

Severe hypertension & eclampsia Heather Helen September 2024 Session objectives Recap on diagnosis and management of hypertensive disorders of pregnancy Emergency management of severe hypertension, severe pre- eclampsia and eclampsia Updates from the 2019 NICE guideline – hypertension in pregnancy Updates from MBRRACE-UK reports and recommendations (2019 & 2023 reports) Human factors considerations (highlighted by helicopter symbol) Scope of problem Infographics from Action on pre-eclampsia (APEC) and Tommy’s  MBRRACE – UK 2016: Case history “A woman was seen at the antenatal clinic at 30 weeks’ gestation with 3+ proteinuria. Her blood pressure was not recorded. At 32 weeks she presented feeling unwell and with decreased fetal movements. She had 3+ proteinuria and BP 210/140. She was reviewed by a junior doctor and treated with nifedipine. She was transferred to the antenatal ward. One-to-one care was not provided. Her blood pressure was not recorded until three hours later. No MOEWS chart was completed. She died from an intracranial haemorrhage.” Recommendations: Importance of baseline antenatal care e.g routine BP check, though should have been prompted by proteinuria Appropriate escalation & use of IWEWS charts Midwives should seek senior support if they have concerns about care SPECIFIC communication re BP measurement Maternal Mortality Mortality rate remains low (0.3/100,000) but is four times higher than in 2012 (MBRRACE 2022) MBBRACE 2023 MBRRACE-UK 1997-2020 Cause of death relating to pre-eclampsia (Bunch & Knight 2022) MBRRACE –UK-2022 In 2018-2020 8 women died from hypertensive disorders of pregnancy, all either during pregnancy or up to six weeks after the end of pregnancy​ 2 women died following intracranial haemorrhage in association with HELLP syndrome​ 2 died from acute Fatty Liver of Pregnancy​ 2 died of eclamptic seizures 2 women died from pulmonary oedema (both died at home and neither woman's death was associated with IV fluid administration​ The care of 3 women who died was potentially impacted by pandemic-related factors, including remote consultation and concern around hospital attendance (Knight et al 2022) MBRRACE-UK - 2019 6 women died from hypertensive disorders between 2015 - 2017 In all cases improvements in care may/would have made a difference in outcome Importance of commencing Aspirin from 12/40 for eligible women Indications for aspirin from 12 weeks One HIGH risk factor: Two or more MODERATE risk factors: Hypertensive disorder in previous Primip pregnancy Age 40 or older Chronic kidney disease Pregnancy interval >10 years Autoimmune disease (e.g. SLE or BMI of 35 or more at booking visit antiphospholipid syndrome) Family history of pre-eclampsia Type 1 or type 2 diabetes Multi-fetal pregnancy Chronic hypertension Hypertensive disorders - recap Definitions 1 Essential / Chronic Gestational hypertension hypertension = Hypertension diagnosed = New diagnosis of hypertension before pregnancy or 20/40 For both: No proteinuria Mild/ Moderate: BP ≤ 159/109 mmHg Severe: BP ≥ 160/110 mmHg Definitions 2 Pre-eclampsia = New hypertension >20/40 + significant proteinuria Urinalysis ≥ 1+ protein or PCR ≥ 30mg/mmol Severe pre-eclampsia = pre-eclampsia With severe hypertension +/- symptoms +/- biochemical or haematological impairment Eclampsia = Convulsive condition associated with pre-eclampsia Pre-eclampsia signs and symptoms Frontal headache Visual disturbance – blurring or flashing Vomiting and epigastric pain Sudden swelling of face, hands or feet Reduced fetal movements Abdominal pain +/- vaginal bleeding (placental abruption) Maternal complications Intracranial haemorrhage Placental abruption & Disseminated Intravascular Coagulation (DIC) Eclampsia HELLP syndrome: - Haemolysis, elevated liver enzymes & low platelets Renal failure Pulmonary Oedema Acute respiratory arrest Intracranial haemorrhage Still rare in pregnancy (15:1,000,000 pregnancies) However for every 100 women who have a haemorrhage, 96 of them will have blood pressure >160/110mmHg BP ≥ 160/110 mmHg in a pregnant woman or postnatal woman is an emergency Fetal complications with pre-eclampsia Intrauterine growth restriction Oligohydramnios Hypoxia from placental insufficiency Placental abruption Preterm birth Infographic from Action on pre-eclampsia (APEC) Managing Severe hypertension  Managing severe gestational hypertension: BP ≥ 160/110 Treat: Admit and treat until BP stabilised Follow NICE guidance/Severe hypertension algorithm Aim for BP of 135/85 mmHg or less on treatment** Monitor: **Improved implementation required from MBRRACE-UK 2019 BP ever 15-30 minutes until 60mg) of immediate-release nifedipine Moreover, immediate-release nifedipine should be avoided in women with renal disease, where precipitous drops in blood pressure could be harmful Managing Severe pre-eclampsia Management of severe pre-eclampsia Eclampsia emergency box  Stabilise 1. Control blood pressure 2. Prevent seizures: Consider Magnesium sulphate if birth is planned within the next 24 hours and one or more of these features of severe PET are present: Ongoing or recurring severe headaches Visual scotomata Nausea/vomiting Epigastric pain Oliguria and severe hypertension Progressive deterioration of blood tests 3. Escalate & involve senior obstetrician and anaesthetist Magnesium Sulfate: Emergency regimen When to consider Magnesium Sulphate Primary prophylaxis Women with severe pre-eclampsia where birth is planned within the next 24 hours Secondary prophylaxis After eclamptic fit Should be continued for 24 hours from time of commencement or for 24 hours after delivery Magnesium Sulphate Loading Dose- Saolta Loading dose: 4g Magnesium Sulphate in 50mls of Water for Infection over 15-20 mins SLOWLY Observe for magnesium toxicity Antidote to Mg2+ toxicity: 10mls of 10% solution Calcium Gluconate IV over 10mins (See Guideline on Q pulse and Flow charts in emergency trays) Check patellar reflexes after loading dose Note: The same dose is used for the prevention of seizure recurrence in eclampsia and the prevention of seizures in pre-eclampsia. Magnesium Sulphate: Loading Dose Maintenance Dose Magnesium Sulphate (MgSO4) Dose 1 g/hr for 24 hours NB. Magnesium sulphate infusions should only be administered in Labour Ward, Theatre or HDU. Maintenance infusion of Magnesium Sulphate: Magnesium Sulphate 20g in 500ml water for injection This should be administered via a volumetric pump at a rate of 25ml/hour (i.e. magnesium sulphate 1g/hour ). Continuous infusion for 24 hours or until 24 hours after delivery or last sesizure- whichever is the later. Magnesium Sulphate: Maintenance Dose  Magnesium Sulfate management Should be continued for 24hrs from starting, or for 24hrs after birth Monitor hourly urine output, deep tendon reflexes and respiratory rate Signs of toxicity: Loss of deep tendon reflexes Double Vision Slurred Speech Respiratory depression Respiratory arrest Cardiac arrest **Magnesium Sulphate is excreted by the kidneys and therefore the risk of toxicity is higher with oliguria If toxicity suspected, stop infusion and take blood for MgSo4 levels Confirmed toxicity is an emergency and can be treated with Calcium Gluconate 1g (10ml of 10%) Observations – Magnesium Sulphate Pulse, BP 15 – 30 mins until stable Temperature 2 hourly Respiratory Rate before and after loading dose then hourly Electrocardiograph – during loading dose and until stabilised Pulse oximetry Patellar reflexes – after loading dose then hourly (Triceps / biceps with spinal epidural) Hourly urine output Continuous CTG if appropriate  Monitor: Strict Fluid Balance Excessive fluid input can lead to worsening hypertension, pulmonary and cerebral oedema: Input - Restrict to 1ml/kg/hr or 80ml/hr (unless other ongoing fluid losses e.g. haemorrhage) Hourly urine output measurements - > 100ml/4hrs If oral intake is adequate, IV replacement not necessary Do not pre-load with IV fluids if epidural needed Management of Further Seizures Repeat bolus dose If possible, take bloods for magnesium levels prior to giving bolus dose In some instances 2gms may be administered as a loading does Consider alternative diagnoses for fits Monitor: Maternal Critical Care Manage in a HDU setting, ideally on labour ward Vital signs recorded on IMEWS chart Observations as above Bloods – FBC, U&E, LFT, Clotting, G&S, VBG Should be reviewed at least 4hrly by senior obstetrician If not delivered continuous CTG Plan for labour/birth Stabilise BP before administrating anaesthesia Syntocinon/carbetocin NOT syntometrine/ergometrine for 3rd stage of labour C/S or induction of labour depending on severity of situation and preferences of woman Second stage does not necessarily need to be shortened unless BP not responsive to treatment Postnatally: avoid Non-Steroidal Anti-Inflammatory medications Plan venous thromboprophylaxis (dependent on platelet count) Eclampsia Immediate management of eclampsia Call for help (2222/emergency bell) Declare the emergency / SBAR Get emergency box ABC High flow oxygen Lie mother in left lateral IV access and bloods Commence MgSO4 (same regime as for severe pre-eclampsia) Electronic fetal monitoring Immediate management of eclampsia N.B Remember to don PPE in line with local Trust policies e-learning Postnatal care MBRRACE-UK 2019: Case history ‘A woman had raised blood pressure in labour and was given a single dose of oral therapy. She went home shortly after birth, without treatment and had no postnatal checks of her blood pressure. She had a cerebral haemorrhage at home.’ Recommendation: Any woman treated with anti-hypertensive medication antenatally/intrapartum requires additional postnatal BP checks, and to continue anti-hypertensives until hypertension has fully resolved. MBRRACE 2023 Postnatal considerations: gestational hypertension and PET Continue antihypertensives if they were required Advise women that the duration of postnatal treatment will usually be similar to the antenatal Reduce medication if BP falls below 130/80 All woman should have a care plan outlining: 1. Who will provide follow up care recommended review by GP at 2/52 postnatal if on medication All women should have a review by GP at 6-8 weeks 2. Frequency of BP monitoring 3. Thresholds for reducing or stopping treatment 4. Indications for referral to primary care for BP review 5. Self monitoring for symptoms Key learning points Mind the gap: - BP measurement and urine need to be measured at each antenatal interaction - All women need a clear postnatal care plan - Seek input from seniors and other specialists in severe pre-eclampsia/if women are deteriorating - Commence aspirin from 12/40 for at risk women The leading cause of death from hypertensive disorders in pregnancy is intra-cerebral haemorrhage: - BP >160/110 is an emergency and requires prompt treatment and escalation - Communication between staff should include exact BP measurements  Key clinical points Some automated BP monitoring systems underestimate systolic BP in pre-eclampsia - If in doubt use a manual BP measurement Remember to consider VTE prophylaxis – VTE is the leading direct cause of death in pregnancy, and hypertensive conditions are a risk factor *do not give low molecular weight heparin in thrombocytopenia or if birth planned within 12 hours Headache of sufficiency to seek medical attention >20/40 is PET unless proven otherwise: - Beware misdiagnosing migraines in these women - Perform neurological examination & assessment for neck stiffness in all pregnant women with new onset headaches or headaches with atypical features, particularly focal symptoms References Bunch K and Knight M on behalf of the MBRRACE-UK Maternal Mortality in the UK 2018-2020 Surveillance and Epidemiology. In Knight M, Bunch K, Patel R, Shakespeare J, Kotnis R, Kenyon S, Kurinczuk JJ (Eds.) on behalf of MBRRACE- UK. Saving Lives, Improving Mothers’ Care Core Report - Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2018-20. Oxford: National Perinatal Epidemiology Unit, University of Oxford 2022: p2-20. Bunch K and Knight M on behalf of the MBRRACE-UK Maternal Mortality in the UK 2019-2021 Surveillance and Epidemiology. In Knight M, Bunch K, Patel R, Shakespeare J, Kotnis R, Kenyon S, Kurinczuk JJ (Eds.) on behalf of MBRRACE- UK. Saving Lives, Improving Mothers’ Care Core Report - Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2019-21. Oxford: National Perinatal Epidemiology Unit, University of Oxford 2023: p7-25. Knight M, Harding K, Page L, Rusey N, Holden S, on behalf of the MBRRACE-UK hypertensive disorders chapter writing group Lessons on prevention and treatment of hypertensive disorders. In Knight M, Bunch K, Patel R, Shakespeare J, Kotnis R, Kenyon S, Kurinczuk JJ (Eds.) on behalf of MBRRACE-UK. Saving Lives, Improving Mothers’ Care Core Report - Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2018-20. Oxford: National Perinatal Epidemiology Unit, University of Oxford 2022: p63- 73 NICE (2019) Hypertension in pregnancy. Diagnosis and Management. NICE Guideline NG133. NICE London. Available from: https://www.nice.org.uk/guidance/ng133/chapter/Recommendations#reducing-the-risk-ofhypertensive-disorders-in- pregnancy Royal College of Physicians in Ireland (2016) Clinical Practice Guideline. The management of hypertension in pregnancy. IOG, RCPI & HSE Dublin. Thank you