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MRCOG PART 2 SBAs and EMQs

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ESSAY 233 - PRE-ECLAMPSIA

Posted by NIRMALA SARASWA P.
It is a case of Pre eclampsia.The risk of Preeclampsia,to the mother is eclampsia,multiorgan failure,venousthromembolism,caesarean section,disseminated intravascular coagulation.Hypertension in pregnancy is the second most common cause for maternal mortality,according to confidential enquiries of maternal death.The risk of preeclampsia to the fetus,is intrauterine growth restriction,intrauterine death,hypoxia,intrauterine fetal distress.Multidisciplinary management,that include senior obstetrician,physician,senior midwife,anaesthetist,and pediatrician,will improvise the outcome.
This patient,has to be admitted in the labour ward,for close monitoring.Detailed history of headache,nausea vomiting,blurring of vision,and epistric pain are asked for.PR,BP,examination of general well being,abdominal examination for the fundal height,presentation,position of the fetus,and also look into her antenatal notes,to confirm the gestational age,and exclude any other abnormalities.
FBC for Hb,platelet count,24 hr urine for protein,Liver function tests-SGOT,SGPT,urea creatinine,coagulation profile,blood grouping.Ultrasound scan for the fetus ,presentation position,liquour,placenta and estimation of the fetal weight.
BP monitoring 4-6hrly daily,daily urine analysis,and CTG daily for the fetal well being.
Methyl dopa,is the antihypertensive drug of choice,it is safe although, clinician must be aware of its side effects - depression,+direct coomb\'s test,drug rash.B-blockers,cause intrauterine growth restriction so they are contraindicated,calcium channel blockers,nifedepine is an alternative drug which is safe.The side effects are tachycardia,hypotension,palpitations,etc.,
since the fetus is at risk of IUGR,growth scans 2-weekly,umbilical artery doppler,so that,fetal compromise is identified early and appropriate action taken timely.Ultimate treatment is the delivery of the fetus,but the aim of the management is to achieve a healthy fetus,with minimal morbidity to the mother.
Furthur management depends on the results of the investigations and maternal and fetal compromise.If the monitoring parameters are normal and no evidense of maternal or fetal compromise,the pregnacny may be continued until 37weeks,and then induced.
But,if the BP is difficult to control or if the biochemical and hematological parameters are abnormal,associated with symptoms and signs,or evidence of fetal compromise,the pregnancy may be induced regardless of the gestational age.If a decision is taken to deliver, corticosteroids are administered.Betamethasone,12mg,2 doses administered 24 hrs apart,will prevent respiratory distress syndrome,neonatal intraventricular hemorrhage,and the costs of neonatal admission and neonatal care.
If there is evidence of progression of the disease to eclampsia,MAGNESIUM SULPHATE,is administered.It is the drug of choice for eclampsia(magpie trial).Women is informed about the diagnoses and its implications,and information leaflets are provided.Continuous,support from the midwife also may be beneficial as the women may be anxious.
Posted by Sarwat F.
Management will include control of hypertension, preventing complications and optimizing maternal and fetal outcome.
Antihypertensives that can be administered for acute control of hypertension include labetolol, nifedipine and hydralazine. Intravenous route of administration is selected for labetolol and hydralazine. Patient will be explained about the side effects of antihypertensives which include tachycardia, palpitations and headache for hydralazine and nifedipine. Antihypertensive therapy is maintained and converted to oral after blood pressure is stabilized.
Patient will be asked about any symptoms of imminent eclampsia like headache, blurring of vision, edema and epigastric pain. Reflexes will be checked. In case any of the above symptoms are present and there is hyper reflexia intravenous magnesium sulphate infusion is considered.
Patient will be transferred to delivery suite for monitoring. Bloods will be sent for full blood picture, renal function, urea and electrolytes and urates. Coagulation studies are done if platelent count is low.
Management will be multidisciplinary with early involvement of senior obstetrician, anaesthetist and neonatologist. Aim of management is to prevent complications llike eclampsia, cerebrovascular accidents, pulmonary edema and HELLP syndrome. Fluid balance is very important in management of preeclampsia as there is a risk of fluid overload and pulmonary edema. Hospital protocol for management of preeclampsia will be followed.
Her chart will be reviewed for babys growth in previous visits. CTG will be done to ensure fetal well being. As she is only 32 weeks, steroids will be administered as betamethasone 12mg intramuscularly two doses 24 hours apart. Nursery will be alerted in case emergency delivery is needed. In utero transfer may be considered only after stabilization of maternal condition in case neonatal cots are not available.
In case maternal condition becomes stable that is blood presuure comes down and symptoms are improved, she will be shifted back to antenatal ward.
If however her condition does not improve or worsens, delivery will be planned. She will be explained that only definitive treatment of preeclampsia is delivery as it is caused by toxins released from placenta. At 32 weeks chances of vaginal delivery after induction of labour are very low as bishops scoring of cervix is likely to be low. Caesarean section is usually needed. Mother will be explained about both options and decision is made after detailed counseling regarding risks and benefits of caesarean section and induction of labour.
A neonatalogist will be present at the time of delivery as baby is premature and may need nursey admission.
Fluid balance in postpartum period is very important as there is a risk of pulmonary edema so strict input output is maintained. Blood pressure pulse is monitored. Thromboprophylaxis will be administered according to hospital protocol.
Posted by Sarwat F.
Management will include control of hypertension, preventing complications and optimizing maternal and fetal outcome.
Antihypertensives that can be administered for acute control of hypertension include labetolol, nifedipine and hydralazine. Intravenous route of administration is selected for labetolol and hydralazine. Patient will be explained about the side effects of antihypertensives which include tachycardia, palpitations and headache for hydralazine and nifedipine. Antihypertensive therapy is maintained and converted to oral after blood pressure is stabilized.
Patient will be asked about any symptoms of imminent eclampsia like headache, blurring of vision, edema and epigastric pain. Reflexes will be checked. In case any of the above symptoms are present and there is hyper reflexia intravenous magnesium sulphate infusion is considered.
Patient will be transferred to delivery suite for monitoring. Bloods will be sent for full blood picture, renal function, urea and electrolytes and urates. Coagulation studies are done if platelent count is low.
Management will be multidisciplinary with early involvement of senior obstetrician, anaesthetist and neonatologist. Aim of management is to prevent complications llike eclampsia, cerebrovascular accidents, pulmonary edema and HELLP syndrome. Fluid balance is very important in management of preeclampsia as there is a risk of fluid overload and pulmonary edema. Hospital protocol for management of preeclampsia will be followed.
Her chart will be reviewed for babys growth in previous visits. CTG will be done to ensure fetal well being. As she is only 32 weeks, steroids will be administered as betamethasone 12mg intramuscularly two doses 24 hours apart. Nursery will be alerted in case emergency delivery is needed. In utero transfer may be considered only after stabilization of maternal condition in case neonatal cots are not available.
In case maternal condition becomes stable that is blood presuure comes down and symptoms are improved, she will be shifted back to antenatal ward.
If however her condition does not improve or worsens, delivery will be planned. She will be explained that only definitive treatment of preeclampsia is delivery as it is caused by toxins released from placenta. At 32 weeks chances of vaginal delivery after induction of labour are very low as bishops scoring of cervix is likely to be low. Caesarean section is usually needed. Mother will be explained about both options and decision is made after detailed counseling regarding risks and benefits of caesarean section and induction of labour.
A neonatalogist will be present at the time of delivery as baby is premature and may need nursey admission.
Fluid balance in postpartum period is very important as there is a risk of pulmonary edema so strict input output is maintained. Blood pressure pulse is monitored. Thromboprophylaxis will be administered according to hospital protocol.
Posted by AMNA  K.
Severe pre-eclampsia is a rare but serious complication of pregnancy with an incidence of five per thousand maternities in UK. This patient is at risk of eclampsia, placental abruption, intrauterine growth restriction (IUGR) and multi-system involvement. She there for needs in patient treatment with management based on a detailed maternal and fetal assessment, stabilization, continued monitoring and delivery at the optimal time for mother and baby. Senior obstetric, anesthetic and pediatric staff and experienced midwifes should be involved.
This patient?s current symptomatology (headache, visual symptoms, nausea, and right upper quadrant pain) will be enquired and a complete obstetrical, cardio vascular, respiratory and neurologic examination will be carried out. This is done to assess her disease severity. In view of the high false positive rates with dipstick, laboratory testing by 24 hour urine collection is recommended to confirm significant protein urea. Maternal blood tests include a full blood count, liver and renal function test to assess disease severity, to monitor progression and response to treatment. A platelet counts of less then 100 should be a consideration for delivery. An AST level above 75 IU/L is seen as significant and a level above 150 is associated with increased maternal morbidity. Anemia, hemolysis and thrombocytopenia suggest HELLP syndrome. Clotting studies are not required if platelet counts is over 100. Close fluid balance with intake/ output charting is essential as she is at risk of developing pulmonary oedema.
Initial fetal assessment is with cardiotocography which provides daily short-term assessment of fetal well being. Further fetal assessment with ultrasound measurement of fetal size, liquor volume and umbilical artery Doppler should be undertaken as fetus has a 30% risk of being growth restricted (RCOG recommendation). Maternal administration of cortico steroids will be done to reduce neonatal RDS, death and intra cranial hemorrhage. Repeated courses of antenatal steroids are presently not recommended. Anti hypertensive therapy will be started to prevent hypertensive encephalopathy and cerebral hemorrhage. The most commonly used agents for acute management of severe hypertension are labetolol, nifidepine or hydralazine. Methyl dopa and labetolol are the most commonly used drugs for long term control of hypertension. Atenolol (causes IUGR) angeotensin enzyme inhibitors and angeiotensin receptor blockers (cause adverse fetal affects) should be avoided. Diuretics should be reserved for pulmonary odema. Magnesium sulphate for seizure prophalyxis should be given once a decision for delivery has been made and in the immediate postpartum period (RCOG recommendation0

If after 72-96 hours of conservative therapy the patient is stable and A symptomatic then a conservative management plan can be put in place. Maternal monitoring will involve 4 hourly BP charting, daily urine dipstick testing and CTG, twice weekly haematology and biochemistry, weekly 24 hour urinary proteins and fortnightly ultrasound for fetal growth. Umbilical artery Doppler scan should be done for fetal surveillance. Timing of delivery is dependant on adequacy of BP control, degree of protein urea, presence of fetal compromise (fetal distress or growth restriction), worsening maternal bio-chemistry and/or haematology or development of eclampsia. Timing of delivery should be discussed with pediatric and SBCU team especially if the baby is premature.
Posted by Freha Z.
This is a case of pre-eclampsia which is associated with increased fetomaternal mortality and morbidity therefore urgent management is required.
The management is based on careful assessment, stabilization, continued monitering and planning for delivery which is the definitive management of pre-eclampsia.
Management should be done by multidisciplinary team involving obstetrician, anaesthetist, physician and neonatologist.
The signs and symptoms of severe pre-eclampsia should be looked for which may be headcahe, visual disturbance, epigastric pain, liver tenderness and ankle clonus. Full blood count, platelets, Liver, renal function tests and proteinuria should be done. Platelets <100/dl, AST>75IU/L and raised uric acid associated with severe disease. Fetal assessment should be done with CTG in acute setting although does not give predictive information.
Stabilization of blood pressure done by antihypertensive drugs in acute setting by Labetalol or Hydralazine intravenously or oral Nifedipine. Antihypertensive therapy given to reduce risk of cerebral haemorrhage.
Monitering of blood pressure should be done every 15 min in acute setting and every 30 min in initial phase of assessment and 4 hourly if conservative management decided. Haematological and biochemical parameters done every day or more frequently if abnormal.
Once maternal condition is stablised plan of delivery should be made by senior obstetrician. If condition stable delivery can be deferred then corticosteroids ( betamethasone 12mg 2 doses 24 hours apart) given however the decision of conservative management reconsidered after 24 hours and should be carefully balanced against the risk to mother. Because of the risk of intrauterine growth restriction regular growth scans should be done. Umbilical artey dopplers and biophysical profile should be done for fetal assessment where conservative management is planned.
If there is suspicion of risk of eclampsia Magnesium sulphate should be started in the setting where decision of delivery has been made and continued for 12 hours after delivery. Magnesium sulphate is effective in preventation of convulsions.
Posted by Parveen  Q.
This is a case of pre-eclampsia which occurs in 5/1000 maternities in U.K. Previous history of hypertension to know if PET has superimposed, history of any hypertensive medication in the past will reinforce the diagnosis. I will also enguire about headache, blurring of vision, epigastric pain to ascertatin impending eclampsia. The aim of management is to reduce the blood pressure, to prevent complications like pulmonary edema, CVA and DIC , and to improve outcome for the mother and fetus. Multidisclipinary team of obstetrician, anaesthetist, pediatrician and senior midwife should be involved in her care. I will recheck her blood pressure to confirm the high level and korotkoff phase 5 is the appropriate measurement of diastolic blood prssure and document it in the notes. A spot protein creatinine ratio will be done to confirm proteinuria. Her immediate care will involve inpatient admission in the delivery suite, senoir obstetrician will be informed. Basic investigations of FBC, liver function test, urea, electrolytes, uric acid, plate let count done.Blood group and save done. Intake output chart will be maintained to monitor for correct fluid balance. Pulse oximetry for oxygen saturation to assess for pulmonary oedma. 24 hour urine collection for proteinuria. Clotting profile done if platelet is less than 100,000/l. CTG monitoring for fetus intially continously later as dedictated by the clinical condition. High blood pressure is controlled by iv labetalol or hydralazepine,and the side effects are headache, tachycardia. Steriods given betamethasone 12mg 2doses 24 hours apart to prevent respiratory distress syndrome .Magnesium sulphate given as a bolus followed by infusion if there is a risk of eclampsia. the blood pressure ischecked every 15 minutes in acute setting then every 30mts till she is stabilised, less frequently 4hourly when conseravative management is the plan. Blood chemistry repeated daily and more fequently if clinical condition changes or if there is any abnormality in the reading. If her clincal condition improves and the blood pressure is stabilised to diastolic blood pressure of 100 or less, she can be shifted to the antenatal ward and discharged to be followed up in the antenatal clinic. Featal assessment done by umblical artery doppler and amnitic fluid volume. Serial growth scans to rule out IUGR.
If the blood pressure remains high and the clincal condition dteteriorates despite treatment , she should be counselled about definite treatment which delivery in this case. In this case, caesarean section is the best option . paeditrician and theatre satff will be informed. Antihypertensives should be continued after delivery ,as dictated by the blood pressure. she should be carefully assessed for signs and symptoms of ecalmapsia, as 44% of eclampsia occrus postpartum.
Posted by neera  B.
This women has severe preeclampsia so she needs urgent assessment due to high risk of maternal and perinatal complications .
I will review her antenatal notes to confirm maturity from dating scan because she is likely to need preterm delivery .
I will enquire about headache , epigastric pain, nausea , vomiting, blurring of vision and oliguria as these may indicate impending eclampsia. Fetal movements will be asked about.
Clinical examination will be performed for respiratory rate, clonus , liver tenderness, papilloedma as they indicate severity of preclampsia. Fetal lie presentation and Bishop?s score will be assessed because they will help to decide mode of delivery.
Maternal blood will be sent for FBC , urea and electrolytes, aspartate aminotransferase(AST) and ALT. 24 hour urine protein collection will be started .If platelets are low , coagulation profile is sent. In case of epigastric pain or liver tenderness peripheral smear for fragmented RBC and LDH levels are sent to look for hemolysis which occurs in HELLP syndrome. CTG will be done to assess fetal wellbeing. In case conservative management is planned , color Doppler will be done to assess fetal growth , liqor volume and flows.
Multidisciplinary team involving consultant obstetrician , anaesthetist, neonatologist, hematologist and senior midwife will be involved in her care under a single lead clinician in a HDU . Unit protocol will be followed . Two doses of betamethesone 12mg 24 hr apart will be given but I will not necessarily wait for them to act . These decrease the risk of respiratory distress syndrome, IVH, periventricular leucomalacia , NEC and neonatal death. Rapidly acting antihypertensives like intravenous labetolol or hydralazine will be given because they decrease the risk of cerebral hemorrhage . If seizure is imminent , intravenous magnesium sulfate will be started as it prevents seizures . Availability of NICU beds will be enquired and neonatologist will be informed because baby is premature. I shall counsel her about the risk of eclampsia , renal failure, cerebral hemorrhage and intrauterine fetal death with severe PE . Timing of delivery aims to balance risk of prematurity with maternofetal complications. Prognosis of baby will be explained jointly with the neonatologist . Monitoring of blood pressure , pulse, fluid balance , biochemical and hematological indices will be done .Urinary catheter and CVP line will be considered so that accurate fluid balance can be maintained. Thromboprophylaxis risk assessment will be done because preclampsia is a risk factor and thromboprophylaxis offered accordingly.
If maternal condition becomes stable , conservative management can be followed for steroids to have their effect in 24 hrs. But if maternal or fetal condition is not stable, delivery should be hastened by induction of labour or cesarian depending on fetal presentation , fetal condition and Bishop score. Patient is involved in decision making and informed consent is taken.
Posted by Srivas  P.
She is a case of severe pre ecclampsia and according to recent maternal mortality report 2002, hypertension in pregnancy is the second highest cause of maternal death. Complications in severe pre ecclampsia which could contribute to maternal morbidity and death are abruptio placenta, coagulopathy, pulmonary edema, aspiration pneumonia, intra cranial hemorrhage, acute renal failure and liver rupture. Most of these sequelae are following uncontrolled hypertension. So it is imperative that her hypertension is controlled quickly, failing which an immediate delivery is planned.

She needs to be admitted immediately under consultant care.

I will take her history to look for signs of impending ecclampsia?cerebral and visual disturbances, head ache, blurred vision epigastric and right upper quadrant pain. I will review the drugs she has taken so far. I will look at her notes and look for dating scan as I may consider early delivery.

Her B.P, sensorium, edema feet, genl anasarca, liver tenderness and presence or absence of ankle clonus will be noted. P/Abd I will look for fetal lie, presentation, presence of IUGR and any sign of fetal distress on auscultation.

Her base line investigations include FBC, clotting profile, RFT, LFT, platelet count, Fibrinogen, 24 hr urinary protein and 24 hr creatinine clearance. Fetal assessment involves NST, BPP, ultrasound biometry and umbilical artery doppler.

Options for management in this patient with 32 weeks pregnancy with severe PE is either expectant management with immediate control of B.P followed by continued increased maternal and fetal surveillance so as to gain a few more weeks or immediate delivery if B.P is not controlled by medications or if she shows signs and symptoms of impending ecclampsia or the fetus is in jeopardy.

She should have BP 4 hrly, intake-output record and daily monitoring of all biochemical parameters listed. B.P should be immediatelycontrolled with Labetalol, Nifedepine, Hydralazine or Sodium Niroprusside. All are effective and depends on choice of doctor and immediate response. Labetalol is alpha and beta adrenoceptor agonist with rapid action and can be given both orally or intravenously. Nitroprusside and hydralazine can cause precipitate fall in B.P and this can be prevented by prior I/V fluid bolus.

The woman may continue conservatively if B.P gets controlled, Bio chemical parameters remain within normal range and there are no signs of impending ecclampsia and fetus is not compromised.

Factors which indicate immediate delivery include uncontrolled B.P >160/110 despite therapy, elevation in SGOT//SGPT, platelet count <100000/ml, S fibrinogen <150mg/100ml, BUN >30mg/100ml and creatinine clearance <50ml/min along with signs and symptoms of impending ecclampsia. Signs of fetal compromise include non reactive NST, reversal in S/D in Doppler study.

Once decision is taken to deliver her, dexamethasone should be given to prevent and minimize RDS, ICH, NEC in baby. Magnesium sulphate may be given to prevent potential convulsants, NICU should be informed and neonatologist should be briefed, who should counsel parents regarding risks of prematurity to fetus and the care proposed. If NICU beds are not available, arrangements should be in place for ex-utero transfer of baby to tertiary centre.

Mode of delivery should be discussed with consultant and the woman. If Bishop score is favorable, she may be induced with Prostaglandins as vaginal tablets along with continuous electronic fetal monitoring in the labor ward. C,S may be indicated if Bishop score is unfavorable, there is fetal distress or deterioration in maternal condition.

This is a high risk pregnancy and consultant should be involved early and at all stages of decision making.
Posted by sailaja devi K.
Woman is a case of severe preeclampsia. Preeclampsia is associated with risk for women and her fetus. Involves senior obstetrician, anaesthetist and midwife in initial assessment and management of women with severe preeclampsia. Inform consultant obstetrician & anaesthetist.Enquire about complaint of headache, visual disturbance, vomiting and epigastric pain as these are symptoms of preeclampsia,important in management decision. Blood pressure should be measured correctly and consistently. Monitor blood pressure every 15 min until the women is stabilized and then every 30 min in the initial phase. When she is stable and asymptomatic check blood pressure every 4th hour.Check for knee reflexes,pedal edema & vulval edema.
Assesment of the women includes FBC, LFT, RFT. This test should be repeated daily if the results are normal and more often if abnormal.Check for any hemoconcentration. If platelet count is less than 100 X 106 / lt check the clotting studies for any associated coagulation abnormality. Fall in platelet count indicate worsening preeclampsia, risk to mother and need to deliver. Check the liver enzymes AST, ALT. A level above 75 iu/ lt is significiant ,a level above 150iu/ lt increases the morbidity to the mother. Preeclampsia is associated with HELLP syndrome, so consider it if there are elevated liver enzymes, fall in platelet count and haemolysis. If the creatiine is elevated susect renal disease.
Confirm proteinuria with spot urine protein/ creatinine ratio or 24 hour urine protein.
Consider bladder catheterization with an hourly urometer as close fluid balance with input and output chart is essential.

Asses the fetal condition with cardiotocography . CTG is the mainstay of fetal monitoring, it detects fetal well being at that time, can be repeated regularily, easily,is not expensive, no need for skilled person.

Control blood pressure effectively as cerebral haemorrhage is the most common cause of death in preeclampsia. For acute management the drug of choice depends on local unit protocol. Drugs used are labetolol intravenous or oral route or nifedipine orally or intravenous hydralazine can be used for acute management. Labetolol has advantage that it can be given orally. It is not prescribed in asthma. Evidence shows hydralazine is less preferred to labetolol. Sublingual nifedipine is associated with profound hypotension and should not be used.

The women is at risk of eclampsia so consider magnesium sulphate once delivery decision has been made. MAGPIE trial demonstrated that administration of magnesium sulphate in women with preeclampsia reduces the risk of seizure by 58%.
Fluid management in preeclampsia is important as PE is associated with volume overload. Pulmonary edema is cause of death in preeclampsia. Fluid restriction is associated with good outcome.

Consider steroids 12mg injection betamethasone 24 hours apart 2 doses for lung maturity. Steroids decrease respiratory distress in newborn and is not associated with risk of infection.
Fetal monitoring with ultrasound to estimate fetal size, presentation, fetal biophysical profile and Doppler for umbilical artery.
Once stabilized decision to deliver should be made, with involvement of senior obstetrician & discuss with the neonatologist.
Consider in utero transfer if NICU facilities are not available, if SCBU cots are not available and if ICU care for mother is not available. Do not jeopardize maternal safety, may be safer to deliver mother and then transfer mother and baby. Discuss with the women about management decisions, provide written information leaflets & document the same in case notes.