Give an account on principles of management of post partum eclampsia.

Introduction –
Hypertension complicates about 10% of all pregnancies
2 nd most commonest cause of direct maternal death
Preeclampsia complicates 5% of pregnancies.
Preeclampsia is defined as

1. New onset of hypertension (over 140 mmHg systolic or over 90 mmHg diastolic)
2. after 20 weeks of pregnancy
3. and the coexistence of 1 or more of the following new-onset conditions:

Proteinuria

1. urine protein:creatinine ratio of ≥ 30mg/mmol
2. or albumin:creatinine ratio of ≥ 8mg/mmol
3. or at least 1 g/litre [2+] on dipstick testing

Other maternal organ dysfunction:

1. Renal insufficiency (creatinine 90 micromol/litre or
   more, 1.02 mg/dl or more)
2. Liver involvement (elevated transaminases [AST/ALT >
   40 IU/L] with or without right upper quadrant or
   epigastric abdominal pain)
3. Neurological complications such as eclampsia, altered
   mental status, blindness, stroke, clonus, severe
   headaches or persistent visual scotomata. (hyperreflexia is not included)
4. Visual disturbances: scotomatas, blurring of vision,
   flashing lights, double vision, visual halos, transient
   blindness, sudden loss of vision due to retinal
   detachment.
5. Hematological complications such as thrombocytopenia
   (platelet < 150,000/microlitre), disseminated
   intravascular coagulation or haemolysis
6. Uteroplacental dysfunction such as fetal growth
   restriction, abnormal umbilical artery Doppler waveform
   analysis, or stillbirth.

Eclampsia is the convulsive condition associated with Pre eclampsia
Post partum period is defined as the period of time from the delivery of products of conception upto 6 months after the event

Eclampsia is the convulsive condition associated with Pre eclampsia
Post partum period is defined as the period of time from the delivery of products of conception upto 6 months after the event

25% of eclampsia will present in the postnatal period

High blood pressure in the postpartum period is most commonly seen in women with antenatal
hypertensive disorders, but it can develop de novo in the postpartum time frame. By definition this De
Novo Post partum hypertension and PP Pre eclampsia will occur after 48hrs of delivery and can occur upto
4 weeks post partum.
Emerging evidence suggests that severe maternal morbidity is associated with de novo post partum
eclampsia compared to patients who had antenatal hypertension
Principles of management will encompass

1. Identifying patients at risk
2. Monitoring and anticipating Eclampsia
3. Prevention
4. Diagnosis
5. Acute management
6. Immediate post event management
7. Long term management
8. Planning for next pregnancy
9. Monitoring for long term complications

Risk Factors

Atleast 1 High risk Factor

1. hypertensive disease during a previous
   pregnancy
2. chronic kidney disease
3. autoimmune disease such as systemic
   lupus erythematosus or antiphospholipid
   syndrome
4. type 1 or type 2 diabetes
5. chronic hypertension

Atleast 2 moderate risk factors

1. first pregnancy
2. age 40 years or older
3. pregnancy interval of more than 10 years
4. body mass index (BMI) of 35 kg/m2 or
   more at first visit
5. family history of pre-eclampsia
6. multi-fetal pregnancy

Apart from this

1. a patient who has had hypertension during the current pregnancy and
2. those who have had pre eclampsia or eclampsia during the current pregnancy
   should be regarded as a patient with high risk of eclampsia during the post partum period.
   Monitoring

Gestational Hypertension + or meeting risk factor criteria

1. BP daily for the first 2 days after birth
2. BP at least once between day 3 and day 5 after birth
3. BP as clinically indicated
   if antihypertensive treatment is changed after birth.

In women with pre-eclampsia who did not take antihypertensive treatment

1. at least 4 times a day while the woman is an inpatient
2. at least once between day 3 and day 5 afterbirth
3. on alternate days until normal, if bloodpressure was abnormal on days 3–5

In women with pre-eclampsia who took antihypertensive treatment

1. at least 4 times a day
   while the woman is an inpatient
2. every 1–2 days for up to
   2 weeks after transfer to community care until
   the woman is off treatment and has no hypertension

Also,
Advise pregnant women to inform immediately if they experience symptoms of pre-eclampsia.

1. severe headache
2. problems with vision, such as blurring or flashing before the eyes
3. severe pain just below the ribs
4. vomiting
5. sudden swelling of the face, hands or feet
   

Prevention

Gestational Hypertension + or meeting risk factor criteria

1. continue
   antihypertensive
   treatment if required
2. advise women that the
   duration of their
   postnatal
   antihypertensive
   treatment will usually
   be similar to the
   duration of their
   antenatal treatment
   (but may be longer)
3. reduce antihypertensive
   treatment if their blood
   pressure falls below
   130/80 mmHg

In women with pre-eclampsia who did not take antihypertensive treatment

1. Start anti hypertensive treatment if blood pressure is150/100mmHg or higher

In women who have pre eclampsia with mild or moderate hypertension, or after step-down from critical care:

measure platelet count, transaminases and serum
creatinine 48–72 hours after birth or step-down
do not repeat platelet count, transaminases or serum creatinine measurements if
results are normal at 48–72 hours
If biochemical and haematological indices are outside the reference range in
women with pre-eclampsia who have given birth, repeat platelet count,
transaminases and serum creatinine measurements as clinically indicated until
results return to normal.
In women with pre-eclampsia who have given birth, carry out a
urinary reagentstrip
test 6–8 weeks after the birth Offer women who had pre eclampsia and still have
proteinuria (1+ or more) at 6–8 weeks after the birth, a
further review with their GP or specialist at 3months after the birth to assess
kidney function
Consider referring women with an abnormal kidney function
assessment at 3 months for a specialist kidney assessment

In women with pre-eclampsiawho took antihypertensivetreatment

1. continueantihypertensivetreatment
2. consider reducingantihypertensivetreatment if their blood
   pressure falls below140/90 mmHg
3. reduce antihypertensivetreatment if their blood pressure falls below130/80 mmHg

Explain to women with hypertension who wish to breastfeed that:

1. antihypertensive medicines can pass into breast milk

2. most antihypertensive medicines taken while breastfeeding only lead to very low levels in breast
   milk, so the amounts taken in by babies are very small and would be unlikely to have any clinical
   effect
   As antihypertensive agents have the potential to transfer into breast milk:
3. consider monitoring the blood pressure of babies, especially those born preterm, who have
   symptoms of low blood pressure for the first few weeks
4. when discharged home, advise women to monitor their babies for drowsiness, lethargy, pallor,
   cold peripheries or poor feeding
   Offer enalapril to treat hypertension in women during the postnatal period, with appropriate monitoring
   of maternal renal function and maternal serum potassium
   For women with hypertension in the postnatal period, if blood pressure is not controlled with a single
   medicine, consider a combination of nifedipine[3] (or amlodipine) and enalapril[5]. If this combination is
   not tolerated or is ineffective, consider either:
5. adding atenolol or labetalol to the combination treatment or
6. swapping 1 of the medicines already being used for atenolol or labetalol
7. Where possible, avoid using diuretics or angiotensin receptor blockers[5] to treat hypertension in women
8. in the postnatal period who are breastfeeding

Diagnosis
Watch out for pre eclampsia if

1. sustained systolic blood pressure of 160 mmHg or higher
2. any maternal biochemical or haematological investigations that cause concern, for example, a
   new and persistent:
   a. rise in creatinine (90micromol/litre or more, 1mg/100ml or more) or
   b. rise in alanine transaminase (over 70 IU/litre, or twice upper limit of normal range) or
   c. fall in platelet count (under 150,000/microlitre)
3. signs of impending eclampsia
4. signs of impending pulmonary oedema
5. other signs of severe pre-eclampsia – Pre-eclampsia with severe hypertension that does not
   respond to treatment or is associated with ongoing or recurring severe headaches, visual
   scotomata, nausea or vomiting, epigastric pain, oliguria and severe hypertension, as well as
   progressive deterioration in laboratory blood tests such as rising creatinine or liver transaminases
   or falling platelet count, or failure of fetal growth or
6. any other clinical signs that cause concern

MGSO4 –
If a woman in a critical care setting who has severe hypertension or severe preeclampsia has or
previously had an eclamptic fit, give intravenous magnesium sulfate
Consider the need for magnesium sulfate treatment, if 1 or more of the following features of severe pre eclampsia is present:

1. ongoing or recurring severe headaches
2. visual scotomata
3. nausea or vomiting
4. epigastric pain
5. oliguria and severe hypertension
6. progressive deterioration in laboratory blood tests (such as rising creatinine or liver
   transaminases, or falling platelet count).
   Use the Collaborative Eclampsia Trial regimen for administration of magnesium sulfate

• A loading dose of 4 g should be given intravenously over 5 to 15 minutes, followed by an
  infusion of 1 g/hour maintained for 24 hours. If the woman has had an eclamptic fit, the infusion should be continued for 24 hours after the last fit.
• Recurrent fits should be treated with a further dose of 2–4 g given intravenously over 5 to
  15minutes.
• Do not use diazepam, phenytoin or other anticonvulsants as an alternative to magnesium
  sulfate in women with eclampsia.
  

• ANTIHYPERTENSIVES
  Treat women with severe hypertension who are in critical care during pregnancy or after birth immediately with 1 of the following:

1. labetalol (oral or intravenous)
2. oral nifedipine
3. intravenous hydralazine
   In women with severe hypertension who are in critical care, monitor their response to treatment:
4. to ensure that their blood pressure falls
5. to identify adverse effects for both the woman and the baby
6. to modify treatment according to response
   FLUID BALANCE
   In women with severe pre-eclampsia, limit maintenance fluids to 80 ml/hour unless there are other ongoing fluid losses (for example, haemorrhage)
   NEED CRITICAL CARE AND MONITORING IF,

1. eclampsia
2. HELLP syndrome
3. haemorrhage
4. hyperkalaemia
5. severe oliguria
6. coagulation support
7. intravenous antihypertensive treatment
8. initial stabilisation of severe hypertension
9. evidence of cardiac failure
10. abnormal neurology

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