postpartum management of preeclampsia

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peripartum management of preeclampsia

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postpartum management of preeclampsia

  1. 1. Postpartum management of preeclamptic womenVeerendrakumar C MAssociate professorDept of OBG,VIMSBellary17 August 2012 veerendrakumar 1
  2. 2. Peripartum care• erratic and fragmented17 August 2012 veerendrakumar 2
  3. 3. Obstetric care provider• Vigilant• Knowledgeable• Competent and• Willing to participate in critical care• Empathetic17 August 2012 veerendrakumar 3
  4. 4. Understanding is changing..17 August 2012 veerendrakumar 4
  5. 5. Pre-eclampsia is more than a disorder of pregnancy• PE is not a ‘benign’ and resolvable condition, and that it is a condition that unmasks an underlying propensity for later cardiovascular problems. Eur J of Ob & Gynecol,160 (2012) 6–1217 August 2012 veerendrakumar 5
  6. 6. Atypical preeclampsia17 August 2012 veerendrakumar 6
  7. 7. • A woman with clinical features of PE such as hypertension thrombocytopenia and liver disease, but without proteinuria is often considered to have ‘atypical’ pre-eclampsia.17 August 2012 veerendrakumar 7
  8. 8. • ….the SOMANZ group, which do not define the necessity to have proteinuria to make the diagnosis of PE…..Lowe SA, Aust N Z J Obstet Gynaecol 2009;49:242–6.17 August 2012 veerendrakumar 8
  9. 9. inclusive approach explains• widespread and variable nature of preeclampsia including maternal liver, renal, platelet and neurological problems.17 August 2012 veerendrakumar 9
  10. 10. Comprehensive critical care• High dependency care and intensive care words to be replaced by CRITICAL CARE Wheatley et al, J ob Anesth 2010 DH document ,London 200017 August 2012 veerendrakumar 10
  11. 11. Critical care• Level 0 -routine ward care• Level 1- higher level of observation• Level 2- basic respiratory support &single organ support• Level 3- Advanced respiratory support+more than 1 organ support RCOG, 201117 August 2012 veerendrakumar 11
  12. 12. Element of complacency17 August 2012 veerendrakumar 12
  13. 13. Ongoing Risk Assessment• Postpartum period• – the time of greatest risk• – continued surveillance, intervention17 August 2012 veerendrakumar 13
  14. 14. • 75% of ICU admissions occur in postpartum period• 66% of them are due to preeclampsia related17 August 2012 veerendrakumar 14
  15. 15. In addition to hypertension,• the proteinuria & other adverse conditions of preeclampsia may also worsen post partum, usually in the first few days, and especially in the setting of severe disease. Eur J Obstet Gynecol Reprod Biol 200617 August 2012 veerendrakumar 15
  16. 16. Monitor• Vitals• Laboratory values• Imaging studies• Physical findings ACOG practice bulletin No.100, 200917 August 2012 veerendrakumar 16
  17. 17. • Intensive therapy does not just begin in intensive care! – Stabilise / optimise / transfer main ICU – designated delivery rooms for critical care – tertiary hospital17 August 2012 veerendrakumar 17
  18. 18. Continue Mgso4 therapy17 August 2012 veerendrakumar 18
  19. 19. Risk of eclampsia• preterm gestations -75% had antepartum eclampsia• Term gestations – 75% had intrapartum or postpartum eclampsia Douglas and Redman, BMJ 1994;309:1395-99 17 August 2012 veerendrakumar 19
  20. 20. Late postpartum eclampsia• > 48 hrs and < 4 weeks of delivery• 56% of postpartum eclampsia Lubarsky, Obstet gynecol 199417 August 2012 veerendrakumar 20
  21. 21. Consider CT scan• Patient with repetitive seizures• Late onset postpartum eclampsia• Focal neurological deficits BM Sibai, Am J Obstet Gynecol 198517 August 2012 veerendrakumar 21
  22. 22. VIMS experience 100 pts Joshi Suyajna 2005• 57% of postpartum eclampsia cases had abnormal findings.• 80% of scans in cases with eclampsia within 2 days after delivery were normal where as• 77.7% of scans with eclampsia after 2 days of delivery were abnormal17 August 2012 veerendrakumar 22
  23. 23. Antihypertensive therapy• Anti-hypertensive medication should be continued after delivery as dictated by the blood pressure.• It may be necessary to maintain treatment for up to 3 months RCOG Guideline No. 10(A) 200617 August 2012 veerendrakumar 23
  24. 24. • avoid alpha methyldopa in the postnatal period because of its adverse effect profile, particularly depression.17 August 2012 veerendrakumar 24
  25. 25. • Antihypertensive agents acceptable for use in breastfeeding include the following:• nifedipine XL,• labetalol,• captopril, and enalapril17 August 2012 veerendrakumar 25
  26. 26. We use• Single dose Mgso4 (VIMS regimen) 4 g iv and 4 g im• IV Labetalol for HTN emergency (VIMS REGIMEN) 15 mg every 15 minutes maximum 15 times (225mg)17 August 2012 veerendrakumar 26
  27. 27. Fluid restriction is advisable• total fluids should be limited to 80 ml/hour or 1 ml/kg/hour.• If there is associated maternal hemorrhage, fluid balance is more difficult and fluid restriction is inappropriate. 17 August 2012 RCOG Guideline No. 10(A) veerendrakumar 27
  28. 28. Fluid management• Don’t use diuretics to induce forced diuresis• Oliguria common in 24hrs postpartum• Repeated fluid challenges may cause pulmonary edema.17 August 2012 veerendrakumar 28
  29. 29. analgesics• NSAIDs should not be given post partum if hypertension is difficult to control or if there is oliguria, an elevated creatinine or platelets < 50,000 (III-I) JOGC MARS 200817 August 2012 veerendrakumar 29
  30. 30. HELLP postpartum• Decreasing LDH and increasing PLT count should routinely be observed by 4th postpartum day.• Women not showing significant recovery should be suspected of TTP. -normal coagulogram - greatly elevated LDH 20,000 iu/l - neurological signs/symptoms17 August 2012 veerendrakumar 30
  31. 31. • High dose steroids might accelerate recovery -routine administration is highly advocated (10 mg of dexamethasone every 12 hours) Clin Obstet Gynecol 1999, int J Gynaecol Obstet 2003,• Routine use not beneficial Katz, Am J Obstet Gynecol 200817 August 2012 veerendrakumar 31
  32. 32. Postpartum HELLP• 30% cases occur postpartum• Majority within 48hrs(few hrs – 7days)• Risk of renal failure and pulmonary edema is significantly increased compared to antenatal onset Clin Perinatol 2004, 31:807-33. Am J Obstet Gynecol 1993, 16817 August 2012 veerendrakumar 32
  33. 33. Pancreatitis• Diuretics should be used with caution as it may increase the risk of pancreatitis esp in preeclamptics with ARF Marcovici et al ,Am J perinatol 200217 August 2012 veerendrakumar 33
  34. 34. Hypertensive cardiomyopathy• PE patient with pulmonary edema may wrongly labeled as Peripartum cardiomyopathy• HTN CMP shows good recovery and regain cardiac function on follow up17 August 2012 veerendrakumar 34
  35. 35. Malignant ventricular arrhythmias• Not commonly noted perhaps due to we do not routinely monitor them!• Beta adrenergic blockers in the peripartum period significantly reduced the incidence of dangerous arrhythmias. Naidoo 1991,Am J obstet gynecol ,16417 August 2012 veerendrakumar 35
  36. 36. Thromboprophylaxis• particularly following antenatal bed rest for more than four days or after Caesarean section.• LMWH should not be administered post partum until at least two hours after epidural catheter removal.17 August 2012 veerendrakumar 36
  37. 37. Follow up• There should be confirmation that end-organ dysfunction of preeclampsia has resolved. 17 August 2012 veerendrakumar 37
  38. 38. Follow up• To endorse earlier diagnosis of preeclampsia• 30% patients had alternative diagnosis• 70% multiparous patients had alternate diagnosis.• Patients with underlying problems are more likely develop recurrence and renal17 August 2012 veerendrakumar 38 complications.
  39. 39. Care beyond 6 weeks postpartum• screen for pre-existing hypertension, underlying renal disease and thrombophilia esp when PE occurred before 34 weeks.• intervals between pregnancies of < 2 or 10 years are both associated with recurrent preeclampsia.• overweight should be encouraged to attain a healthy body mass index to decrease risk in future pregnancy & for long-term health. 17 August 2012 veerendrakumar 39
  40. 40. Outcome more important than your efforts !• Anger• Dissatisfaction• Perinatal loss/maternal death• Prolonged hospital stay• Financial burden 17 August 2012 veerendrakumar 40
  41. 41. 17 August 2012 veerendrakumar 41

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