PRE ECLAMPSIA AND POSTNATAL CARE

Layla LavalleeResearch MidwifeNuffield Department of Primary Care Health SciencesUniversity of Oxford

OVERVIEW

Background

Importance of good postnatal care

Management

Discharge to the community

Future pregnancies

Long term health implications

BACKGROUNDDelivery doesn’t halt progression of disease immediately

PE can continue, worsen or present for the 1st time following delivery

Approximately 1/3 of women will continue to have HT during 1st week

Up to 28% of PE presents for the first time (66% following discharge)

32 - 44% of Eclamptic fits happen PN (most w/in 48 hours but have been occured up to 28 days PN)

Most hypertension and proteinuria resolves within first week:

Up to 57% by day 3

Up to 85% by day 7

*Prevalence probably underestimated*

WHY GOOD POSTNATAL CARE IS SO IMPORTANT

Findings from confidential enquiries into maternal deaths:

- PE related maternal deaths largely due to treatable pathology

- Substandard care occurred in the majority of cases (failure to recognise severity of disease and to act appropriately and quickly enough)

MBBRACE 2019 REPORT

6 PRE-ECLAMPSIA RELATED MATERNAL DEATHS

1 in antenatal period or on day of delivery

4 between 1 – 42 days following delivery

1 > 42 days after delivery

LACK OF AWARENESS

“DELIVERY IS NOT A CURE FOR PRE-ECLAMPSIA”

“The message I hope to express is to always trust your intuition and advocate for yourself. I was a part of the 5% of women who have experienced Postpartum Preeclampsia and HELLP and none of my health care providers would listen or took my symptoms seriously until it was too late. I often still wonder if they would have, if it would have gotten as bad as it did… I spent a long time angry about that”

(Natalie, symptoms dismissed as PND, later fitted and spent six days in ITU).

FAILURE TO SPOT THE DANGERS…

“A healthy low risk woman in her first pregnancy was delivered in a freestanding midwifery unit. Following delivery she developed a severe headache and moderate hypertension. Opiate analgesia was verbally prescribed. Over the following three hours she had severe hypertension but she was not transferred to the consultant unit until she had neurological signs. On arrival in the consultant unit her blood pressure was normal but she had lost airway control and CT scan performed shortly after her transfer showed a large intracranial bleed”.

MBBRACE, 2019

ON A HAPPIER NOTE…

UK trends show a significant decline in pre-eclampsia related deaths which are a testament to the high quality care UK women receive overall

UK TRENDS

2 deaths between 2012 – 2014 equates to < 1 woman/million or less than 1 death/year (Shennan, Green and Chappell, 2017)

GLOBAL COMPARISONS

(UK – 2%)

7.4% (Review to Action, 2018) 14% (WHO, 2014)

CAUSES OF POSTNATAL HYPERTENSION

Chronic, pre-existing hypertension – may have been previously undetected

Gestational Hypertension

Pre-eclampsia

Renal disease

Hyperthyroidism

Primary hyperaldosteronism

Pheochromocytoma (tumour of the adrenal gland)

OTHER CAUSES OF HT…Normal physiological changes

Pain/anxiety

Volume overload

Regional anaesthetic

Instrumental delivery

Delayed mobilisation

Medications NSAIDS – can cause vasoconstriction and sodium/water retention

Ergometrine

Decongestants e.g. Ephedrine, Phenylpropanolamine

SO WHAT DO WE DO?

AVOID SYNTOMETRINE“Two women presented so late in labour that their blood pressures were not measured before delivery. One of the women had had a normal blood pressure recording and normal urinalysis at the antenatal clinic the previous day. Both women received intramuscular syntometrine for third stage prophylaxis, and both were found subsequently to be hypertensive. In both cases, by coincidence, the blood pressures rose to maxima of 210/115 mm/Hg. One woman remained hypertensive despite intravenous hydralazine and experienced eclamptic seizures despite magnesium sulphate. She died from a large cerebral haemorrhage. The other woman had her hypertension treated aggressively, and improved for some time before becoming profoundly hypotensive. At laparotomy she was found to have a large haemoperitoneum from, in part, a tear of the liver capsule. She died, much later, of multi-organ failure in the intensive care unit. In both cases, the progress of pre-eclampsia was extremely rapid.”

Saving Mothers Lives report (2007)

LOW RISK WOMEN

Check and document BP within six hours of delivery

BP normal and no symptoms of PE

Diastolic > 90 with no symptoms of PE

Diastolic > 90 plus symptoms of PE

Severe or persistent headache with or w/out raised BP

No further action required

If no symptoms of PE repeat in 4 hours

• If normal then no further action

• If still > 90 then emergency action

Emergency action Emergency action

WHERE TO CARE FOR WOMEN Levels of Care

Level 1 (postnatal ward) Level 2 (HDU) Level 3 (ITU)

Pre-eclampsia with hypertension

Step-down treatment after birth

Eclampsia

HELLP

Haemorrhage

Hyperkalaemia

Severe Oliguria

Coagulation support

IV anti-HT treatment

Initial stabilisation of severe

hypertension

Evidence of cardiac failure

Abnormal neurology

Step-down treatment from level 3

Severe PE requiring ventilation

MANAGEMENT

Women with severe HT [>160/110]…

Measure blood pressure every 15-30 minutes until <160/110

Anti-hypertensives:

Labetalol (oral or IV)

Nifedipine (oral)

IV hydralizine

MAGNESIUM SULPHATECONSIDER GIVING IF ONE OR MORE OF THE FOLLOWING PRESENT…

Ongoing or recurrent severe headaches

Visual disturbances

Nausea/vomiting

Epigastric pain

Oliguria and severe hypertension

Progressive deterioration of bloods (rising creatinine and/or liver enzymes, falling platelets)

*Every postnatal ward should have an Eclampsia box*

MAGNESIUM SULPHATE REGIME

Loading dose

4g IV over 15 – 15 minutes followed by infusion of 1g/hour for 24 hours

Recurring fits

2 – 4g IV over 5 – 15 minutes

MONITORING BLOOD PRESSURE

Not medicated

At least 4 times/day while inpatient

At least once a day between day 3-5

If still high on days 3-5 then on alternate days until normal

Target BP < 140/90

If BP > 150/100 start medication and aim for a target of 135/85

Medicated

Min 4 times/day while inpatient

Every 1 -2 days for up to 2 wks until off treatment and/or no HT

Continue with anti-HT medication and aim for 135/85

Considering decreasing medication if BP < 140/90

Decrease medication if < 130/80

*Ask about severe headache and epigastric pain each time BP taken*

MEDICATION

Stop Methyldopa within two days – can increase risk of PN depression

BP may drop within the first 48 hours then increase day 3-6 so be very cautious reducing or stopping medication

Diuretics may be required for fluid overload

BEWARE SIGNS OF CEREBRAL PATHOLOGY…

Urgent senior review:

Altered consciousness

Agitation

Restlessness

Neuroimaging should be considered early in women multiple fits and those who do not become fully conscious within an hour of their fit.

ANTI-HYPERTENSIVES1st line

Ace inhibitors – Enalapril (preferred – once/day)

Captopril

For Black African/Caribbean women consider Ca channel blocker first

Second Line

Combination of ACE inhibitors and Calcium channel blockers (eg Nifedipine, Amlodipine)

If Nifedipine and Enalapril not effective can try Beta Blockers such as Atenolol or Labetalol (preferably Atenolol as OD versus 3 times/day)

BREASTFEEDINGContinue to promote breastfeeding.

Medications can get into BM in very small amounts but unlikely to have an effect.

Potential risks: hypoglycaemia, hypothermia, hypotension, bradycardia.

Consider monitoring baby’s BP if any concerns especially premature and look out for drowsiness, lethargy, pallor, cold peripheries or poor feeding.

Diuretics and Angiotensin 2 receptor blockers (e.g. Losartan) should be avoided in women who want to breastfeed as they can reduce the milk supply.

Women who aren’t breastfeeding should be treated according to NICE guidelines for HT in adults.

NSAIDS

Avoid or use with cautionCan:

Increase BP

Antagonise some anti-HT meds

Exacerbate or cause renal problems

URINE OUTPUT AND FLUID RESTRICTION

Fluid overload can lead to pulmonary oedema

Monitor output hourly and limit maintenance fluid to 80 mls/hr with severe PE and MGSO4 unless ongoing fluid losses

Observe for SOB, low sats, reduced urine output (< 100 mls/4 hours)

HAEMATOLOGICAL AND BIOCHEMICAL MONITORINGIn women with mild/mod HT …

Check PCR, Platelets, Liver enzymes, Serum creatinine and Electrolytes 48 -72 hours after birth (or stepdown from critical care)

If normal then no need for further testing if abnormal then repeat as clinically indicated until normal.

VTE – ASSESSMENT AND PROPHYLAXIS

Assess daily - PE can increase risk of VTE

Compression stockings

Use of heparin depends on platelet count, renal/liver function and BP control so may be contraindicated

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EMOTIONAL SUPPORT

Increased risk of postnatal depression

May experience grief, anger, fear, anxiety

Separation from baby

May find it hard to care for baby depending on how unwell she is

Don’t forget the partner

Debriefing

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DEBRIEFINGAll women with severe PE should be offered de-briefing session with senior Obstetrician covering:

Screening for anti-phospholipid syndrome if PE < 34 weeks.

Estimates of risk for future pregnancies

Management plan for future pregnancy

Information on where to get immediate and ongoing support: APEC www.apec.or.uk

Tommy’s (pregnancy and birth related problems) www.tommy’s.org

SANDS (Stillbirth and NND) www.uk.sands.org

Implications for future health

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DISCHARGE TO COMMUNITY

When no symptoms of PET

BP controlled with or without medication

Bloods stable or improving

Most women can be discharged by day 5

teds

POSTNATAL CARE PLAN

Upon discharge women should have written care plan outlining:

Who will provide f/u care including medical review if needed

Frequency of BP checks – if self-monitoring instructions on what to do with readings

Threshold for titrating medication

Indications for referral to primary care for blood pressure review

*All hypertension needs follow up monitoring – even if resolved*

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“A woman had raised blood pressure in labour and was given a single dose of oral therapy. She went home shortly after the birth, without

treatment and had no postnatal checks of her blood pressure. She had a cerebral haemorrhage at home”

(MBBRACE, 2019)

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” Any woman treated with antihypertensives in the antenatal or intrapartum period, even if only a single dose, requires additional postnatal blood pressure checks and continuing preventive antihypertensive treatment until it is certain that the hypertension was solely related to pregnancy and has completely resolved. There is a risk of ‘rebound hypertension’ and so there is a need to have repeated checks of the blood pressure at home. Every woman who has had hypertension in pregnancy should have a documented plan for postnatal blood pressure surveillance and antihypertensive treatment and this plan should be included in the postnatal discharge notes and communicated to the woman’s general practitioner and community midwife”.

MBBRACE, 2019

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SYMPTOMSAll women should be advised on symptoms to look out for

Can be easily overlooked or attributed to other factors

“…Four days after being discharged I had severe swelling on my limbs and genital area, as well as an unbearable headache (which was HBP, but I did not know then), nausea and vomiting. I took a nap thinking that would cure the headache, yet when I woke up at feeding time for my baby, I realized I was so confused and had altered consciousness to the point that I could not get off the bed because my brain was doing other movements with my limbs. After that I do not remember anything and my husband claims that is when I went into seizures. I had continuous seizures and was in the ICU 11 days… It’s been 7 years since the episode yet my husband and I are still traumatized and scared to try for another”.

(Testimonial from Pre-eclampsia Foundation website)

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FOLLOW UP Offer a medication review with GP two weeks after transfer to community care

Offer all women a medical review with GP or specialist 6 - 8 weeks after the birth.

Six week check should include:

Proteinuria check – if present offer further r/v at 3 months to assess kidney function (12-17% of severe PE associated with underlying renal disease).

Relative risk of kidney disease raised but absolute risk is low for women with no proteinuria or HT at six weeks and no further f/u required

Discussion regarding contraception, future pregnancies, future CVD risks

FUTURE PREGNANCIESIf planning another pregnancy soon then need to consider medications

Will need to see midwife/GP asap in next pregnancy and take 75 –150 mg of aspirin daily from 12 weeks

Will also need referral to obstetrician early on to make a plan for care

Overall risk to next pregnancy approximately 1:5 but will vary individually based on severity of PE in this pregnancy, gestation at delivery and presence of other risk factors

Maintaining a healthy weight can reduce risk of PE and an interval of > 10 years between pregnancies can increase risk

FUTURE RISKS

Type of hypertension in previous or current pregnancy

Prevalence of hypertensive

disorder in future pregnancy

Any hypertension in pregnancy

Pre-eclampsia Gestational hypertension

Any hypertension Approximately 21%1:5 women

Approximately 20%1:5 women

Approximately 22%1:5 women

Pre-eclampsia Approximately 14%1:7 women

Up to 16% (1:6)28 - 34 wks: 33% (1:3)34 – 37 wks: 23% (1:4)

Approximately 7%1:14 women

Gestational hypertension

Approximately 9%1:11 women

Approximately 6 – 12%Up to 1:8 women

Between 11 – 15 %Up to 1:7 women

Chronic hypertension

N/A Approximately 2%Up to 1:50 women

Approximately 3%Up to 1:34 women

FUTURE CVD RISKS

PE significantly increases the risk of CVD in later life – the more severe the PE the greater the risk

Children of affected pregnancies more likely to have:

Hypertension in childhood and adolescence

Hypertension and stroke as adults

Lifestyle interventions and tighter control of BP following delivery could mitigate risks and women should be advised to discuss this with their GP at the six week check

FUTURE CVD RISKS

Pre-eclampsia

Major adverse CV event 1.5 - 3 times higher

Cardiovascular mortality 2 times higher

Stroke 2 – 3 times higher

Hypertension 2 - 5 times higher

MAIN POINTS…Pre-eclampsia can worsen or present for the first time following delivery

Early recognition, management and escalation of care are key

Avoid Syntometrine, NSAIDS and Methyldopa

All women with HT (even if resolved) BP require further monitoring upon discharge

Aspirin from 12 weeks in future pregnancies

Advise women of future pregnancy and CVD risks and how these can be mitigated

ONE LAST POINT… 2014 report by RCM highlighted the impact poor staffing on postnatal care provision:

Staffing levels main factor influencing number of postnatal visits not the needs of women

Length of hospital stay and number of postnatal visits have decreased significantly over the years with little evaluation of its impact

Of women surveyed 3.4% reported receiving no postnatal care, 14.1% had only one visit

Most MW’s reported not having enough time to convey all PN information they need to

REFERENCESAction on Pre-eclampsia - Supporting familes affected by Pre-eclampsia [Internet]. Action on Pre-eclampsia. [cited 2020 Jan 16]. Available from: https://action-on-pre-eclampsia.org.uk/

Bramham K, Nelson-Piercy C, Brown MJ, Chappell LC. Postpartum management of hypertension. BMJ. 2013 Feb 25;346:f894.

Building capacity to to review and prevent maternal deaths: Report from nine maternal mortality review committees. [Internet]. [cited 2020 Feb 6]. Available from: https://reviewtoaction.org/Report_from_Nine_MMRCs

Cairns Alexandra E., Tucker Katherine L., Leeson Paul, Mackillop Lucy H., Santos Mauro, Velardo Carmelo, et al. Self-Management of Postnatal Hypertension. Hypertension. 2018 Aug 1;72(2):425–32.

Lazdam M, Davis EF, Lewandowski AJ, Worton SA, Kenworthy Y, Kelly B, et al. Prevention of Vascular Dysfunction after Preeclampsia: A Potential Long-Term Outcome Measure and an Emerging Goal for Treatment. J Pregnancy [Internet]. 2012 [cited 2020 Jan 17];2012. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3235810/

Lewis, Gwyneth Editor Centre for Maternal and Child Enquiries Saving mothers’ lives : reviewing maternal deaths to make motherhood safer: 2006–08 : the eighth report on Confidential Enquiries into Maternal Deaths in the United Kingdom. BJOG ; 118 (Suppl. 1): 1–203 London : CMACE, 2011

Recommendations | Postnatal care up to 8 weeks after birth | Guidance | NICE [Internet]. [cited 2020 Feb 10]. Available from: https://www.nice.org.uk/guidance/cg37/chapter/1-Recommendations

REFERENCES

Recommendations | Hypertension in pregnancy: diagnosis and management | Guidance | NICE [Internet]. [cited 2020 Jan 16]. Confidential Enquiry into Maternal Deaths | MBRRACE-UK | NPEU [Internet]. [cited 2020 Jan 16]. Available from: https://www.npeu.ox.ac.uk/mbrrace-uk/reports/confidential-enquiry-into-maternal-deaths(can access past confidential enquiry reports from this page)

Royal College of Midwives. Pressure Points: the case for better post-natal care, 2014.

Say L, Chou D, Gemmill A, Tunçalp Ö, Moller A-B, Daniels J, et al. Global causes of maternal death: a WHO systematic analysis. The Lancet Global Health. 2014 Jun 1;2(6):e323–33.

Shennan AH, Green M, Chappell LC. Maternal deaths in the UK: pre-eclampsia deaths are avoidable. The Lancet. 2017 Feb 11;389(10069):582–4.)

Sibai BM. Etiology and management of postpartum hypertension-preeclampsia. American Journal of Obstetrics & Gynecology. 2012 Jun 1;206(6):470–5.

Website. 2014 Preeclampsia Awareness Survey Highlights Need for Education [Internet]. Preeclampsia Foundation Official Site. 2014 [cited 2020 Jan 16]. Available from: https://www.preeclampsia.org/the-news/44-press-releases/366-2014-preeclampsia-awareness-survey-highlights-need-for-education