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MANAGEMENT OF COMPLICATIONS OF PIH : AN OVERVIEW.

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Presentation on theme: "MANAGEMENT OF COMPLICATIONS OF PIH : AN OVERVIEW."— Presentation transcript:

1 MANAGEMENT OF COMPLICATIONS OF PIH : AN OVERVIEW

2 DR.VANDANA WALVEKAR Former Dean, Nowrosjee Wadia Maternity Hospital, Former President, Mumbai Obs and Gyn society, Consultant, Bhatia Hospital, Mumbai

3 PIH PIH can occur without warning at any time during pregnancy or early postpartum period.It also occurs as a chronic form, gradually becoming worse with advancing pregnancy PIH can occur without warning at any time during pregnancy or early postpartum period.It also occurs as a chronic form, gradually becoming worse with advancing pregnancy In its mild form it causes NO significant deleterious effect on the mother and the baby BUT inn the severe form plays havoc in their lives with complications In its mild form it causes NO significant deleterious effect on the mother and the baby BUT inn the severe form plays havoc in their lives with complications

4 PIH What is more the complications are unpredictable!!! What is more the complications are unpredictable!!! Am JOB 2006 Aug:Ganzewoot etal Am JOB 2006 Aug:Ganzewoot etal 216 women with cntrols with HELLP 216 women with cntrols with HELLP Adverse fetal outcome:g.age :ODratio 0.4 Adverse fetal outcome:g.age :ODratio 0.4 Adverse mat outcome:parity :ODratio 0.4 Adverse mat outcome:parity :ODratio 0.4 Hence prediction of clinical course and development of complications is NOT FEASIBLE Hence prediction of clinical course and development of complications is NOT FEASIBLE

5 PIH : COMPLICATIONS Maternal complications: Obstetric: Maternal complications: Obstetric: Abruptio placentae, Eclampsia, Preterm labour, PPH,DIC and coagulopathy HELLP Abruptio placentae, Eclampsia, Preterm labour, PPH,DIC and coagulopathy HELLP Non Obstetric: acute pulm. Edema,CVA, blindness, ARF, acute pancreatitis, acute Non Obstetric: acute pulm. Edema,CVA, blindness, ARF, acute pancreatitis, acute Cholecystitis Cholecystitis Fetal coplications: IUGR, Prematurity, IUFD, neonatal/childhood neurological deficits Fetal coplications: IUGR, Prematurity, IUFD, neonatal/childhood neurological deficits

6 PIH : PATHOPHYSIOLOGY It is a multisystem disease with vasospas It is a multisystem disease with vasospas & coagulation defects begins with endothelial dysfunction : platelet activation: release of thromboxane A &serotonin: vasospasm: pl. aggregation: damage with coagulopathy multiorgan failure: TERMINATES WITH DELIVERY & coagulation defects begins with endothelial dysfunction : platelet activation: release of thromboxane A &serotonin: vasospasm: pl. aggregation: damage with coagulopathy multiorgan failure: TERMINATES WITH DELIVERY

7 ABRIPTIO PLACENTAE Commonest, most often mixed APH, occ. Concealed :USG usually confirms the diag. & indicates severity Commonest, most often mixed APH, occ. Concealed :USG usually confirms the diag. & indicates severity MGT: depends on g.age, parity, inducibility with Bishops score, fetal heart +/- MGT: depends on g.age, parity, inducibility with Bishops score, fetal heart +/- Hypertension prophylaxis, supportive mgt with transfusion if needed, ARM/LSCS as delivery only will sort the problem Hypertension prophylaxis, supportive mgt with transfusion if needed, ARM/LSCS as delivery only will sort the problem

8 PPH Simple, atonic: preterm labour,ut. Inertia, incoordinate ut. Action, ass. with abruptio Simple, atonic: preterm labour,ut. Inertia, incoordinate ut. Action, ass. with abruptio Usually responds to standard mgt. with oxytocics etc. Usually responds to standard mgt. with oxytocics etc. 2-5% severe needing surgical measures: B.Lynch suture, stepwise devscularisation of uterine, hysterectomy or int. iliac ligation 2-5% severe needing surgical measures: B.Lynch suture, stepwise devscularisation of uterine, hysterectomy or int. iliac ligation Ass. With APH: couvelaire uterus: HELLP Ass. With APH: couvelaire uterus: HELLP

9 ECLAMPSIA 5% approx. :ante, intra post partum epileps 5% approx. :ante, intra post partum epileps Mgt with magsulph Pritchard/modified Pritchard has stood the test of time:RCTS Mgt with magsulph Pritchard/modified Pritchard has stood the test of time:RCTS Invest: PT, PTT, FDP, Fibrinogen, D-dimer Invest: PT, PTT, FDP, Fibrinogen, D-dimer Mgt: supportive measures, IV 4-6gm Mgso4, foll by 4-6gm im 4-6hrly with close monitoring till under control Mgt: supportive measures, IV 4-6gm Mgso4, foll by 4-6gm im 4-6hrly with close monitoring till under control Induction/LSCS: g.age, FHS +/-,Bishops, Induction/LSCS: g.age, FHS +/-,Bishops, Intercurrent ecl: R Bhatt: in rare cases Intercurrent ecl: R Bhatt: in rare cases

10 ECLAMPSIA ECLAMPSIA in UK ECLAMPSIA in UK hospitals, feb 229 hospitals, feb Incidence: 2.7/10,000 Incidence: 2.7/10,000 38% proteinuria seen only one week prior 38% proteinuria seen only one week prior 99% treated with Mgso4 99% treated with Mgso4 NO mortality NO mortality Non eclampsia related compl :10% Non eclampsia related compl :10% PNMR:59/10,000 PNMR:59/10,000

11 help.. HELP.. HELLP Syndrome Dr. Vandana Walvekar

12 Wein Stein : 1982 Wein Stein : 1982 H = Hemolysis H = Hemolysis EL = Elevated liver enzymes EL = Elevated liver enzymes LP = Low platelets in a women with pre- eclampsia / eclampsia LP = Low platelets in a women with pre- eclampsia / eclampsia Appears 24 wks. – post partum (1wk -33%) Appears 24 wks. – post partum (1wk -33%) Maternal Mortality of 24-40% Maternal Mortality of 24-40% Perinatal Mortality of 30-80% Perinatal Mortality of 30-80%

13 Classification – Mississippi, Tennesse I. < 50,000 / l platelets, altered LFT microangiopathic anemia – highest MMR PNMR II. > 50,000 /1 platelets 50,000 /1 platelets < 100,000/ l. III. > 100,000 /1 platelets 600 I.U./l, AST 70 I.U./l, ALT 40 I.U./l Partial HELLP: one or two of the features

14 Considered a Variant of P.E. & Eclampsia Prognosis:- Failure of platelet count to with in 96 hrs. denotes multiorgan non compensatory dysfunction Prognosis:- Failure of platelet count to with in 96 hrs. denotes multiorgan non compensatory dysfunction Also occurs : Severe sepsis, Lung injury, multiorgan failure with DIC Also occurs : Severe sepsis, Lung injury, multiorgan failure with DIC

15 HELLP – Pathophysiology Vascular endothelial dysfunction Platelet aggregation fibrin activation & consumption Selective organ (Liver) insufficiency clinical HELLP Vascular endothelial dysfunction Platelet aggregation fibrin activation & consumption Selective organ (Liver) insufficiency clinical HELLP

16 Clinical Spectrum Disease of multipara Disease of multipara tension > 150/90 tension > 150/90 Proteinuria Proteinuria Convulsion Convulsion Epigastric pain Epigastric pain Vomiting Vomiting Abruptio placenta Abruptio placenta Retinal detachment with acute blindness Retinal detachment with acute blindness Hemolysis Hemolysis Pts with ART techniques – donor egg, new partum more prone Pts with ART techniques – donor egg, new partum more prone MSAFP & ­­ HCG more prone MSAFP & ­­ HCG more prone

17 Laboratory Diagnosis Platelets < 100,000/ul Platelets < 100,000/ul LDH >600 I.U./1 LDH >600 I.U./1 AST >70 I.U. AST >70 I.U. ALT > 40 I.u. ALT > 40 I.u. Uric acid > 7.8mg % Uric acid > 7.8mg % Creatinine > 1.0 mg% Creatinine > 1.0 mg%

18 Maternal Mortality : 25-40% Causes : Cardio pulm. failure Causes : Cardio pulm. failure DIC DIC CVA CVA Hepatic rupture Hepatic rupture Post caesarean shock Post caesarean shock Multiorgan failure Multiorgan failure Associated conditions – complement Associated conditions – complement

19 Early disease can be only suspected as the diagnostic symptoms come too late in the course of the diseases

20 Laboratory Evidence Peripheral smear : burr cells Peripheral smear : burr cells LDH ( sensitive) LDH ( sensitive) S. Haptoglobins early, sensitive S. Haptoglobins early, sensitive Thrombocytopenia Thrombocytopenia prothrombin time, partial thromboplastin time, Fibrinogen, FDP prothrombin time, partial thromboplastin time, Fibrinogen, FDP AST 70 IU/l AST 70 IU/l ALT 40 I.u./l ALT 40 I.u./l S. creatinine S. creatinine

21 Management of HELLP Syndrome (Univ. of Mississippi Medical Center) Anticipate the disease Anticipate the disease Laboratory evidence to evaluate severity of maternal disease Laboratory evidence to evaluate severity of maternal disease Fetal management: depends on Fetal management: depends on G.age G.age Severity of mat.disease Severity of mat.disease 34 – deliver within 24 hrs. irrespective of class of disease vag/abd. del. 34 – deliver within 24 hrs. irrespective of class of disease vag/abd. del – hospitalise, monitor, steroids : Dexa 10 mg 12 hrly till mat. Condition improves – hospitalise, monitor, steroids : Dexa 10 mg 12 hrly till mat. Condition improves

22 HELLP Management (contd.) Steroids : Fetal; lung maturity. Mat: platelet count stabilised, AST/ALT Steroids : Fetal; lung maturity. Mat: platelet count stabilised, AST/ALT Gain time for induction of labour Gain time for induction of labour Gain time transfer to III institution Gain time transfer to III institution Vital to continue post partum to prevent rebound phenomena Vital to continue post partum to prevent rebound phenomena Nitric Oxide – reverse platelet destruction & promote vasodilation Nitric Oxide – reverse platelet destruction & promote vasodilation Admin. Of FFP – provide other factors removal of angiopathic debris Admin. Of FFP – provide other factors removal of angiopathic debris Platelet transfusion: essential if < pt for immediate C.S., bleeding from I.V. sites, vag del. Imminent, after delivery : for 24 hrs. till pt. Stabilise at 50,000 in C.S. 20,000 in vag.del. Platelet transfusion: essential if < pt for immediate C.S., bleeding from I.V. sites, vag del. Imminent, after delivery : for 24 hrs. till pt. Stabilise at 50,000 in C.S. 20,000 in vag.del. Refractory pts. Plasma change as a desperate measure Refractory pts. Plasma change as a desperate measure

23 Control of Tension To minimise Abruptio To minimise Abruptio Alpha-dopa/ Labetelol Alpha-dopa/ Labetelol Nifedepine : sublingual /oral normalises platelet count, urine output Nifedepine : sublingual /oral normalises platelet count, urine output Control of convulsions: MgSO 4 is the drug of choice 4-6gm iv foll. by im 4-6gm every 4-6 hrs. Control of convulsions: MgSO 4 is the drug of choice 4-6gm iv foll. by im 4-6gm every 4-6 hrs. Monitoring is essential Monitoring is essential IV fluids to maintain output, restriction in cases of renal involvement IV fluids to maintain output, restriction in cases of renal involvement

24 Management of Labour & Delivery Delivery is the only way deterioration can be stopped Delivery is the only way deterioration can be stopped 34 wks. – expeditions delivery 68% LSCS rate 34 wks. – expeditions delivery 68% LSCS rate 34 wks. –cortisone – induction of labour Dexamethazone amelicrates the process & allows time for cervical ripening 34 wks. –cortisone – induction of labour Dexamethazone amelicrates the process & allows time for cervical ripening LSCS LSCS Spontaneous expulsion of placenta Spontaneous expulsion of placenta In situ repair of incision In situ repair of incision Mass closure of abd.wall Mass closure of abd.wall Ascitic fluid loss to be compensated Ascitic fluid loss to be compensated Regional anaesthesia safer Regional anaesthesia safer Look for hepatic haemorrhage Look for hepatic haemorrhage

25 Post Partum HELLP PE to be monitored till PE to be monitored till Platelet count > 100,000 Platelet count > 100,000 LDH LDH Diuresis 100 ml/hr Diuresis 100 ml/hr BP BP Clinical improvement Clinical improvement Post partum corticosteroids Post partum corticosteroids ? D&C to remove decidual tissue ? D&C to remove decidual tissue Hepatic complications: rupture-surgery Hepatic complications: rupture-surgery Recurrent risk: preeclampsia –42%, HELLP – 19-27% Recurrent risk: preeclampsia –42%, HELLP – 19-27% Higher risk in del. < 32 wks Higher risk in del. < 32 wks

26 HELLP:ASSORTED FACTS Essentially: supportive mgt, seizure prophylaxis, BP control, termination Essentially: supportive mgt, seizure prophylaxis, BP control, termination Pulm. Edema: IV immunoglobulin viable Pulm. Edema: IV immunoglobulin viable Refractory HELLP: pl.<30,000,ele. LFT, also need rpt. Transfusions for hematcrit maintenance Refractory HELLP: pl.<30,000,ele. LFT, also need rpt. Transfusions for hematcrit maintenance Hepatic imaging & liver biopsy DO NOT correlate the sverity of HELLP Hepatic imaging & liver biopsy DO NOT correlate the sverity of HELLP Anasthesia: GA with sevoflurane without epidural/epidural Anasthesia: GA with sevoflurane without epidural/epidural

27 CARDIOVASCULAR COMPLICATIONS Acute pulm. Edema, usually associated with eclampsia, acute hypertensive crisis without convulsions, can occur postpartum Acute pulm. Edema, usually associated with eclampsia, acute hypertensive crisis without convulsions, can occur postpartum MGT: multidisciplinary, ICU MGT: multidisciplinary, ICU Rapid digitalisation, diuretics, supportive Rapid digitalisation, diuretics, supportive Not advisable to terminate unless pt. stable irresp. of g.age, vag del preferred Not advisable to terminate unless pt. stable irresp. of g.age, vag del preferred Surgical mgt only if mandatory Surgical mgt only if mandatory Fluid restriction at induction, (conentrated oxytocic admn) no data with misoprostol Fluid restriction at induction, (conentrated oxytocic admn) no data with misoprostol

28 PE AND FUTURE CARDIOVASCULAR RISK NEWSTEAD et el:mar2007:Ex,Rev.cardiovascular therapy NEWSTEAD et el:mar2007:Ex,Rev.cardiovascular therapy Pregnancy is a metabolic and vascular STRESS TEST for the woman. Those who FAIL are at a risk of long term cardiovascular complications,obesity adds a further risk Pregnancy is a metabolic and vascular STRESS TEST for the woman. Those who FAIL are at a risk of long term cardiovascular complications,obesity adds a further risk

29 CEREBROVASCULAR ACCIDENTS Usually asociated with eclampsia Usually asociated with eclampsia Acute hypertensive crisis without convulsions: mged with MgSo4, sublingual nifedepine, termination Acute hypertensive crisis without convulsions: mged with MgSo4, sublingual nifedepine, termination VigilPE, GraciaP :RCT :mgt. of severePE VigilPE, GraciaP :RCT :mgt. of severePE IV Hydralazine (apresoline) or labetelol IV Hydralazine (apresoline) or labetelol 82 women SPE,HELLP: 82 women SPE,HELLP: IV hydralazine5mg. Slow bolus every 20mts for 5 doses IV hydralazine5mg. Slow bolus every 20mts for 5 doses IV labetelol20mg bolus:40mg if no hypotension in 20mts:foll by 80mg every 20mts till max 300mg IV labetelol20mg bolus:40mg if no hypotension in 20mts:foll by 80mg every 20mts till max 300mg Safe & effective in postpartum period Safe & effective in postpartum period With intracranial hage: LSCS with decompression; Dai etal :nov2007, cl. hypertension With intracranial hage: LSCS with decompression; Dai etal :nov2007, cl. hypertension

30 FOOTPRINTS IN THE URINE Acute renal failure: with eclampsia or SPE Acute renal failure: with eclampsia or SPE No positive clinical findings, anuria, hypertension, renal profile abnormal only after hrs No positive clinical findings, anuria, hypertension, renal profile abnormal only after hrs Multidisciplinary approach, hemodialysis essental for reversal as anuria is prerenal Multidisciplinary approach, hemodialysis essental for reversal as anuria is prerenal

31 VISUAL CALAMITIES..AND Blurring of vision &temp blindness are known and are reversible totally Blurring of vision &temp blindness are known and are reversible totally Permanat blindness: rare: associated with SPE & HELLP : reports by Moseman etal OBGY,nov2007 vol100 Permanat blindness: rare: associated with SPE & HELLP : reports by Moseman etal OBGY,nov2007 vol100 Acute pancreatitis, cholecystitis can occue due microvascular disturbances even with splanchnic circulation Acute pancreatitis, cholecystitis can occue due microvascular disturbances even with splanchnic circulation

32 SEVERE PE WITH IUGR Expectant mgt of SPE with IUGR:AMJ mar2007,Hadad et al Expectant mgt of SPE with IUGR:AMJ mar2007,Hadad et al 239 pts, 24-33wks expectantly managed with steriods till del 239 pts, 24-33wks expectantly managed with steriods till del Maternal outcomes similar by way of labour and other complications to controls Maternal outcomes similar by way of labour and other complications to controls Fetal :higher death rath with severe IUGR Fetal :higher death rath with severe IUGR

33 NEONATES AND PIH MOTHER Ind j of pediatrics:july2007,vol 74, s. shivkumar: Babies of PIH mothers Ind j of pediatrics:july2007,vol 74, s. shivkumar: Babies of PIH mothers Thrombocytopenai:22%,higher in preterm Thrombocytopenai:22%,higher in preterm No correlation in mat & fetal pl counts No correlation in mat & fetal pl counts Neutropenia:well documented Neutropenia:well documented Nucleated RBCs :22% polycythemic in term IUGR: due to chronic asphxia: duration to produce polycythemia not knkwn: Philips et al Nucleated RBCs :22% polycythemic in term IUGR: due to chronic asphxia: duration to produce polycythemia not knkwn: Philips et al

34 FUTURE THOUGHTS In this erratic, unpredictable entity it is posible that In this erratic, unpredictable entity it is posible that Serum, urine InhibinA may provide a marker: HamaB et al AmJObGy Dec2006 Serum, urine InhibinA may provide a marker: HamaB et al AmJObGy Dec2006 Plasmaferresis: in severe SPE, refractory HELLP, DIC Plasmaferresis: in severe SPE, refractory HELLP, DIC Aspirin early in pregnancy :evidence inconclusive Aspirin early in pregnancy :evidence inconclusive

35 COMMON PROBLEM COMMON PROBLEM UNPREDICTABLE UNPREDICTABLE MULTIPLE MANAGEMENT MODALITIES MULTIPLE MANAGEMENT MODALITIES CHALLENGE TO THE OBSTETRICIAN!!! CHALLENGE TO THE OBSTETRICIAN!!! THANK YOU THANK YOU

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