National and Unified Obstetric and Newborn care Guidelines and Protocols Postpartum care -The maternal condition should continue to be monitored at least every 4 hrs for at least the next 24 hrs following childbirth -The blood pressure may initially rise after delivery but should gradually return to normal by the end of the first postnatal week. -Persistent hypertension will need to be treated. Methyldopa should be avoided postpartum because of the risk of postpartum depression. - the drug of choice is atenolol and/or nifedipine. Most antihypertensive drugs are compatible with breastfeeding

National and Unified Obstetric and Newborn care Guidelines and Protocols Signs of impending eclampsia The midwife should be alert to any of these signs and summon medical assistance immediately. - The aim of care to save and fetus by controlling hypertension, inhibiting seizures and preventing coma

National and Unified Obstetric and Newborn care Guidelines and Protocols -Signs of impending eclampsia A sharp rise in blood pressure Headache, which is usually severe, persistent and frontal in location (cerebral vasospasm) Drowsiness or confusion (cerebral vasospasm) Visual disturbances, such as blurring of vision or blindness (cerebral vasospasm) Diminished urinary output & increase in proteinuria (renal failure) Upper abdominal pain (liver oedema) ± nausea and vomiting.

National and Unified Obstetric and Newborn care Guidelines and Protocols Eclampsia demonstrated that over a 60-year period, the incidence of eclampsia had fallen from 74 to 7.4 per deliveries. -More recently, the reported rate of eclampsia in Europe and other developed countries is 1 in 2000– 3000 deliveries -Usually pre-eclampsia is diagnosed and treatment to prevent eclampsia but occasionally pre-eclampsia is so rapid in onset and progress that eclampsia ensues before any action can be taken. -In this situation, pre-eclampsia is termed ‘fulminating’

National and Unified Obstetric and Newborn care Guidelines and Protocols Eclampsia is associated with increased risks of maternal and perinatal morbidity and mortality. - Significant maternal life-threatening complications as a result of eclampsia include : -placental abruption -hemorrhage -DIC - pulmonary edema - multi-organ failure including cardiac, renal and liver, HELLP syndrome and brain hemorrhage

National and Unified Obstetric and Newborn care Guidelines and Protocols - MRI studies suggest that there is cerebral vasospasm causing ischemia and cellular oedema, especially in the territory of the posterior cerebral arteries. -Detecting and managing eclampsia is also made more difficult in that, unlike other types of seizure, warning symptoms are not always present before onset of the convulsion. -occurring antenatally, intrapartum and postpartum -Late postpartum eclampsia has also been described, where eclampsia can occur between 48 hrs and 4 weeks after birth -In fulminating pre-eclampsia or eclampsia, delivery of the mother should take place as soon as possible

National and Unified Obstetric and Newborn care Guidelines and Protocols Care of a woman with eclampsia The aims of immediate care are to: summon medical aid clear and maintain the mother's airway – this may be achieved by placing the mother in a semiprone position in order to facilitate the drainage of saliva/vomit ensure maternal oxygenation – during the convulsive episode, hypoventilation and respiratory acidosis may occur therefore oxygen should be administered via a face mask at 8– 10 L/min and oxygen saturation monitoring commenced prevent maternal injury

National and Unified Obstetric and Newborn care Guidelines and Protocols determine the fetal heart rate – fetal compromise secondary to maternal hypoxaemia or placental abruption will indicate the need for an emergency caesarean section under general anaesthesia -The midwife must remain with the mother constantly and provide assistance with medical treatment. - if the mother dies then fetal death is inevitable. -The woman will require intensive/high dependency care as she may remain comatose for a time following the seizure or may be sleepy. -Clinical observations should be measured and recorded

National and Unified Obstetric and Newborn care Guidelines and Protocols The midwife must observe for periodic restlessness associated with uterine contraction, which indicates that labour has commenced. -The woman's partner should be kept informed and the midwife will need to give emotional support. - It is usual to deliver the baby as soon as possible when eclampsia occurs, initial seizures are usually of short duration but may become prolonged while the woman remains pregnant; in this instance caesarean section is the usual mode of delivery.

National and Unified Obstetric and Newborn care Guidelines and Protocols Anticonvulsant therapy -Magnesium sulphate (MgSO4) is drug of choice to treat and prevent eclampsia rather than diazepam or phenytoin. -It is thought to aid vasodilatation thereby reducing cerebral oedema and preventing seizures. - There is a reduction in the incidence of pneumonia, artificial ventilation and admission to intensive care in women treated with MgSO4 compared with those treated with diazepam -Diazepam is used to control other types of seizures and has a sedative effect and should only be used in the treatment of pre- eclampsia if MgSO4 is not available.

National and Unified Obstetric and Newborn care Guidelines and Protocols MgSO4 is administered intravenously according to a protocol. - a loading dose of 4 g is given over 5–10 min i.v. followed by a maintenance dose of 5 g/500 mL normal saline given as an i.v. infusion at a rate of 1–2 g/hr until 24 hrs following delivery or the last seizure. -Recurrent seizures should be treated with a further bolus of 2 g.

National and Unified Obstetric and Newborn care Guidelines and Protocols -Continuous infusion of MgSO4 can be toxic particularly in women with renal insufficiency. - Early signs and symptoms of toxicity include nausea, weakness, slurred speech, double vision and loss of patellar reflexes. -In more severe cases muscular paralysis, respiratory arrest and cardiac arrest. - The respiratory rate (>14/min) and oxygen saturation levels (>95%) and deep tendon reflexes should be monitored hourly. -In women with oliguria, serum magnesium levels should be monitored and maintained within the therapeutic range (2–3 mmol/L).

National and Unified Obstetric and Newborn care Guidelines and Protocols In the event of toxicity, the MgSO4 infusion should be stopped and ventilatory and circulatory support given as required. -Calcium gluconate (10–20 mL of 10% solution) is the antidote for magnesium toxicity and should be readily available

National and Unified Obstetric and Newborn care Guidelines and Protocols Treatment of hypertension Severe hypertension is defined as >160/110 mmHg or a mean arterial pressure >125 mmHg. -The aim of treating severe hypertension is to avoid the loss of cerebral auto regulation and prevent cerebral hemorrhage. - Intravenous hydralazine is the most useful agent to gain control of the blood pressure quickly; 5–10 mg should be administered slowly intravenously and the blood pressure measured at 5 min intervals until the diastolic pressure reaches 90–100 mmHg

National and Unified Obstetric and Newborn care Guidelines and Protocols The diastolic blood pressure may be maintained at this level by titrating the infusion of hydralazine against the blood pressure. - Labetalol may be used in preference to hydralazine, in which case 20 mg is given i.v. followed at 10-min intervals by 40 mg, 80 mg and 80 mg up to a cumulative dose of 300 mg -Care should be taken when using nifedipine in conjunction with MgSO4 as this may result in excessive calcium channel blockade and potentiate hypotension.

National and Unified Obstetric and Newborn care Guidelines and Protocols Fluid balance -Care must be taken not to overload the maternal system with intravenous fluids as discussed in the management of pre-eclampsia. -Frequent assessment of the fluid intake (intravenous, oral and blood products) and urine output, as well as monitoring by pulmonary function (pulse oximetry and respirations) is essential

National and Unified Obstetric and Newborn care Guidelines and Protocols Anaesthesia Use of anaesthesia in eclampsia is difficult, as the condition of women with eclampsia varies considerably. Both general and regional (epidural/spinal) anaesthesia carry a degree of risk epidural is preferred in eclamptic women who are conscious, haemodynamically stable and cooperative

National and Unified Obstetric and Newborn care Guidelines and Protocols Postnatal care As soon as the baby is born, the woman's partner should be encouraged to hold him and accompany him to the neonatal intensive care unit - It is important that the partner has early interaction with the baby so that an account can be given of the baby's progress from the time of birth. - the midwife should liaise with the neonatal unit staff and explain the treatment given to the baby and the likely prognosis.

National and Unified Obstetric and Newborn care Guidelines and Protocols - A photograph should be taken of the baby so that the mother can see him as soon as she recovers. -Postpartum care should be given, as recommended by and as soon as the mother's condition permits, -she should be taken in her bed or a chair to see her baby. - if the baby's condition is good, he may be returned to his mother.

National and Unified Obstetric and Newborn care Guidelines and Protocols Parameters to monitor are: a return to normal blood pressure, an increase in urine output, reduction in proteinuria, a reduction in oedema and a return to normal laboratory indices. -Antithrombotic agents and the use of thromboelastic stockings will prevent deep vein thrombosis. -Antihypertensive therapy should be maintained and gradually reduced as the blood pressure returns to normal; this may take up to 12 weeks. - Most antihypertensive drugs are compatible with breastfeeding.

National and Unified Obstetric and Newborn care Guidelines and Protocols Future care and management following hypertensive disease Women with a history of severe pre-eclampsia before 32 weeks' gestation have risk of recurrence by this gestational age. -Recent studies have also identified that women who have a history of pre-eclampsia are more likely to develop cardiovascular disease in later life -Usually the blood pressure returns to normal within several weeks but the proteinuria may persist for a longer period.

National and Unified Obstetric and Newborn care Guidelines and Protocols Six weeks after the birth of her baby, the mother is examined by the obstetrician and if all is well, she will be discharged and advised to seek advice as soon as a subsequent pregnancy occurs. -The mother may have very little recollection of the birth and the events surrounding it if she was unconscious or heavily sedated at the time.

National and Unified Obstetric and Newborn care Guidelines and Protocols

HELLP syndrome The syndrome of haemolysis (H) - elevated liver enzymes (EL) - low platelet count (LP).

National and Unified Obstetric and Newborn care Guidelines and Protocols Clinical presentation -HELLP syndrome typically manifests itself between 32 and 34 weeks' gestation and 30% of cases will occur postpartum. -With postpartum presentation, the onset is typically within the first 48 hrs following birth

National and Unified Obstetric and Newborn care Guidelines and Protocols -Women with HELLP syndrome often complain of : -malaise - nausea and vomiting - upper abdominal pain with tenderness -some will have non-specific viral-syndrome- like symptoms. -Hypertension and proteinuria may be minimal or absent

National and Unified Obstetric and Newborn care Guidelines and Protocols Diagnosis -Early diagnosis of HELLP syndrome is critical; any woman presenting with the above symptoms should have a full blood count, platelet count and liver function tests, irrespective of maternal blood pressure. - Haemolysis with elevated lactate dehydrogenase (LDH) and raised bilirubin levels, low (<100 × 109/L) or falling platelets and elevated liver transaminases (AST, ALT and GGT) assist in confirming the diagnosis of HELLP syndrome - A positive D-dimer test (indicator of coagulopathy) in conjunction with pre-eclampsia has also been found to be predictive of women who will develop HELLP syndrome

National and Unified Obstetric and Newborn care Guidelines and Protocols -HELLP syndrome may be classified partial (one or two features of the full (all three features). - It may also be classified on the basis of the platelet Class I <50 × Class II 50–100 × Class III 100–150 × 109/L. -Women with Class I HELLP syndrome are at increased risk for maternal and perinatal morbidity and mortality

National and Unified Obstetric and Newborn care Guidelines and Protocols Complications -Serious maternal complications include : -abruptio placentae -disseminated intravascular coagulation (DIC) -eclampsia -acute renal failure - sub capsular haematoma of the liver

National and Unified Obstetric and Newborn care Guidelines and Protocols -Rupture of the liver is a very rare but potentially fatal complication of the HELLP syndrome and usually presents with severe upper abdominal, neck and shoulder pain, which may persist for several hours. -Radiographic imaging of the liver is required to assess the extent of the damage

National and Unified Obstetric and Newborn care Guidelines and Protocols -surgical intervention and/or liver transplantation, may be required to prevent hemorrhagic shock and liver failure -Infants whose mothers have HELLP syndrome are often small for gestational age and are at risk of perinatal asphyxia

National and Unified Obstetric and Newborn care Guidelines and Protocols Treatment -Prompt recognition of HELLP syndrome and initiation of therapeutic interventions are essential -Women with the HELLP syndrome should be admitted to a consultant unit with intensive or high dependency care facilities available. -Treatment and interventions are based on the gestational age and the health of the mother and fetus. - Corticosteroids may stabilize some of the abnormal biochemical and clinical parameters, as well as aid fetal lung maturity.

National and Unified Obstetric and Newborn care Guidelines and Protocols In term pregnancies, or where there is a deteriorating maternal or fetal condition, immediate delivery is recommended. - A significant number of women with HELLP syndrome also require blood product transfusions to correct the coagulation abnormalities

National and Unified Obstetric and Newborn care Guidelines and Protocols