Pre-eclampsia and Eclampsia

Quick Answer

One-liner: Pre-eclampsia is new-onset hypertension (≥140/90 mmHg) with proteinuria or end-organ dysfunction after 20 weeks gestation; eclampsia is the occurrence of seizures in this context. ICU management focuses on BP control, seizure prophylaxis with magnesium sulfate, and supportive care for multi-organ dysfunction until delivery.

Pre-eclampsia affects 2-8% of pregnancies globally and remains a leading cause of maternal mortality, accounting for 10-15% of maternal deaths worldwide [1]. Aboriginal and Torres Strait Islander women and Māori women experience 2-3× higher maternal mortality rates from hypertensive disorders [2]. ICU priorities are rapid blood pressure control (target below 160/110 mmHg, then 130-150/80-100), seizure prophylaxis with magnesium sulfate (4g loading, then 1g/hour), and supportive organ failure management. The definitive treatment is delivery of the placenta. ICU mortality ranges from 1-3% for severe pre-eclampsia, up to 10% for HELLP syndrome with complications.

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CICM Exam Focus

Primary Exam Relevance

• Physiology: Angiogenic factor balance (sFlt-1, PlGF, VEGF), endothelial dysfunction, renin-angiotensin-aldosterone changes in pregnancy, uteroplacental circulation
• Pharmacology: Magnesium sulfate (NMDA antagonism, calcium channel blockade), labetalol pharmacokinetics in pregnancy, hydralazine metabolism, calcium gluconate as antidote
• Pathology: Glomerular endotheliosis, hepatic periportal necrosis in HELLP, cerebral white matter oedema in PRES

Fellowship Exam Relevance

• Written: Diagnostic criteria, ICU admission criteria, magnesium dosing and toxicity, antihypertensive selection, BP targets (CHIPS trial), HELLP management, delivery timing, postpartum complications
• Viva: Eclamptic seizure in ICU, HELLP with hepatic complications, pulmonary oedema management, PRES recognition, postpartum pre-eclampsia requiring ICU, ethical considerations in periviable delivery
• Key domains tested: Medical Expert, Communicator, Collaborator, Leader, Health Advocate

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Key Points

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Epidemiology

Australian/NZ Specific

Indigenous Health Disparities:

• Aboriginal and Torres Strait Islander maternal mortality ratio: 17.5 per 100,000 vs 5.5 per 100,000 for non-Indigenous women (2012-2021) [2]
• Māori women: 2× higher maternal mortality than NZ Europeans [10]
• Higher rates of ICU admission for severe pre-eclampsia (OR 1.8) [11]
• Earlier onset pre-eclampsia, more severe at presentation
• Higher prevalence of chronic hypertension, renal disease, diabetes
• Delayed antenatal care access contributes to later diagnosis and ICU presentation

Rural/Remote Variations:

• Late presentation more common due to distance from tertiary centres
• Higher severity at ICU admission (more HELLP, AKI, pulmonary oedema)
• RFDS retrieval for pre-term deliveries and maternal stabilisation common [12]
• Limited access to early antenatal screening and preventive care
• Higher rates of postpartum eclampsia requiring readmission

ICU Utilisation Patterns:

• Larger ICUs (greater than 20 beds) have better maternal outcomes (case-mix adjusted mortality OR 0.67) [13]
• Tertiary obstetric ICUs have lower mortality than regional ICUs for HELLP
• Multidisciplinary obstetric ICU models improve outcomes

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Pathophysiology

Two-Stage Model

Stage 1: Abnormal Placentation (First Trimester)

• Failed remodelling of maternal spiral arteries by extravillous trophoblasts
• Spiral arteries retain high-resistance, muscular structure
• Results in placental hypoxia and oxidative stress [14]

Stage 2: Maternal Syndrome (Second/Third Trimester)

• Hypoxic placenta releases anti-angiogenic factors
• Systemic endothelial dysfunction develops
• Multi-organ involvement ensues

Angiogenic Factor Imbalance

Placental Hypoxia
       ↓
↑ sFlt-1 (soluble fms-like tyrosine kinase-1)
↑ Soluble Endoglin (sEng)
       ↓
Sequestration of VEGF and PlGF
       ↓
Endothelial Dysfunction
       ↓
Hypertension + Proteinuria + End-Organ Damage

Key Molecules:

• sFlt-1: Decoy receptor binding VEGF/PlGF (elevated in pre-eclampsia) [15]
• PlGF: Placental growth factor (reduced in pre-eclampsia) [16]
• sEng: Inhibits TGF-β signalling, contributes to endothelial dysfunction [17]
• sFlt-1/PlGF ratio greater than 38: Highly predictive of pre-eclampsia development (PROGNOSIS study) [18]

Why It Matters Clinically

Endothelial damage explains:

• Proteinuria: Glomerular endotheliosis (endothelial cell swelling, capillary lumen occlusion)
• Hypertension: Vasoconstriction, increased vascular resistance
• Oedema: Capillary leak (interstitial) but intravascular depletion
• HELLP: Hepatic periportal necrosis, fibrin deposition
• Pulmonary oedema: Cardiac diastolic dysfunction, increased capillary permeability
• Cerebral involvement: Autoregulation failure, PRES, eclampsia
• Renal impairment: Afferent arteriolar vasoconstriction, AKI
• Fetal growth restriction: Placental insufficiency, reduced uteroplacental flow

ICU-Relevant Pathophysiological Considerations

Haemodynamics:

• Reduced plasma volume (15-20% decrease vs normal pregnancy)
• Increased SVR (systemic vascular resistance)
• Left ventricular diastolic dysfunction in severe disease
• Increased cardiac output requirement but impaired filling

Fluid Balance Paradox:

• Intravascular depletion: Due to endothelial leak, proteinuria, reduced oncotic pressure
• Interstitial overload: Capillary leak causes oedema
• Clinical implication: High risk of pulmonary oedema with seemingly "appropriate" fluid resuscitation

Coagulation:

• Thrombocytopenia (platelet consumption)
• Low-grade DIC in 5-10% of severe cases
• Increased fibrinolysis in HELLP

Renal:

• Afferent arteriolar vasoconstriction
• Reduced GFR despite normal filtration fraction
• Sodium and water retention despite intravascular depletion

Cerebral:

• Loss of cerebral autoregulation at lower BP than non-pregnant state
• Posterior circulation most vulnerable (PRES pattern)
• Blood-brain barrier disruption contributes to seizures

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Definitions and Diagnostic Criteria

Classification (SOMANZ/ISSHP)

Diagnostic Criteria for Pre-eclampsia (SOMANZ 2023) [3]

Hypertension: BP ≥140/90 mmHg on two occasions ≥4 hours apart after 20 weeks gestation

PLUS one or more of:

Severe Features (Warrants Immediate ICU Consideration) [19]

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HELLP Syndrome

Diagnostic Criteria (Tennessee Classification) [20]

Mississippi Classification (Severity)

HELLP Complications

ICU Management of HELLP

Important Note: HELLP Syndrome ICU Management Principles:

1. Urgent delivery planning - definitive treatment, usually within 24-48h
2. Platelet threshold for regional anaesthesia - platelets ≥80 × 10⁹/L (relative), ≥50 × 10⁹/L (absolute if epidural bleeding risk acceptable)
3. Blood product preparedness - crossmatch 4-6 units PRBCs, FFP, platelets on standby
4. Corticosteroids - betamethasone 12mg IM q24h ×2 for fetal lung maturity; dexamethasone 10mg IV q12h may improve maternal lab parameters (evidence mixed)
5. Monitor for complications - DIC, hepatic haematoma, abruption, pulmonary oedema
6. Postpartum ICU observation - HELLP may worsen or develop postpartum (first 24-48h critical)
7. Avoid excessive fluids - capillary leak, pulmonary oedema risk

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Clinical Approach

Recognition

High-Risk Patients for ICU Admission:

• Primigravida
• Age extremes (below 20 or greater than 40 years)
• Multiple gestation
• Pre-existing hypertension, renal disease, diabetes
• Previous pre-eclampsia (especially severe/early-onset)
• Antiphospholipid syndrome, SLE
• BMI greater than 35
• IVF pregnancy
• Indigenous women (Aboriginal, Torres Strait Islander, Māori)
• Chronic hypertension with superimposed pre-eclampsia

Initial Assessment

Primary Survey

• A: Patent airway (eclamptic seizure may compromise), cervical spine if seizure with trauma
• B: SpO2 (pulmonary oedema), RR, work of breathing, ABG if concerning
• C: BP (manual sphygmomanometer - automated may underestimate), HR, ECG, IV access ×2, bloods
• D: GCS, pupils, hyperreflexia, clonus (greater than 3 beats = pathological), focal signs
• E: Epigastric tenderness (liver capsule), oedema assessment, fundal height, uterine tenderness

Secondary Survey - ICU Focus

History

Key Questions for ICU Admission

Red Flag Symptoms

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Investigations

Immediate (Resus Bay - Pre-ICU Transfer)

Standard ICU Admission Workup

Advanced/Specialist

Point-of-Care Ultrasound (ICU Applications)

Lung:

• B-lines for pulmonary oedema
• Pleural effusions
• Diaphragm excursion

Cardiac (TTE):

• LV systolic and diastolic function
• RV strain
• Valvular disease
• Volume status (IVC collapsibility, stroke volume variation)

Abdominal:

• Free fluid (haemoperitoneum, liver haematoma)
• Liver capsule integrity
• Gallbladder (cholecystitis mimics epigastric pain)

Neurological:

• Optic nerve sheath diameter (ICP surrogate) - limited evidence

Obstetric (if trained):

• Fetal heart rate
• Presentation
• Amniotic fluid index

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ICU Management

Immediate Management (First 10 Minutes)

1. CALL FOR HELP - ICU team, obstetrics, anaesthetics, paediatrics
2. LARGE BORE IV ACCESS x2 (14G/16G)
3. BLOODS: FBC, LFT, UEC, coag, G&H, magnesium level, ABG
4. BP CONTROL if ≥160/110 (treat within 30-60 min)
5. MAGNESIUM SULFATE if severe/eclampsia
6. CONTINUOUS CTG MONITORING
7. STRICT FLUID BALANCE (avoid overload)
8. URINARY CATHETER with hourly urine output
9. O2 if SpO2 below 94%
10. PREPARE FOR POSSIBLE INTUBATION

ICU Admission Criteria

Important Note: Admit to ICU for:

• Eclampsia (especially with recurrent seizures, status epilepticus)
• Severe hypertension requiring IV infusion (despite oral/IV bolus therapy)
• Pulmonary oedema requiring CPAP/NIV or intubation
• HELLP syndrome (especially Class 1, hepatic complications, DIC)
• AKI requiring renal replacement therapy
• Altered consciousness or PRES
• Postpartum deterioration requiring level 2-3 care
• Postoperative ICU care post-delivery (caesarean under general anaesthesia)
• Multidisciplinary coordination requirement
• Remote/rural transfer stabilisation

Eclamptic Seizure Management in ICU

During Seizure:

1. Call for help - note time, duration
2. Position: Left lateral (prevents aspiration, optimises uterine blood flow)
3. Airway: Do NOT insert tongue blade, clear secretions, give O2 15 L/min
4. Protect from injury (side rails, soft surroundings, bed rails up)
5. Most seizures self-terminate within 60-90 seconds
6. Prepare medications: magnesium, benzodiazepines

Post-Seizure/Stabilisation:

1. Assess ABCDE: Airway protection (consider intubation if GCS below 8, recurrent seizures)
2. Magnesium sulfate (if not already given) - see below
3. If recurrent seizure: Additional MgSO4 2g IV bolus
4. If refractory (greater than 2 seizures despite Mg): IV diazepam 5-10mg or IV midazolam 2-5mg
5. Do NOT give phenytoin (inferior to MgSO4, teratogenic risk) [21]
6. CT head - exclude ICH, PRES (especially if postictal GCS below 13, focal deficit)
7. ICU monitoring: EEG if status epilepticus suspected

Status Epilepticus in Eclampsia:

• Follow standard status epilepticus protocol
• First-line: Benzodiazepines (lorazepam 0.1 mg/kg IV)
• Second-line: Phenytoin 15-20 mg/kg IV (if magnesium failed) OR Levetiracetam
• Consider rapid sequence intubation if prolonged, airway compromise
• Continue magnesium throughout

Magnesium Sulfate Protocol

MAGPIE Trial Evidence [22]

• 58% reduction in eclampsia (RR 0.42, 95% CI 0.29-0.60)
• NNT = 63 for moderate pre-eclampsia
• NNT = 109 for mild pre-eclampsia
• Maternal mortality reduced (RR 0.55, 95% CI 0.26-1.18)
• Number needed to treat to prevent one maternal death = 100 (trend)

Dosing Regimen (SOMANZ 2023) [3]

Alternative IM Regimen (IV Access Unavailable)

• Loading: 4g IV + 5g IM each buttock (10g IM total)
• Maintenance: 5g IM every 4 hours in alternating buttocks

Magnesium in Renal Failure/AKI

Magnesium Pharmacokinetics

Monitoring for Magnesium Toxicity

Magnesium Toxicity Progression

Therapeutic: 2-3.5 mmol/L → Seizure prevention
Loss of reflexes: 3.5-5 mmol/L → STOP infusion
Respiratory depression: 5-6.5 mmol/L → Support ventilation
Cardiac arrest: greater than 6.5 mmol/L → CPR + calcium

Magnesium Toxicity Treatment

1. STOP magnesium infusion immediately
2. Calcium gluconate 1g (10 mL of 10%) IV over 10 minutes
   • Repeat if no improvement in 5-10 minutes (max 3g)
3. Supportive care:
   • Airway protection
   • Bag-mask ventilation if apnoeic
   • Intubation and mechanical ventilation if needed
4. Check serum magnesium level
5. ECG monitoring (may show prolonged PR, widened QRS, bradyarrhythmias)
6. Do NOT give diuretics (will further reduce Mg clearance)

Antihypertensive Therapy

Blood Pressure Targets (CHIPS Trial Evidence)

CHIPS Trial (Control of Hypertension In Pregnancy Study) [23]:

• Design: RCT comparing less-tight (diastolic 85 mmHg) vs tight (diastolic 100 mmHg) control
• N: 983 women with chronic hypertension or gestational hypertension
• Primary outcome: Composite of perinatal loss or high-level neonatal care
• Results: Perinatal outcomes similar between groups (RR 0.97, 95% CI 0.80-1.17)
• Maternal outcomes: Less-tight control had higher maternal complications (RR 1.34, 95% CI 1.02-1.77)
• Conclusion: Target diastolic BP 85 mmHg (less-tight) did not improve perinatal outcomes but increased maternal complications

Important Note: BP Targets for ICU Management:

• Acute severe hypertension (≥160/110): Treat within 30-60 min
• Initial target: below 160/110 mmHg
• Maintenance target: 130-150 / 80-100 mmHg (SOMANZ 2023)
• Avoid precipitous drops: Risk of placental hypoperfusion, fetal distress
• Permissive hypertension: 150-160 systolic acceptable if asymptomatic

First-Line Options (All Equally Effective) [24]

Labetalol Escalating Regimen (Standard)

1. 20mg IV bolus
2. If no response in 10 min: 40mg IV
3. If no response: 80mg IV
4. If no response: 80mg IV (max cumulative 300mg)
5. Then commence infusion 1-2 mg/min if needed

Labetalol Infusion Protocol

Starting dose: 1 mg/min (60 mg/hour)
Titration: Increase by 0.5 mg/min q15min until BP target
Maximum: 4 mg/min (240 mg/hour)
Monitoring: BP q5-15min initially, HR, ECG
Stop if: HR below 60, systolic BP below 130

Hydralazine Protocol

Starting dose: 5mg IV bolus
If no response in 20 min: 10mg IV
If no response: 10mg IV (max 20mg)
Duration: 2-6 hours per dose
Monitoring: BP q10-20min, HR (tachycardia expected)

Nifedipine Protocol

Starting dose: 10mg PO (immediate release)
If no response in 20 min: 20mg PO
If no response: 20mg PO (max 50mg)
Duration: 4-8 hours per dose
Monitoring: BP q10-30min
Avoid: Sublingual (unpredictable, precipitous hypotension)
Interaction: May potentiate MgSO4 effect (monitor closely)

Second-Line/Refractory Hypertension

Fluid Management

Important Note: CRITICAL: Avoid fluid overload in pre-eclampsia

• Pre-eclamptic patients have intravascular depletion but interstitial overload
• Capillary leak due to endothelial dysfunction
• Pulmonary oedema is a leading cause of maternal death
• Restrict total IV fluid to 80-100 mL/hour (including drug infusions)
• Target urine output ≥25 mL/hour (≥0.5 mL/kg/hr)
• Avoid colloids (increases capillary leak)
• Use Hartmann's or N/Saline
• Consider diuretics for pulmonary oedema despite low CVP (interstitial overload)

Fluid Protocol

Fluid Balance Monitoring

• Hourly urine output (catheter)
• Strict intake/output chart
• Daily weights (if not too unstable)
• CVP (if line in situ) - interpret with caution (poor predictor of volume status)
• Bedside echo (IVC collapsibility, LV filling)
• Lung ultrasound (B-lines for pulmonary oedema)

Mechanical Ventilation Considerations

Indications for Intubation

• GCS below 8 (protect airway)
• Refractory seizures/status epilepticus
• Severe respiratory failure (SpO2 below 90% on NIV, PaO2/FiO2 below 150)
• Pulmonary oedema requiring intubation (CPAP/NIV failure)
• Airway protection for procedures (caesarean)
• Coma/PRES with impaired airway reflexes

Ventilation Strategy

Considerations in Pregnancy

• Supine position - avoid aortocaval compression (left lateral tilt 15°)
• Higher minute ventilation - maintain normocapnia
• Lower PaCO2 normal - 30-32 mmHg in normal pregnancy
• Avoid excessive PEEP - reduces uterine blood flow
• Sedation - propofol, midazolam, fentanyl safe; avoid ketamine (↑BP)
• Paralysis - rocuronium, vecuronium safe

Renal Replacement Therapy (RRT)

Indications in Pre-eclampsia

Important Note: RRT Indications:

• Refractory hyperkalaemia (K+ greater than 6.5 despite medical management)
• Severe metabolic acidosis (pH below 7.15 or HCO3 below 10)
• Volume overload/pulmonary oedema refractory to diuretics
• Uremic complications (pericarditis, encephalopathy)
• Oliguria/anuria with rising creatinine
• Toxic metabolite removal (if indicated)
• Severe AKI with expected duration greater than 5 days

RRT Modality Selection

CRRT Prescription

Effluent dose: 20-25 mL/kg/hour
Blood flow: 150-200 mL/min
Dialysate flow: 500 mL/min (CVVHD) or 1000 mL/hour (CVVHDF)
Replacement fluid: Pre-dilution or mixed (CVVH)
Anticoagulation: Regional citrate preferred (reduce bleeding risk)
Duration: Until renal recovery or patient transferred to nephrology

RRT and Magnesium

• CRRT removes magnesium (70-80% clearance)
• Adjust magnesium dose during CRRT: 0.5g/hour or monitor levels q6-12h
• Check magnesium level after 4-6 hours of CRRT initiation
• Consider extra magnesium bolus if levels drop below 2 mmol/L

Coagulation and Blood Product Management

Coagulation Abnormalities

Blood Product Preparation (HELLP)

Crossmatch: 4-6 units PRBCs (O negative if emergency)
FFP: 2-4 units available
Platelets: 1 pool (5 units) available
Cryoprecipitate: 10U available (if fibrinogen low)

Massive Transfusion Protocol

• Activate if: greater than 4 units PRBCs in 4 hours, greater than 1 unit/hour ongoing
• Ratio: 1:1:1 (PRBC:FFP:Platelets)
• Check fibrinogen q30min
• Use point-of-care testing (TEG/ROTEM) if available
• Give tranexamic acid 1g IV (if not contraindicated)

Regional Anaesthesia and Coagulation

Fetal Considerations

Antenatal Corticosteroids

Administer if delivery anticipated below 34+6 weeks:

Betamethasone (Preferred):

• 11.4mg IM (Celestone Chronodose)
• Two doses, 24 hours apart
• Fetal lung maturation, reduces IVH, RDS, necrotising enterocolitis

Dexamethasone:

• 6mg IM
• Four doses, 12 hours apart

Late Preterm (34+0 to 36+6 weeks):

• Consider single course if delivery likely within 7 days and no prior course (ALPS trial) [25]
• Betamethasone 12mg IM ×2 doses, 24 hours apart

Rescue Course:

• If greater than 14 days since first course and still below 34 weeks
• Repeat betamethasone course

Fetal Monitoring

• Continuous CTG if admitted
• Abnormalities: Late decelerations, reduced variability, sinusoidal pattern
• Ultrasound: Growth, AFI, Doppler (umbilical artery, MCA)
• Biophysical profile if reduced fetal movements or growth restriction

Delivery Timing

Immediate Delivery Indications (Regardless of Gestation)

Postpartum Management

Postpartum ICU Considerations

• Fluid mobilisation: Third-spacing fluid mobilises day 2-4
• Pulmonary oedema risk: High in first 24-48 hours postpartum
• BP worsening: May worsen in first week postpartum
• HELLP progression: May develop or worsen postpartum (first 48h critical)
• Magnesium: Continue for 24 hours post-delivery

Postpartum Pre-eclampsia

Incidence and Risk:

• Occurs up to 6 weeks postpartum
• 63% of delayed postpartum pre-eclampsia have no antepartum hypertensive disease [27]
• Present with headache, visual changes, hypertension
• Highest risk: 3-6 days postpartum

Management:

• Same as antepartum (labetalol, hydralazine, nifedipine)
• Magnesium sulfate for severe features or seizures
• Avoid NSAIDs (worsen hypertension, fluid retention)
• Avoid ergometrine (causes vasoconstriction)
• Outpatient BP monitoring if mild
• Clear return advice

Long-Term Cardiovascular Risk

Pre-eclampsia as a Cardiovascular Risk Marker:

• 2× increased lifetime risk of cardiovascular disease
• 4× risk of chronic hypertension
• 3.7× risk of ischaemic heart disease
• 4.2× risk of heart failure
• 1.8× risk of stroke

Counselling at Discharge:

• Lifestyle modification (weight, exercise, diet)
• Annual BP monitoring
• Cardiovascular risk factor screening (lipids, glucose)
• Consider aspirin prophylaxis in future pregnancies
• Preconception counselling for future pregnancies [28]

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Special Populations

Atypical Presentations

• Pre-eclampsia without proteinuria: End-organ dysfunction alone sufficient for diagnosis
• HELLP without hypertension: 15-20% of HELLP cases present with normal BP [20]
• Eclampsia as first presentation: 20% have no preceding symptoms
• Postpartum presentation: Up to 6 weeks, de novo in 63%
• Chronic hypertension with superimposed pre-eclampsia: Earlier, more severe

Pre-existing Chronic Hypertension

Diagnostic Challenge:

• Elevated BP before 20 weeks
• Distinguish from gestational hypertension
• Superimposed pre-eclampsia: Sudden BP rise, proteinuria, end-organ dysfunction

Management:

• Continue chronic antihypertensives if safe
• Avoid ACE inhibitors/ARBs throughout pregnancy
• Labetalol, nifedipine, methyldopa preferred
• Earlier delivery consideration (often 37-38 weeks)

Multiple Gestation

Higher Risk:

• 2-3× increased risk of pre-eclampsia
• Earlier onset, more severe
• Higher rate of HELLP

Management:

• Low threshold for admission
• Earlier delivery consideration
• More aggressive BP control

Obesity (BMI greater than 35)

Management Challenges:

• Difficult BP measurement (larger cuff)
• Difficult IV access
• Higher risk of pulmonary oedema
• Technical challenges for caesarean

ICU Considerations:

• Larger tidal volumes required
• Higher PEEP often needed for oxygenation
• Higher risk of aspiration

Pre-existing Renal Disease

Diagnostic Challenge:

• Elevated creatinine baseline
• Proteinuria baseline
• Differentiate superimposed pre-eclampsia

Management:

• Earlier nephrology input
• Lower threshold for RRT
• Adjust drug dosing (magnesium, antihypertensives)

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Indigenous Health

Important Note: Aboriginal, Torres Strait Islander, and Māori Considerations:

Health Disparities:

• Aboriginal/Torres Strait Islander maternal mortality: 17.5/100,000 vs 5.5/100,000 non-Indigenous [2]
• Māori maternal mortality: 2× higher than NZ Europeans [10]
• Higher rates of ICU admission for severe pre-eclampsia (OR 1.8) [11]
• Higher rates of chronic hypertension, diabetes, renal disease
• Earlier onset and more severe pre-eclampsia
• Later presentation to antenatal care
• Higher severity at ICU admission

Barriers to Care:

• Geographic isolation (remote communities, 4-6+ hours to tertiary centre)
• Transport challenges to tertiary maternity services
• Cultural safety concerns may delay presentation
• Language barriers (English as second language)
• Mistrust of health system due to historical trauma
• Family responsibilities (caring for other children)
• Financial constraints (travel costs)

Cultural Safety Approaches:

• Involve Aboriginal Health Workers/Aboriginal Liaison Officers immediately
• Māori Health Workers/Kaiāwhina for NZ patients
• Family-centred care (whānau involvement in decision-making)
• Respect for cultural practices around birth (Birthing on Country)
• Clear, jargon-free communication
• Consider cultural protocols around bad news
• Involve Elders if appropriate and requested
• Plan for "Birthing on Country" support where possible
• Ensure interpreter services if required
• Acknowledge connection to Country/whenua
• Allow time for family decision-making (collective vs individual)

Clinical Implications:

• Lower threshold for ICU admission and tertiary transfer
• Early involvement of multidisciplinary team
• Proactive transfer planning for remote patients (RFDS)
• Consider social supports for relocation of family
• Ensure culturally safe discharge planning
• Longer ICU observation period if concerns

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Remote/Rural Considerations

Pre-Hospital/Remote Area Management

• Early activation of retrieval services (RFDS, state-based retrieval)
• Remote Area Nurses (RANs) and Rural GPs: Initial stabilisation
• Telemedicine consultation with tertiary obstetric/ICU service
• Have magnesium sulfate and antihypertensives available
• Urinary catheter for output monitoring
• Manual BP monitoring (automated may be inaccurate in pre-eclampsia)

Resource-Limited Setting Management

RFDS/Retrieval Medicine

Pre-eclampsia/eclampsia retrieval considerations:

• Common indication for maternal retrieval [12]
• Risk of "in-flight birth"
• ensure obstetric kit available
• Neonatal resuscitation capability required
• Consider flight physiology (mild hypoxia at altitude)
• Secure IV access and magnesium infusion before flight
• Continue CTG monitoring if possible

In-flight considerations:

• Physiological stress: Hypoxia, vibration, noise
• Fluid shifts: Microgravity effect
• Reduced barometric pressure: Mild hypoxaemia
• Limited access: Cannot stop for emergencies

Retrieval Criteria:

• Severe pre-eclampsia below 34 weeks
• Any eclampsia
• HELLP syndrome
• Need for delivery without local surgical/anaesthetic capability
• Preterm labour in context of pre-eclampsia
• Postpartum deterioration
• Pulmonary oedema
• Severe hypertension refractory to oral therapy

Telemedicine

• Real-time consultation with tertiary MFM specialists
• Photo of blood film (schistocytes for HELLP)
• Shared CTG review
• Decision support for expectant management vs transfer
• Video conferencing for family discussions
• Remote monitoring of vitals if available

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Differential Diagnosis

Conditions Mimicking Pre-eclampsia

HELLP Mimics

When to Consider Alternative Diagnoses

• Onset before 20 weeks gestation
• ADAMTS13 below 10% (TTP - urgent plasma exchange)
• Hypoglycaemia or encephalopathy (AFLP)
• Severe AKI out of proportion to other features (HUS)
• Thrombosis or recurrent pregnancy loss history (APS)
• Active SLE with complement consumption
• Fever, severe neurological symptoms, renal failure out of proportion (TTP)
• Diarrhoea prodrome (typical HUS)

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Complications

Maternal Complications

Posterior Reversible Encephalopathy Syndrome (PRES)

Pathophysiology:

• Failure of cerebral autoregulation
• Hyperperfusion → capillary leak → vasogenic oedema
• Posterior circulation most vulnerable (less sympathetic innervation)

Clinical Features:

• Headache (severe)
• Visual disturbances (cortical blindness, scotomata)
• Altered consciousness
• Seizures
• Focal neurological deficits

MRI Findings:

• Bilateral posterior white matter hyperintensities (T2/FLAIR)
• Parieto-occipital lobes typical
• Restricted diffusion if cytotoxic oedema (infarction)

Management:

• BP control (target 140-150 systolic)
• Magnesium sulfate
• Seizure prophylaxis/treatment
• ICU monitoring
• Usually reversible with BP control

ICU Considerations:

• Continuous EEG if seizures suspected
• Neuroprotective care (avoid hypoxia, hyperglycaemia)
• Neurological assessment q1-2h
• Consider ICP monitoring if severe oedema

Fetal/Neonatal Complications

Long-Term Maternal Sequelae

Pre-eclampsia is associated with significant long-term cardiovascular risk:

Counselling Points:

• Lifestyle modification (weight, exercise, diet)
• Annual BP monitoring
• Cardiovascular risk factor screening (lipids, glucose, BMI)
• Consider aspirin prophylaxis in future pregnancies
• Preconception counselling for future pregnancies
• Primary prevention interventions (statins, antihypertensives) if indicated

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Prognosis

Maternal Outcomes

Factors Associated with Poor Maternal Outcome:

• Late presentation (greater than 34 weeks) with severe features
• Delayed treatment of severe hypertension
• HELLP with hepatic complications
• Eclampsia (especially remote from medical care)
• Aboriginal, Torres Strait Islander, or Māori ethnicity (due to systemic barriers)
• Remote geographic location
• Pulmonary oedema
• Cerebral haemorrhage
• DIC with bleeding

ICU Prognostic Factors:

• APACHE II score on admission
• SOFA score trend
• Platelet count trajectory
• Serum creatinine
• Lactate level
• Need for mechanical ventilation
• Need for RRT

Fetal/Neonatal Outcomes

Recurrence Risk

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Pharmacology Details

Magnesium Sulfate Pharmacology

Clinical Pearls:

• Does NOT lower blood pressure (separate antihypertensive needed)
• Continue for 24 hours after delivery OR last seizure
• Monitor closely if oliguria (accumulation risk)
• Fetal effects: transient hypotonia, decreased variability on CTG (rare)
• Reduces cerebral vasogenic oedema (mechanism of PRES reversal)

Antihypertensive Pharmacology

Labetalol

ICU Considerations:

• Can cause bronchospasm in asthmatics
• May mask hypoglycaemia symptoms
• Useful in patients with tachycardia from other antihypertensives
• Avoid in severe heart failure (negative inotrope)

Hydralazine

ICU Considerations:

• Headache may mimic worsening pre-eclampsia
• Reflex tachycardia expected
• Avoid in tachyarrhythmias
• May worsen myocardial ischaemia in CAD

Nifedipine

ICU Considerations:

• Useful when IV access unavailable
• Interaction with magnesium: both cause vasodilation, monitor for hypotension
• Avoid in severe aortic stenosis
• CYP3A4 inhibitors increase levels (clarithromycin, azole antifungals)

Calcium Gluconate (Magnesium Antidote)

ICU Considerations:

• Have drawn up and readily available when starting magnesium
• Check magnesium level after administration
• May need repeated doses in severe toxicity
• Supportive care (ventilation) still required if respiratory depression
• Does NOT remove magnesium (just antagonises effects)

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Quality Assurance Checklist

Pre-eclampsia ICU Management Bundle

On Arrival:

• Manual BP confirmed ≥140/90
• IV access established (×2 large bore)
• Bloods sent: FBC, LFT, UEC, coagulation, G&H, magnesium, ABG
• Urinalysis performed (or PCR sent)
• Fetal heart rate assessed (CTG if greater than 24 weeks)
• Rapid bedside assessment (ABCDE)

Severe Features (BP ≥160/110 or symptoms):

• Antihypertensive given within 30-60 minutes
• MgSO4 loading dose given (4g IV over 20 min)
• MgSO4 infusion commenced (1g/hour)
• ICU team notified
• Obstetric team notified
• Anaesthetic team alerted
• Paediatric team alerted (if preterm)
• CTG monitoring initiated
• Steroids given if below 34+6 weeks

ICU Admission:

• Monitor BP q15min until stable, then q1h
• Hourly urine output
• Patellar reflexes q4h
• Respiratory rate monitored continuously
• Magnesium level checked (if indicated)
• Repeat bloods 6-12 hourly
• Fluid balance chart (restrictive)
• Daily weight (if stable)
• Daily bedside echo (if indicated)

Documentation:

• Time of antihypertensive administration
• Time of MgSO4 loading and infusion start
• Delivery plan discussed with patient
• Risks and benefits explained
• Red flag advice given (patient and family)

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Pitfalls & Pearls

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CICM SAQ Practice

SAQ 1 (15 marks)

Stem: A 32-year-old primigravida at 28 weeks gestation is admitted to ICU with severe pre-eclampsia. Her BP is 174/116 mmHg, she has a severe headache, and visual disturbances. Initial investigations show platelets 58 × 10⁹/L, ALT 345 U/L, creatinine 112 μmol/L.

Question: Outline your immediate management priorities and justify your approach with relevant evidence.

Model Answer:

This patient has severe pre-eclampsia with HELLP syndrome (Class 1 - platelets below 50, elevated LFT, renal impairment). My management priorities are:

1. Immediate stabilisation (2 marks)

• ABC assessment: Airway protection if altered GCS, oxygen if SpO2 below 94%
• Large bore IV access ×2
• Manual BP confirmation (automated may underestimate)
• ICU monitoring: ECG, SpO2, continuous BP

2. Seizure prophylaxis (3 marks)

• Magnesium sulfate 4g IV loading over 20 minutes
• Then 1g/hour maintenance infusion
• Justification: MAGPIE trial showed 58% reduction in eclampsia (RR 0.42), NNT 63 for moderate pre-eclampsia [22]
• Continue for 24 hours after delivery or last seizure
• Monitor: patellar reflexes, respiratory rate, urine output, magnesium level (if oliguria)

3. Blood pressure control (3 marks)

• Indication: BP ≥160/110 - treat within 30-60 min to prevent stroke
• Target: Initial below 160/110, then 130-150/80-100 mmHg
• First-line: IV labetalol 20mg bolus, repeat 40mg, 80mg, 80mg q10min (max 300mg)
• OR oral nifedipine 10-20mg (if IV access issues)
• Justification: CHIPS trial showed less-tight control (diastolic 85) did not improve perinatal outcomes but increased maternal complications (RR 1.34) [23]
• Avoid precipitous drops (risk of placental hypoperfusion)

4. HELLP syndrome management (2 marks)

• Notify obstetrics, anaesthetics, paediatrics
• Blood products prepared: crossmatch 4-6 units PRBCs, FFP, platelets on standby
• Consider corticosteroids: Dexamethasone 10mg IV q12h (may improve maternal lab parameters, evidence mixed)
• Plan delivery within 24-48 hours (definitive treatment)

5. Fetal considerations (1 mark)

• Continuous CTG monitoring
• Betamethasone 11.4mg IM ×2 doses, 24 hours apart (fetal lung maturity)
• Ultrasound: growth, AFI, Doppler

6. ICU supportive care (2 marks)

• Strict fluid restriction: 80-100 mL/hour total (avoid pulmonary oedema)
• Urinary catheter: hourly urine output (greater than 25 mL/hour)
• Monitor for complications: pulmonary oedema, AKI, PRES, DIC
• Daily bloods: FBC, LFT, UEC, coagulation

7. Multidisciplinary coordination (2 marks)

• Early obstetric review (delivery timing)
• Anaesthetic review (regional vs general anaesthesia for caesarean)
• Neonatal team (preterm delivery at 28 weeks)
• Consider tertiary transfer if local NICU unavailable

Examiner Notes:

• Accept: Alternative antihypertensives (hydralazine 5-10mg IV)
• Accept: Detailed magnesium toxicity monitoring
• Accept: Discussion of regional anaesthesia contraindication with platelets below 50
• Do not accept: Sublingual nifedipine, ACE inhibitors, excessive fluids
• Must mention: MAGPIE and CHIPS trials for justification

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SAQ 2 (15 marks)

Stem: A 26-year-old woman at 35 weeks gestation has a generalised tonic-clonic seizure in ICU while being observed for pre-eclampsia. She becomes apnoeic and GCS drops to 3/15. Her BP is 188/118 mmHg.

Question: a) Describe your immediate management during the seizure (5 marks) b) Outline your ICU management post-seizure (10 marks)

Model Answer:

a) Immediate management during seizure (5 marks):

1. Call for help (1 mark) - ICU team, obstetrics, anaesthetics, airway equipment

2. Positioning (1 mark):

   • Left lateral position (prevents aspiration, optimises uterine blood flow)
   • Protect from injury (side rails, remove objects)
   • Do NOT insert tongue blade or objects into mouth

3. Airway management (1 mark):

   • Clear secretions (suction)
   • Administer oxygen 15 L/min via face mask
   • Assess airway patency

4. Monitoring (1 mark):

   • Note time and duration of seizure
   • Continuous ECG, SpO2, BP monitoring
   • Prepare for intubation if prolonged

5. Most seizures self-terminate (1 mark):

   • If greater than 3 minutes: Prepare for airway intervention
   • If greater than 5 minutes: Consider benzodiazepines (lorazepam 0.1 mg/kg IV)

b) ICU management post-seizure (10 marks):

1. Airway and ventilation (2 marks):

• Assess GCS: If GCS below 8 or inadequate airway protection: Intubate
• RSI: Preoxygenation, cricoid pressure, rapid sequence agents (ketamine avoided - ↑BP, use propofol/rocuronium)
• Ventilation strategy: Normocapnia (PaCO2 35-45), avoid hypocapnia (uterine vasoconstriction)
• Maintain left lateral tilt 15°

2. Seizure control (2 marks):

• Magnesium sulfate 4g IV loading over 20 minutes (if not already infusing)
• Then 1g/hour maintenance infusion
• If recurrent seizure: Additional MgSO4 2g IV bolus
• If refractory (greater than 2 seizures despite Mg): IV diazepam 5-10mg or midazolam 2-5mg
• Do NOT use phenytoin (inferior to MgSO4) [21]

3. Blood pressure control (2 marks):

• Indication: BP ≥160/110 with eclampsia - urgent treatment
• Target: 130-150/80-100 mmHg (avoid precipitous drops)
• IV labetalol 20mg bolus, repeat q10min (max 300mg)
• Consider labetalol infusion 1-2 mg/min if refractory
• Monitor BP q5-10min initially

4. Diagnostic investigations (1 mark):

• CT head - exclude intracranial haemorrhage, PRES
• MRI brain if CT negative (shows characteristic PRES - posterior white matter oedema)
• EEG if status epilepticus suspected or prolonged encephalopathy
• Bloods: FBC, LFT, UEC, coagulation, magnesium level, ABG

5. ICU supportive care (2 marks):

• Strict fluid restriction: 80-100 mL/hour (avoid pulmonary oedema)
• Urinary catheter: hourly urine output (greater than 25 mL/hour)
• Monitor magnesium toxicity: Reflexes, RR, level
• Consider EEG monitoring for subclinical seizures
• Prepare for delivery (definitive treatment)

6. Delivery planning (1 mark):

• Definitive treatment is delivery
• After stabilisation (seizures controlled, BP managed)
• Usually within 12-24 hours
• Caesarean if vaginal delivery not imminent or fetal distress

Examiner Notes:

• Accept: Alternative antihypertensives (hydralazine, nifedipine)
• Accept: Mention of PRES on MRI as typical finding
• Accept: Discussion of EEG monitoring
• Do not accept: Delaying treatment, inadequate BP control, phenytoin as first-line
• Must emphasise: Magnesium as first-line for seizures, left lateral positioning, avoiding tongue blades

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CICM Viva Practice

Viva Scenario 1: Severe Pre-eclampsia in ICU

Stem: A 30-year-old primigravida at 31 weeks gestation is admitted to ICU with severe pre-eclampsia. Her BP is 170/112 mmHg, she has severe frontal headache, visual "flashes", and epigastric pain. Bloods show platelets 62 × 10⁹/L, ALT 289 U/L, creatinine 98 μmol/L.

Opening Question: What are your immediate priorities and why?

Model Answer:

This patient has severe pre-eclampsia with HELLP syndrome (Class 2 - platelets 50-100). My immediate priorities are:

1. Simultaneous assessment and resuscitation

   • ABC assessment: Airway protection, oxygen if needed
   • Large bore IV access ×2
   • Bloods: FBC, LFT, UEC, coagulation, G&H, magnesium level
   • Manual BP confirmation

2. Blood pressure control (treat within 30-60 minutes)

   • IV labetalol 20mg bolus, repeat q10-15min (max 300mg)
   • Target: 130-150/80-100 mmHg
   • Justification: CHIPS trial - less-tight control increases maternal complications [23]

3. Seizure prophylaxis

   • Magnesium sulfate 4g IV loading over 20 minutes
   • Then 1g/hour maintenance infusion
   • Justification: MAGPIE trial - 58% reduction in eclampsia, NNT 63 [22]

4. Fetal assessment

   • Continuous CTG
   • Ultrasound: growth, AFI, Doppler

5. Consider steroids for fetal lung maturity (betamethasone 11.4mg IM)

6. Multidisciplinary coordination

   • Obstetrics, anaesthetics, neonatology
   • Plan delivery within 24-48 hours

Follow-up Questions:

1. She has a generalised tonic-clonic seizure lasting 90 seconds. How do you manage this?

   • Model answer: Position left lateral, protect from injury, do NOT insert tongue blade, give O2, note time. Most seizures self-terminate. Ensure magnesium infusing (loading 4g IV if not given). If recurrent seizure, give additional MgSO4 2g IV bolus. If refractory (greater than 2 seizures despite Mg), consider diazepam 5-10mg IV. Do NOT give phenytoin. Urgent delivery planning after stabilisation. Consider CT head if postictal GCS below 13 or focal deficit.

2. She becomes oliguric (urine output 20mL/hour) and drowsy with absent patellar reflexes. What do you suspect and how do you manage this?

   • Model answer: Magnesium toxicity due to reduced renal excretion (oliguria). Immediate management: STOP magnesium infusion. Check respiratory rate (if below 12 or respiratory depression), give calcium gluconate 1g (10mL of 10%) IV over 10 minutes. Check serum magnesium level (expect greater than 5 mmol/L). Supportive care - consider intubation if apnoeic. Calcium is antidote and first-line treatment. If severe toxicity persists, may need dialysis for magnesium removal. Do not restart magnesium unless renal function improves and still indicated.

3. Her BP remains 178/120 despite labetalol 300mg total. What are your options?

   • Model answer: Options include: (1) Labetalol infusion 1-2 mg/min, (2) Hydralazine 5-10mg IV q20min (watch for reflex tachycardia and headache), (3) Nicardipine infusion 5 mg/hour titrated, (4) Sodium nitroprusside infusion (last resort - cyanide/thiocyanate toxicity risk, fetal cyanide exposure). I would start labetalol infusion 1 mg/min and titrate to BP. Avoid sublingual nifedipine. Avoid ACE inhibitors/ARBs.

4. What are the delivery timing considerations at 31 weeks?

   • Model answer: At 31 weeks with severe pre-eclampsia + HELLP, options include: (1) Immediate delivery if maternal deterioration, (2) Expectant management with corticosteroids and close monitoring at tertiary centre until 34 weeks, (3) Delivery at 32-34 weeks if maternal condition stabilises. This requires multidisciplinary discussion with obstetrics, neonatology, and patient. Given severe features and HELLP, I would trend towards earlier delivery after corticosteroids and maternal stabilisation.

Discussion Points:

• CHIPS trial evidence and BP targets
• MAGPIE trial evidence and magnesium dosing
• HELLP classification and management
• Delivery timing considerations for preterm severe pre-eclampsia
• Magnesium toxicity recognition and treatment
• Antihypertensive options for refractory hypertension

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Viva Scenario 2: Postpartum Eclampsia

Stem: A 34-year-old woman is readmitted to ICU 6 days postpartum after an uncomplicated vaginal delivery. She had a witnessed generalised tonic-clonic seizure at home. On arrival she is post-ictal with BP 188/118 mmHg, GCS 12, and complaining of severe headache.

Opening Question: What is your differential diagnosis and immediate management?

Model Answer:

My primary differential is postpartum eclampsia - this is the most likely cause of seizure in the early postpartum period with severe hypertension. However, I must also consider:

Differential Diagnosis:

• Postpartum eclampsia (most likely)
• Intracranial haemorrhage (ICH)
• Cerebral venous sinus thrombosis (CVST)
• Posterior reversible encephalopathy syndrome (PRES)
• Postpartum preeclampsia (pre-seizure)
• Primary seizure disorder (new or known)
• Other causes: Hypoglycaemia, electrolyte disturbance, drug-related, infection

Immediate Management:

1. ABC stabilisation

   • Airway: Protect if GCS below 8, position left lateral
   • Breathing: O2 15 L/min, SpO2 monitoring, ABG
   • Circulation: IV access ×2, ECG, manual BP

2. Bloods: FBC, LFT, UEC, coagulation, glucose, magnesium level, G&H, toxicology

3. BP control

   • IV labetalol 20mg, repeat q10min (max 300mg)
   • Target: 130-150/80-100 mmHg

4. Magnesium sulfate 4g IV loading + 1g/hour infusion (even if no further seizures)

5. CT head - to exclude ICH, CVST (may show PRES features)

6. Continuous monitoring: BP, SpO2, GCS, neurological checks q1h

Follow-up Questions:

1. She has no antepartum history of hypertension. Is this still likely eclampsia?

   • Model answer: Yes. 63% of delayed postpartum pre-eclampsia/eclampsia occurs without antepartum hypertensive disease. Postpartum eclampsia can occur up to 6 weeks post-delivery, with peak risk at days 3-6. The diagnosis is new-onset hypertension with proteinuria or end-organ dysfunction (seizure in this case) in the postpartum period. Key is maintaining high index of suspicion.

2. CT head shows bilateral posterior white matter changes. What is this and how do you manage it?

   • Model answer: Posterior Reversible Encephalopathy Syndrome (PRES). This is the typical imaging finding in eclampsia - vasogenic oedema predominantly affecting posterior cerebral regions due to endothelial dysfunction and failure of autoregulation. Management includes: BP control (target 140-150 systolic), continue magnesium, neuroprotective care, ICU monitoring. Usually reversible with BP control over days to weeks. Rarely may progress to cytotoxic oedema/infarction if severe or untreated.

3. Her GCS drops to 6 and she requires intubation. What is your RSI approach?

   • Model answer: Preoxygenation with head-up 30°, left lateral tilt 15°. RSI agents: Propofol 2mg/kg (reduces BP, which is beneficial) OR etomidate 0.3mg/kg (haemodynamically neutral). Rocuronium 1.2mg/kg (avoid succinylcholine if hyperkalaemia from AKI). Cricoid pressure (modified by left lateral tilt). Avoid ketamine (increases BP). Ventilation: Normocapnia (PaCO2 35-45), avoid hypocapnia (uterine vasoconstriction, postpartum still relevant for involution). Maintain left lateral tilt 15°.

4. How long do you continue magnesium?

   • Model answer: Continue for 24 hours after the last seizure OR 24 hours postpartum (whichever is later). In this case, seizure was day 6 postpartum, so continue magnesium for 24 hours after the seizure, then reassess. Monitor: reflexes, respiratory rate, urine output, magnesium level. If renal impairment, reduce dose (0.5g/hour) or check levels.

Discussion Points:

• Postpartum eclampsia epidemiology (63% no antepartum disease)
• PRES pathophysiology and management
• RSI considerations in postpartum period
• Magnesium duration in postpartum eclampsia
• Differential diagnosis of postpartum seizures

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Viva Scenario 3: HELLP Syndrome with Complications

Stem: A 28-year-old primigravida at 33 weeks gestation is admitted to ICU with HELLP syndrome. Platelets 42 × 10⁹/L, ALT 487 U/L, LDH 890 U/L, fibrinogen 1.2 g/L. She develops RUQ pain radiating to back and BP drops to 85/45.

Opening Question: What are you concerned about and what is your management?

Model Answer:

I am concerned about subcapsular liver haematoma or impending hepatic rupture - this is a catastrophic complication of HELLP syndrome with high mortality (up to 80% if ruptures).

Immediate Management:

1. Call for help - urgent obstetrics, surgery, anaesthesia, blood bank

2. Massive transfusion protocol

   • Activate immediately
   • O negative blood until crossmatched
   • Target ratio 1:1:1 (PRBC:FFP:Platelets)
   • Cryoprecipitate 10U for fibrinogen below 2 g/L
   • Fibrinogen concentrate 2-4g if available

3. Haemodynamic stabilisation

   • IV fluids: Crystalloid bolus 500-1000mL (cautious - capillary leak)
   • Vasopressors: Norepinephrine infusion if hypotensive despite fluids
   • Invasive arterial line and CVC for monitoring

4. Bloods stat: FBC, coagulation, fibrinogen, crossmatch 8-10 units PRBCs, ABG, lactate

5. Imaging

   • Urgent liver ultrasound (look for subcapsular haematoma)
   • CT abdomen if ultrasound equivocal and patient stable enough

6. Prepare for delivery - definitive treatment for HELLP

   • Emergency caesarean section
   • General anaesthesia likely (platelets below 50, contraindicates epidural)
   • Blood products in theatre

7. Surgical consultation

   • Prepare for possible laparotomy
   • Liver packing or resection if rupture

Follow-up Questions:

1. Ultrasound shows large subcapsular liver haematoma but no rupture. What are the options?

   • Model answer: Options include: (1) Continue medical management and deliver by caesarean (if maternal stabilises), (2) Caesarean + surgical drainage of haematoma, (3) Expectant management (not recommended given clinical deterioration). Given hypotension and expanding haematoma, I would favour urgent delivery by caesarean under general anaesthesia with blood product support, and intraoperative assessment of liver with surgical standby for possible drainage if haematoma enlarges or ruptures.

2. During caesarean, the liver ruptures with massive haemorrhage. What is your management?

   • Model answer: Continue massive transfusion, activate all personnel, maintain perfusion pressure (MAP greater than 65). Surgical options: Packing of liver, segmental resection if localised, hepatic artery ligation if uncontrolled, liver transplantation in extreme cases (unlikely in acute setting). Resuscitation focus: Blood products, factor VIIa if available, tranexamic acid 1g IV, normothermia, calcium repletion, correct acidosis. Involve hepatobiliary surgeon if available. Mortality high (50-80%).

3. Post-operatively, she develops acute kidney injury with creatinine 250 μmol/L and oliguria. Do you start CRRT?

   • Model answer: Indications for CRRT in this setting: (1) Refractory hyperkalaemia, (2) Severe metabolic acidosis, (3) Volume overload/pulmonary oedema unresponsive to diuretics, (4) Uremic complications, (5) Oliguria/anuria with rising creatinine. Given oliguria and AKI in context of multi-organ failure (liver, haemorrhage), I would initiate CRRT earlier rather than later. Use CRRT (CVVHDF) with regional citrate anticoagulation (reduce bleeding risk). Adjust magnesium dose to 0.5g/hour (CRRT removes magnesium).

4. What are the long-term outcomes for patients with HELLP requiring ICU?

   • Model answer: Maternal mortality 1-3% (higher with complications like hepatic rupture). Recurrence risk in future pregnancies 5-19% (HELLP specific). Long-term cardiovascular risk increased (2-3×). Long-term liver function usually recovers fully unless resection/transplantation. Renal function may recover but some develop CKD. Counselling about cardiovascular risk, future pregnancy planning, and close follow-up is essential.

Discussion Points:

• HELLP complications (haematoma, rupture, DIC, AKI, pulmonary oedema)
• Massive transfusion protocol in obstetric haemorrhage
• CRRT indications and prescription in obstetric AKI
• Long-term outcomes and counselling
• Hepatic surgery in pregnancy

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Australian Guidelines

SOMANZ (Society of Obstetric Medicine of Australia and New Zealand) [3]

SOMANZ 2023 Guidelines - Key Points:

• Hypertension definition: ≥140/90 mmHg
• Pre-eclampsia diagnosis: HTN + proteinuria OR end-organ dysfunction after 20 weeks
• Target BP in treatment: 130-150/80-100 mmHg
• Aspirin 150mg nocte for high-risk women (start below 16 weeks)
• Calcium 1.5-2g/day for women with low dietary calcium
• MgSO4 for eclampsia and severe pre-eclampsia
• Delivery at 37+0 weeks for mild pre-eclampsia
• Urgent delivery for severe pre-eclampsia ≥34 weeks

RANZCOG

C-Obs 06: Hypertension in Pregnancy:

• Endorses SOMANZ guidelines
• Emphasises multidisciplinary care
• Recommends tertiary referral for severe preterm disease
• Regional anaesthesia platelet threshold: ≥80 × 10⁹/L (relative), ≥50 × 10⁹/L (absolute)

ANZICS

ANZICS Statement on Critical Care in Pregnancy (2020):

• Recognises pregnancy as a cause for ICU admission (2-4% of ICU admissions)
• Recommends multidisciplinary team approach
• Emphasises maternal stabilisation as priority
• Fetal monitoring secondary but important
• Transfer to obstetric ICU if specialised care needed

State-Specific Guidelines

NSW Health Clinical Guidelines:

• PD2019_038: Maternity - Hypertensive Disorders of Pregnancy
• Specific protocols for escalation and transfer
• Rural and regional transfer pathways

Queensland Health:

• Statewide Maternity and Neonatal Clinical Guideline: Hypertension in pregnancy
• Emergency management algorithms
• Retrieval medicine protocols

Victorian Department of Health:

• Victorian Hypertensive Disorders of Pregnancy Guidelines
• Perinatal Service Network protocols

WA Health:

• WA Clinical Guidelines: Hypertensive Disorders of Pregnancy
• Remote area management protocols

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References

Epidemiology

1. Mol BWJ, et al. Pre-eclampsia. Lancet. 2016;387:999-1011. PMID: 26342729
2. Australian Institute of Health and Welfare. Maternal deaths in Australia 2012-2021. AIHW. 2023.
3. Lowe SA, et al. SOMANZ guidelines for the management of hypertensive disorders of pregnancy 2023. ANZJOG. 2023;63:529-555. PMID: 37705353
4. Knight M. Eclampsia in the United Kingdom 2005-2014. BJOG. 2007;114:1072-8. PMID: 17617191
5. Creanga AA, et al. Maternal morbidity for obstetric intensive care admissions in the United States. Am J Obstet Gynecol. 2014;210:298.e1-8. PMID: 24480620
6. Barton JR, Sibai BM. Prediction and prevention of recurrent preeclampsia. Obstet Gynecol. 2008;112:359-372. PMID: 18669736
7. Polin RA, et al. Intensive care and the obstetric patient. J Intensive Care Med. 2016;31:234-245.
8. Martin JN Jr, et al. HELLP syndrome: The state of the art. Am J Obstet Gynecol. 2006;195:40-7. PMID: 16813742
9. Altman D, et al. Do women with pre-eclampsia, and their babies, benefit from magnesium sulphate? The Magpie Trial. Lancet. 2002;359:1877-1890. PMID: 12057549

Indigenous Health

10. Perinatal and Maternal Mortality Review Committee. 14th Annual Report of the PMMRC. Wellington: Health Quality & Safety Commission. 2020.
11. Chamberlain M, et al. Indigenous status and outcomes for women admitted to intensive care with hypertensive disorders of pregnancy. Aust Crit Care. 2022;35:123-129.
12. Margolis SA, et al. Aeromedical retrieval for obstetric emergencies. Aust J Rural Health. 2011;19:77-83.

Pathophysiology

13. Phipps EA, et al. Pre-eclampsia: pathogenesis, novel diagnostics and therapies. Nat Rev Nephrol. 2019;15:275-289. PMID: 31273318
14. Roberts JM, et al. Preeclampsia: an endothelial cell disorder. Am J Obstet Gynecol. 1989;161:1200-1204.
15. Maynard SE, et al. Excess placental sFlt1 may contribute to preeclampsia pathogenesis. J Clin Invest. 2003;111:649-658. PMID: 12618519
16. Levine RJ, et al. Circulating angiogenic factors and the risk of preeclampsia. N Engl J Med. 2004;350:672-683. PMID: 14764923
17. Venkatesha S, et al. Soluble endoglin contributes to preeclampsia pathogenesis. Nat Med. 2006;12:642-649. PMID: 16751773
18. Zeisler H, et al. Predictive value of the sFlt-1:PlGF ratio in women with suspected preeclampsia. N Engl J Med. 2016;374:13-22. PMID: 26735993

HELLP Syndrome

19. ACOG Practice Bulletin No. 222: Gestational Hypertension and Preeclampsia. Obstet Gynecol. 2020;135:e237-e260. PMID: 32443079
20. Sibai BM. Diagnosis, controversies, and management of HELLP syndrome. Obstet Gynecol. 2004;103:981-991. PMID: 15121574

Seizure Management

21. The Eclampsia Trial Collaborative Group. Which anticonvulsant for women with eclampsia? Lancet. 1995;345:1455-1463. PMID: 7769899
22. Altman D, et al. Do women with pre-eclampsia, and their babies, benefit from magnesium sulphate? The Magpie Trial. Lancet. 2002;359:1877-1890. PMID: 12057549

Antihypertensives and CHIPS

23. Magee LA, et al. Less-tight versus tight control of hypertension in pregnancy. N Engl J Med. 2015;372:407-417. PMID: 25629739
24. Duley L, et al. Drugs for treatment of very high blood pressure during pregnancy. Cochrane Database Syst Rev. 2013;7:CD001449. PMID: 23897483

Delivery Timing

25. Gyamfi-Bannerman C, et al. Antenatal betamethasone for women at risk for late preterm delivery. N Engl J Med. 2016;374:1311-1320. PMID: 26842679
26. Koopmans CM, et al. Induction of labour versus expectant monitoring for gestational hypertension or mild pre-eclampsia after 36 weeks' gestation (HYPITAT). Lancet. 2009;374:979-988. PMID: 19632407

Postpartum Pre-eclampsia

27. Al-Safi Z, et al. Delayed postpartum preeclampsia and eclampsia: demographics, clinical course, and complications. Obstet Gynecol. 2011;118:1102-1107. PMID: 22015879
28. Bellamy L, et al. Pre-eclampsia and risk of cardiovascular disease and cancer in later life. BMJ. 2007;335:974. PMID: 17975258

Remote/Rural

29. Shekhar S, et al. Oral nifedipine versus intravenous labetalol for severe hypertension in pregnancy: a randomised controlled trial. BJOG. 2013;120:1747-1752. PMID: 23906215

Additional Evidence

30. Witlin AG, Sibai BM. Magnesium sulfate therapy in preeclampsia and eclampsia. Obstet Gynecol. 1998;92:883-889. PMID: 9794695
31. Sibai BM. Magnesium sulfate prophylaxis in preeclampsia: lessons learned from recent trials. Am J Obstet Gynecol. 2004;190:1520-1526. PMID: 15284724
32. Duley L, et al. Magnesium sulphate and other anticonvulsants for women with pre-eclampsia. Cochrane Database Syst Rev. 2010;11:CD000025. PMID: 21069663
33. Sibai BM. Diagnosis, prevention, and management of eclampsia. Obstet Gynecol. 2005;105:402-410. PMID: 15684172
34. American College of Obstetricians and Gynecologists. Task Force on Hypertension in Pregnancy. Hypertension in pregnancy. Obstet Gynecol. 2013;122:1122-1131. PMID: 24150343
35. ACOG Practice Bulletin No. 203. Chronic Hypertension in Pregnancy. Obstet Gynecol. 2019;133:e26-e50. PMID: 30575676
36. Lowe SA, et al. SOMANZ guidelines for the management of hypertensive disorders of pregnancy 2014. ANZJOG. 2015;55:11-16. PMID: 25312330
37. Steegers EA, et al. Pre-eclampsia. Lancet. 2010;376:631-644. PMID: 20598363
38. Magee LA, et al. Diagnosis, evaluation, and management of the hypertensive disorders of pregnancy. Pregnancy Hypertens. 2014;4:105-145. PMID: 26104418
39. Brown MA, et al. Hypertensive Disorders of Pregnancy: ISSHP Classification. Hypertension. 2018;72:24-43. PMID: 29899139
40. Abalos E, et al. Antihypertensive drug therapy for mild to moderate hypertension during pregnancy. Cochrane Database Syst Rev. 2018;10:CD002252. PMID: 30277556
41. Roberts D, et al. Antenatal corticosteroids for accelerating fetal lung maturation. Cochrane Database Syst Rev. 2017;3:CD004454. PMID: 28321847
42. Shear RM, et al. Postpartum hypertension and preeclampsia: incidence and associated complications. Obstet Gynecol Clin North Am. 2015;42:37-47.
43. Chames MC, et al. Late postpartum eclampsia: a preventable disease? Am J Obstet Gynecol. 2002;186:1174-1177. PMID: 12066094
44. Euser AG, et al. Acute kidney injury in pregnancy: a systematic review. Clin J Am Soc Nephrol. 2017;12:2162-2172.
45. Gutiérrez G, et al. Acute fatty liver of pregnancy: a systematic review. Ann Hepatol. 2015;14:289-297.
46. Scully M, et al. Management of thrombotic thrombocytopenic purpura. Blood. 2019;133:1554-1564.
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