Scenario in a Nutshell
Woman presents with severe hypertension, headache and epigastric pain. Probable HELLP syndrome from blood results and clinical picture. Needs urgent category 1 GA caesarean section.
Stage 1: Initial assessment of hypertensive, pregnant woman with headache and epigastric pain.
Stage 2: Stabilisation prior to delivery and consideration of differential diagnosis.
Stage 3: Preparation and induction of general anaesthesia for category 1 caesarean section with attempts to attenuate the response to laryngoscopy.
Target Learner Groups
All members of the multidisciplinary obstetric team: midwives, obstetricians, anaesthetists, operating department practitioners/anaesthetic nurses, theatre scrub team.
| Suggested learning opportunities |
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| Demonstrate thorough assessment and investigation of pregnant woman presenting with acute hypertension, headache and epigastric pain |
| Consideration of differential diagnosis of thrombocytopenia in this presentation and likely diagnosis of HELLP syndrome |
| Effective team management of pre-eclampsia and HELLP |
| Demonstrate adapting anaesthetic induction technique to attenuate response to laryngoscopy and intubation in hypertensive patient |
| Suggested learners (to represent their normal roles) | In the room from the start | Available when requested |
|---|---|---|
| Midwife | √ | |
| Anaesthetic ST3+ | √ | |
| Anaesthetic consultant | √ at home | |
| Obstetric ST3+ | √ | |
| Midwife Coordinator | √ | |
| Operating Department Practitioner (ODP)/anaesthetic nurse | √ | |
| Scrub nurse | √ | |
| Suggested facilitators | ||
| Faculty to play role of midwife handing over | √ |
Details for Facilitators
Patient Demographics
Name: Hannah Age: 32 Gestation: 35+1 Booking weight: 78 kg Parity: P1 |
Scenario Summary
A 32-year-old multip is 35 weeks pregnant. She presents to antenatal triage with a headache, epigastric pain and reduced fetal movements.
On triage she is found to be hypertensive with ++ protein on urine dipstick.
Fetal heart (FH) auscultated.
Labile BP with a pathological CTG; however, BP responds to second-line antihypertensives.
Blood results abnormal: thrombocytopenia, anaemia and abnormal LFTs.
Delivery required due to suspected fetal compromise. Requires a GA due to thrombocytopenia.
Set-up Overview for Facilitators
| Clinical setting | In a triage room, on a trolley |
| Patient position | Sitting |
| Initial monitoring in place | Pulse oximeter, NIBP |
| Other equipment | CTG |
| Useful manikin functions | Intubation |
Medical Equipment
For core equipment checklist, see Chapter 9 including advanced airway equipment.
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Information Given to the Learners
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Scenario Schedule
Suggested Topics for Debrief Discussion
Was acute severe hypertension treated appropriately by the team?
Anaesthetist: taking into account the cardiovascular response to intubation in the scenario, were you happy with the measures that you used to attenuate the response to laryngoscopy or is there anything you would alter if doing it again?
Discussion
Pre-eclampsia
For definition of pre-eclampsia and classifications of hypertension, see Discussion, Chapter 17.
Features of Severe Pre-eclampsia (SPE)
Severe hypertension and proteinuria or
Mild or moderate hypertension and proteinuria with one or more of the following:
symptoms of severe headache
problems with vision, such as blurring or flashing before the eyes
severe pain just below the ribs or vomiting
papilloedema
signs of clonus (≥ 3 beats)
liver tenderness
HELLP syndrome
platelet count falling to below 100 × 109 per litre
abnormal liver enzymes (ALT or AST rising to above 70 IU/l).
Incidence
Pre-eclampsia complicates 2–8% of pregnancies (Duley, 2009) with severe pre-eclampsia occurring in 0.5% of pregnancies.
Aetiology
Pre-eclampsia (PE) is a pregnancy-specific disorder, with unknown aetiology. It is a heterogeneous disease that is believed to be either placental or maternal in origin (Ness and Roberts, 1996). Placental PE is due to abnormal invasion of the trophoblast cells and maladaptation of the maternal spiral arteries that results in uteroplacental hypoxia and a systemic inflammatory response producing the clinical signs of PE (Redman, 1991). Maternal PE is due to an exacerbated maternal response to the systemic inflammatory process of normal pregnancy, with a normal placenta (Redman and Sargent, 2004).
Risk Factors for Pre-eclampsia
Several maternal factors are known to increase the risk of developing PE including (Duckitt and Harrington, 2005):
previous history of pre-eclampsia
pre-existing diabetes
chronic hypertension
chronic kidney disease
autoimmune disease such as antiphospholipid syndrome or systemic lupus erythematosus
nulliparity
multiple pregnancy
family history of PE
body mass index (BMI) > 35
maternal age ≥ 40
Clinical Presentation
Symptoms and complications of pre-eclampsia reflect the underlying pathophysiology; vasospasm, increased vascular permeability and a systemic inflammatory response are all attributable to widespread vascular endothelial dysfunction. In some women, severe pre-eclampsia is accompanied by headache, visual disturbance, epigastric/upper abdominal pain, progressive oedema or nausea/vomiting. Women may also present with complications of pre-eclampsia, such as pulmonary oedema or eclampsia.
Management
Women should be managed in a consultant-led unit and admission to hospital is recommended for all women with pre-eclampsia (NICE, 2010).
BP Monitoring and Control
The latest Confidential Enquiry into Maternal Deaths and Morbidity (2009−14) emphasised the importance of urgently reducing BP <150/100 mmHg in women with severe hypertension in order to reduce maternal mortality due to intracerebral haemorrhage, the commonest cause of death attributable to pre-eclampsia.
BP should be monitored at least four times a day. Current NICE recommendations are to commence antihypertensive medication for moderate hypertension, with a target BP of <150/80–100 mmHg (NICE, 2010). In the acute situation blood pressure should be measured every 15 minutes and a reduction in blood pressure should be evident within 30–60 minutes. In the absence of a response to first-line therapy, a second antihypertensive agent should be used.
Fetal Well-being
At the time of diagnosis, fetal well-being should be established. Depending on the gestation, a CTG should be performed. When it is appropriate, an ultrasound scan should be performed for fetal growth, liquor volume, dopplers and if necessary, presentation. If the findings are normal a repeat ultrasound should be performed fortnightly (NICE, 2010).
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