Eclampsia and Severe Pre-eclampsia

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Eclampsia and Severe Pre-eclampsia

• ESMOE

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Importance of pre-/eclampsia

• No 1 direct cause of Maternal Mortality (MM) and
  No 2 overall cause of MM in RSA
• 60 of deaths are associated with substandard
  care
• Pre-eclampsia is a disease of the endothelium and
  therefore potentially always multi-organ

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Diagnosis Hypertension (HT) in pregnancy

• Systolic BP gt 140mmHg or a diastolic BP gt 90 mmHg
  on more than 2 occasions at least 6 hours apart
• Severe HT is a BP of more than 160/110 mmHg
• Gestational HT and pre-eclampsia are diagnosed
  after 20 weeks.

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Diagnosis of Pre-eclampsia

• Hypertension after 20 weeks with 1 or more of the
  following
• Proteinuria
• Renal impairment
• Liver impairment
• Haematological impairment
• Neurological impairment
• Growth restriction
• The range of organs affected are a result of
  endothelial dysfunction

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Principles of management

• Stabilise mother and then deliver fetus
• Treat and prevent fits
• Treat raised blood pressure (BP)
• Attention to fluid balance
• Be aware of and prevent complications

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Controling convulsions

• Check pulse and blood pressure
• Airways
• Breathing
• Disability use AVPU system
• Alert
• V responds to voice
• P responds to pain
• Unresponsive

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Fitting or unconscious

• Call for help
• Left lateral position
• Check pulse and blood pressure
• Assess and if necessary, maintain airway
• Oxygen and assess breathing
• Establish fluid balance urinary catheter

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Magnesium Sulphate the anticonvulsant of choice

• Loading dose 14g
• 4g in 200mls fluid standard giving set
  administered over 20 mins
• 5g with 1ml lignocaine IM in each buttock
• Maintenance
• 5g with 1ml lignocaine IM every 4 hours to until
  24 hours after birth or 24 hours after last
  convulsion

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Magnesium caution!

• Do not give the next dose of magnesium if
• Absent knee jerk
• Urine output less than 100 mls in last 4 hours (lt
  25ml/hr)
• Respiratory rate less than 16 breaths per minute
• If respiratory rate less than 16 breaths / minute
  stop magnesium and give calcium gluconate 1 g iv
  over 10 minutes

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Magnesium Sulphate

• If convulsions recur give an additional 2g 2g
  IV over 10-15 minutes
• Give lower dose (2g) if patient is small and/ or
  weight is less than 70kg

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Managing HT (BP gt 160/110 at risk of CVA)

• Oral Rx
• Nifedipine 10mg po
• Repeat every 15 minutes ? 4 doses or until BP lt
  160/110
• Contra-indications
• Pulse gt 120
• Cardiac lesion
• Unable to swallow

• Parenteral Rx
• Labetolol 20, 40, 80, 80 and 80mg (max 300mg)
• Give a bolus every 10 mins until BP lt 160/110
• Contra-indications
• Patients with asthma and ischaemic heart disease

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Fluid management

• Catheterise start Intake/output chart
• IV Ringers Lactate (R/L) 125 ml/hr
• Output lt 30ml/hr give 200ml R/L bolus
• Urine output lt30ml/hr reduce IV to 80ml/hr

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Fluid Mx 2

• It is better to run a patient dry than drown
  them!
• Capillaries are leaky therefore control fluid
  input to prevent cerebral and pulmonary oedema
• Because of the capillary leak patients are
  intra-vascularly dehydrated and should not
  receive diuretics

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EVALUATION Mother

• Big 5
• CNS
• Resp. System
• CVS
• Liver and GIT
• Renal

• Forgotten 4
• Hematological
• Immune system
• Musculosceletal
• Endocrine
• Core 1
• Obstetrical

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• Systemic clinical exam that include.
• High care observations.
• AVPU, RR, BP, pulse, sats, fluid balance chart.
• Biochemical eval.
• Hematocrit, platelets.
• Creatinine, AST.
• 24 hour protein clearance.

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Maternal stabilisation

• Is only complete when the lab results are back
  and this allows evaluation of the organ systems
  (can do bedside Hb clotting time if lab
  slow/unavailable)
• It is not appropriate to monitor the fetus prior
  to this

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Evaluation of fetus

• Evaluate fetus for viability
• If viable give 12 mg betamethasone
• Arrange transfer or
• Consult re-termination of pregnancy
• There is no place for expectant management in
  district hospitals!

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Delivery

• Pre-eclampsia is a disease of pregnancy and the
  only cure is to end the pregnancy
• Terminate pre-viable pregnancies
• Vaginal delivery at an appropriate level of care
  is optimal
• It is often necessary to individualise Mx

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After delivery

• Monitor in a designated area until diuresis
  occurs
• Remember (pre-)eclampsia can get worse or first
  fit can occur in post partum period
• Continue magnesium for 24 hours no need to
  tail off
• Continue antihypertensives

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Recap

• Recognition of Eclampsia and Severe
  pre- eclampsia
• Resuscitation and drug management
• Use of Magnesuim sulphate
• Monitoring of patients on magnesium sulphate
• Fluid management
• Complications of (pre-) eclampsia
• Delivery of a patient with eclampsia or
  pre- eclampsia