Prof.

MahmoudYoussefAliAhmedAbdalla
AinShamsUniversity.
AinShamsUniversity
y MANAGEMENTOFSEVEREPREECLAMPSIA
y Criteriaofseverepreeclampsia
y SystolicBP160mmHg,orifadmissionDiastolicBP
100mmHg.
y Proteinuria+.
P i i
y Presenceofsymptoms,e.g.,epigastricpain,
y 2.Inform:Obstetricregistrarandconsultant
y Paediatric registrarandconsultant
y Anaesthetic registrarandconsultant
y 3.Assess&Bloodpressure
y Observe/Generalised oedema
y Monitor:Symptoms
y p
y Opticfundi
y Reflexes+/ clonus
y Testurineforprotein
p
y Urinaryoutput(volumeofurine/hour)
y Fluidbalancecharts
y Fetalcardiotocograph
g p &ultrasoundscanonadmission
y Dopplerstudiesifavailable
Investigate:
Blood:Fullbloodpicture&platelets
y Urate,kidneyfunctiontests.
U , y
y LFTs(liverfunctiontests)
y Coagulationscreen
y Bloodgroup&holdserum
y Urine:MSSU
y 24hoururinecollectionsfor:
y totalproteinandcreatinine clearance
y catecholamines
y Ultrasoundforestimationoffetalgrowth.
g
y Managementofseverepreeclampsia:
y Treathypertensionif:
y SystolicBP170mmHg,orif
y DiastolicBP110mmHg,orif
y MeanArterialPressure125mmHg
y AimtoreduceBPtoaround130140/90100mmHg
y Arapidandprecipitousfallinmaternalbloodpressureormaternalhypotensionasa
y resultofintravenousantihypertensivedrugsmaycausefetalheartrateabnormalities,
lt fi t ti h t i d f t lh t t b liti
y especiallyingrowthrestricted/compromisedfetuses
y MonitorFHwithcontinuousCTGduringandafteradministrationofintravenousdrugs
y for30minutes
y Drugs:Hydralazine:10mgIVslowly
y Repeatdoses:5mgIVat20minuteintervalsmaybegivenifnecessary
y (theeffectofasingledosecanlastupto6hours)
y Closediscussionwithanaesthetists:mayrequireplasmaexpansion
y Labetalol:IfBPstilluncontrolled,Labetalol 50mgIVslowly;if
y necessaryrepeatafter20minutesorerectIVinfusionof200mgin200ml
y NSaline,startingat40mg/hour,increasingdoseat1/2hourlyintervalsas
y requiredtoamaximumof160mg/hour
y Ifbloodpressuredoesnotrespondtotheabove,discusswithseniorrenalphysiciansand
anaesthetists
y UseofNifedipine Antepartum:Decisiontoadministernifedipine should
y bemadebyconsultantstaff
y O l t i f d ff ti bli
Oralrouteissaferandaseffectiveassublingualroute
l t
y Dose:10mgorally.MonitorFetalheartratewithCTG
y NOTE:Aninteractionbetweennifedipine andmagnesiumsulphate hasbeenreportedto
produceprofoundmuscleweakness,maternalhypotensionandfetaldistress
y Initiatesteroidsifgestation34weeks
Initiatesteroidsifgestation34weeks.
y Considertheneedforanticonvulsanttherapy(magnesiumsulphate)if
eclampsia imminent(exaggeratedreflexes).
y
y Principlesoffluidbalance:
y BEWARE:IatrogenicfluidoverloadisthemaincauseofmaternaldeathinPreeclampsia/Eclampsia
y Maintenancefluidsshouldbegivenascrystalloidbutadditionalfluid(colloid)maybe
y necessarypriortovasodilatationtopreventmaternalhypotensionandfetalcompromise.
y Considerationshouldalsobegiventocorrectinghypovolaemia
g g yp inwomenwitholiguria
g
y 1.Accuraterecordingoffluidbalance(includingdeliveryandpostpartumbloodloss,input/outputdeficit)
y 2.Maintenancecrystalloidinfusion 85ml/hour,orurinaryoutputinprecedinghourplus30ml
y 3.Selectivecolloidexpansion priortopharmacologicalvasodilatation;oliguria withlowCVP
y 4.Diuretics onlyforwomenwithconfirmedpulmonaryoedema
y 5.SelectivemonitoringofCVP

y Considertheneedforinutero/neonataltransferto

hospitalwithhighriskdeliveryunitandintensivecare
neonatalunitfacilities.
y IfamaternityunitdoesnothaveaccesstoHDU/ICU
If t it itd th t HDU/ICU tocopewithmaternal
t ith t l
y complications,orisunabletocopewithpretermbabies,itmaybeappropriateto
y considerantenataltransferofthemothertohospitalhavefacilities.
y
y Delivery
y Ateameffortinvolvingobstetricians,midwives,anaesthetists andpaediatricians
y Theneedfordeliveryisdependentonthematernalandfetalcondition.
y Eithercaesareansectionorinductionoflabour maybeappropriatedependingonthe
clinicalfindings
l lf d
y Ineclampsia,thedefinitivetreatmentisdelivery
y However,itisinappropriatetodeliveranunstablemotherevenifthereisfetaldistress.
y Onceseizuresarecontrolled,severehypertensionshouldbetreatedandhypoxia
corrected thendelivery
corrected,thendelivery.
y Ergometrine shouldnotbeusedinseverepreeclampsia andeclampsia
y Considerprophylaxisagainstthromboembolism
y Anearlycombinedobstetricandanaesthetic approachtomonitoringandmanagement
providesoptimalcare
y Principlesofcareafterdelivery
y Maintainvigilanceasthemajorityofeclamptic seizuresoccurafterdelivery
y Highdependencycareshouldbeprovidedfor24hours.
y ConsidertheneedforadmissiontoICU
y Monitoringshouldbeundertakenbyexperiencedstaff:
nurse/midwifeshouldbe
y allocatedtoprovideonetoonecare withinputfromseniormedical
allocatedtoprovideonetoonecare,withinputfromseniormedical
staff
y Maintaincloseattentiontofluidbalance
y Reduceantihypertensivemedicationasindicated
yp
y Followup
y Longtermfollowuptomakesurethatbloodpressureresolves
y Specificinvestigations:antiphospholipid antibodies,lupus
anticoagulantand
ti l t d
y thrombophilia screen.Ifeclampsia hasoccurred,considerCTscanof
head
y Discussionwithmotherconcerningwhathashappenedandits
significanceforthefuture
Clinicalpictureofeclampsia
y Clinicalfeatures:Almost,preeclampsiaprecedestheonsetof
eclampticconvulsions, sotheclinicalpictureisthatofsevere
preeclampsiatogetherwithconvulsionswhichpassintothe
f ll i t
followingstages:

y 1 Prodromalstage(Premonitorystage): Disturbedlevelof
consciousness,severeheadacheandhallucinations,twitches
i h d h dh ll i ti t it h
inthesmallmusclesofthehand,footandface,withrollingof
theeyeballs.(Usuallylastsfor35minutes)
y 2 Tonicstage:Allmusclesofthebodyarethrownintoastate
oftetaniccontractions.includingthediaphragmand
intercostals,leadingtocessationofrespirationand
cyanosis. Astheextensorsarestrongerthantheflexors,the
patientassumesanextendedattitudewithbackwardcurveof
thespine(episthotonus). (Usuallylastsfor1520seconds).
y 3 Clonicstage:Reciprocalgroupsofmusclesarethrowninto
contractionandrelaxation Duringthisstagethepatientmay
contractionandrelaxation.Duringthisstagethepatientmay
fallfrombed,withresultantfractureofbones,thetongue
maybebittenunlessprotected. (Usuallylastsfor35minutes).
y 4 Coma:Usuallywomenwilllooseconsciousnessduringthe
fitandremaincomatosed foravariabledurationfollowingthe
fit.
y A Respirationisrapidandshallow,tocompensateforthe
d d h ll f h
acidosisresultingfromthemusculareffort.
y Somepatientsmayrecovercompletelybeforethenextfit;
Oth
Othersmaypassintofurtherfitswithoutregaining
i t f th fit ith t i i
consciousness.
y B Afeverrecordedatthisstageisagravesignthatmay
indicateintracerebralhemorrhage.
indicateintracerebralhemorrhage
y Differentialdiagnosisoffits:
y 1 Epilepticfitofgrandmalepilepsy:Ithasthesamestagesand
alsotheEEGchangesarethesameasthatofeclampticfit.Apast
historyofepilepsywithabsenceofsymptomsofPreeclampsiais
diagnostic.
y 2 Hystericalfit:Notaclassicfit,usuallyduetoapsychogenic
cause.Characteristicallythepatientdoesn'thurtherselfduring
thefit.
thefit
y 3 Cerebralstrokefit: Withlateralizationandnonclassicfit.
DiagnosisdependsuponCTscan.
y 4 Strychninepoisoning:Withtonicphaseandepisthotonusand
4 y p g p p
withhistoryofdrugintake.
y 5 Hypertensiveencephalopathyfit.
y Management:
y Prevention:Eclampsiaisthesecondmostcommoncauseof
maternalmortalityinEgypt.
y Preventingeclampsia :Thedetectionandtreatmentofcaseswith
preeclampsiacanabolishtheriskofeclampsia.
Treatment:Theplanofmanagementisasfollows:
y I.Emergencytreatmentandfirstaid
y II ControlofconvulsionswithMgS04
II.ControlofconvulsionswithMgS04
y III.Controlofseverehypertension.
y IV.Promptdelivery
y V.Avoidanceofdiuretics.
y MANAGEMENTOFIMMINENTECLAMPSIAOR ECLAMPSIA
y GeneralMeasures
y DONOTLEAVEPATIENTALONE
y CALLFORHELP dutyobstetric&anaesthetic
y INFORMCONSULTANTS obstetrician&anaesthetist oncall
INFORMCONSULTANTS
y Isitsafetoapproachthepatient? considerhazardsaroundpatientthatwillaffectsafety
y Preventmaternalinjuryduringconvulsion placeinsemiproneposition.
y Chek ABC
y Airway:Assessandmaintainairwaypatency(mouthgauge,airway).
y Breathing: Notebreathingrate.Oxygensupply.Ventilateasrequired
y Circulation:Evaluatepulse&BP.Ifabsent,initiateCPRandcallarrestteam.Positionofthe
patient:Leftlateraltilt.
y FixIVlineassoonassafelypossible
y Attachpulseoximeter,ECG&automaticBPmonitors
ttac pu se o ete , CG & auto at c o to s
y Urinarycatheter hourlyurinometer readings
y Fluidinput/outputchart
y Observations&Investigations:Considerbloodgases
y CheckforLungsshouldalwaysbeauscultated foraspiration aftertheconvulsionhasended
y
y MedicationfortheManagementofSeizures
y Thevastmajorityoftheinitialseizuresareselflimiting
y MAGNESIUMSULPHATEistheanticonvulsantdrugofchoice
y Avoidpolypharmacy totreatseizures increasesriskofrespiratoryarrest
y AfterABC:
y LoadingDose:4gIVover1015minutes
y Maintenance1gperhour
y 1g/hourisinfusedfor24hoursafterlastfitprovidedthat:
y respiratoryrate>16breaths/minute
y urineoutput>25ml/hour,and
y patellarreflexesarepresent
y Administerviainfusionpump
y REMEMBERTOSUBTRACTVOLUMEINFUSEDwithmagnesiumsulphate FROM
y TOTALMAINTENANCEINFUSIONVOLUME(85ml/hour)
y
y
y Ifseizurecontinues,orifseizuresrecur,giveasecond
bolusofmagnesiumsulphate:
y 24gdependingonweightofpatient,over510minutes
y (2gif<70kgand4gif>70kg)
y Incaseoffailureofcontrolofconvulsionsby
magnesiumsulphate.
g p
y Diazepam(10mg)orthiopentone (50mgIV).
Intubationmaybecome necessaryinsuchwomento
p
protecttheairwayandensureadequateoxygenation.
y q yg
y Furtherseizuresshouldbemanagedbyintermittent
positivepressureventilationand musclerelaxation.
y
y WhenusingMagnesiumSulphate:
y Monitor(observation):Hourlyurineoutput
y Respiratoryrate,oxygensaturation&patellarreflexes every10
minutesforfirsttwohoursandthenevery30minutes
i f fi h d h i
y Checkserummagnesiumlevelseverydayifinfusionis
continuedfor>24hours
y R
RequestMgSO4levelsif:
tM SO l l if
y Respiratoryrate<16breaths/minute(CARE:lowerratemaybe
appropriateifonopiates)
y Urineoutput<25ml/hourfor4hours
y Lossofpatellarreflexes
y Furtherseizuresoccur
y MagnesiumTherapeutic2 0 4 0mmol/lLe els
MagnesiumTherapeutic2.04.0mmol/lLevels
y Magnesiumsulphate toxicity.
y Withincreasingmagnesiumlevels,thefollowingmay
occur:
y Feelingofwarmth,flushing,doublevision,slurred
speech....................................3.85.0mmol/l
p 3 5
y Lossoftendonreflexes.....................................>5.0mmol/l
y Respiratorydepression......................................>6.0mmol/l
y Respiratoryarrest..........................................6.37.1mmol/l
y Cardiacarrest..................................................>12.0mmol/l
y ManagementincaseofmagnesiumToxicity:
y IfUrineoutput<100mlin4hours:Ifnoclinicalsignsofmagnesiumtoxicity,decrease
rateto0.5g/hour
y Reviewoverallmanagementwithattentiontofluidbalanceandbloodloss
y Absentpatellarreflexes:StopMgSO4infusionuntilreflexesreturn
Ab t t ll fl St M SO i f i til fl t
y Respiratorydepression:StopMgSO4infusion
y Giveoxygenviafacemaskandplaceinrecoverypositionbecauseofimpairedlevelof
consciousness
y Monitorclosely
y Respiratoryarrest:StopMgSO4infusion
y GiveIVCalciumgluconate Intubate andventilateimmediately
y Cardiacarrest:CommenceCPR
y StopMgSO4infusion
y GiveIVCalciumgluconate
y Intubate andventilateimmediately
y Ifantenatal,immediatedelivery
y Magnesiumsulphate antidote:10%Calciumgluconate 10mlIVover10minutes