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Severe pre eclampsia

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  • 1. MANAGEMENT OF SEVEREPE/ECLAMPSIA IN DISTRICTHOSPITAL
  • 2. Definition Pre-eclampsia  New hypertension presenting after 20 weeks with significant proteinuria (>300mg protein in 24h) Severe pre-eclampsia  Pre-eclampsia with severe hypertension and/or with symptoms, and/or biochemical and/or haematological impairment Eclampsia  A convulsive condition that arises from PE
  • 3. NICE GUIDELINES
  • 4. Referral to critical care  Indications for referral to critical care levels  Level 3  Severe PE and needing ventilation  Level 2  Severe PE with either of the following:  eclampsia  HELLP syndrome  haemorrhage  hyperkalaemia  severe oliguria  coagulation support  IV antiHTN treatment  Initial stabilisation of severe HTN  Evidence of cardiac failure  Abnormal neurology  Level 1  Mild or moderate PE  Ongoing conservative antenatal Mx of severe pre-term HTN  Step-down treatment after birth
  • 5. Severe pre eclampsia :Management Principle  Control hypertension  Aim diastolic BP between 80–100 mmHg  Aim systolic BP less than 150 mmHg  MgSO4 to prevent seizures  Plan for delivery  Where?  When?  How?
  • 6. Control hypertension Labetalol(oral/IV)  IV 25mg slow bolus  repeat every 20 mins, max 2 doses  If DBP>110 start infusion Nifedipine(oral) Hydralazine(IV)
  • 7. Prevent Eclampsia MgSO4  Loading dose  Maintenance dose  In district hospital – What is the best route while waiting and during transfer?
  • 8. Plan for delivery Manage pregnancy conservatively only in mild PE Immediate delivery once BP controlled and completed antenatal steroids if possible, if -severe HPT develops refractory to treatment -maternal haematological, biochemical or clinical indications -fetal indications
  • 9. Eclampsia: Principle ofmanagement Resuscitation To stop the seizures Prevent recurrent seizure Control BP Plan for delivery
  • 10. Eclampsia Resuscitation  Call for help + refer to tertiary hospital  ABC  Secure 2 IV lines Abort seizure with IV/IM MgSO4 loading dose then maintenance dose Start parenteral anti-hypertensive if DBP >110 or MAP >125 Plan for delivery: timing and mode
  • 11. Case Illustration Hospital Betong on weekend @ 6 PM 18 y.o. G1P0 @ 34 weeks Sudden onset of blurring of vision BP 180/120, urine albumin 3+ Uterus 28 weeks, FH+ Diagnosis ?
  • 12. How to manage ?
  • 13.  Control BP- what drug ? How fast ? MgSO4 ?  Loading  Maintenance Plan delivery  How are you going to arrange  Referral  Transportation
  • 14. During transportation Prepare syringes of IV MgSo4 2g and IV/IM Diazepam 10mg Give IV MgSO4 2g slow bolus over 5 minutes if patient had an eclamptic episode during transit If repeated IV MgSO4 2g does not abort the eclampsia, IV/IM diazepam 10mg can be given by slow bolus over 5 minutes Ensure resus equipments available
  • 15. The deteriorating patient  Worst scenario for the ambulance team  Look for reversible causes *  Do things that you can do  Ask for help *  Don’t panic  Don’t blame  Don’t avoid issue
  • 16. Things that commonly go wrong …  Oxygen supply  Airway obstruction  Vital signs monitoring  Problems with Fluid and Drug delivery  Dislodged definitive airway  Deterioration of condition of patient
  • 17. Key take home messages Understand limitations of district hospital Know when to refer Management of PE in emergency situations