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Protocol for MANAGEMENT OF SEVERE PRE-ECLAMPSIA/ ECLAMPSIA Green top guideline 2010

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Protocol for
MANAGEMENT OF SEVERE
PRE-ECLAMPSIA/
ECLAMPSIA
Green top guideline 2010

Published in: Health & Medicine
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Protocol for MANAGEMENT OF SEVERE PRE-ECLAMPSIA/ ECLAMPSIA Green top guideline 2010

  1. 1. Protocol for MANAGEMENT OF SEVERE PRE-ECLAMPSIA/ ECLAMPSIA Green top guideline 2010 Prof. Aboubakr Elnashar Benha university Hospital, Egypt ABOUBAKR ELNASHAR
  2. 2. BACKGROUND Eclampsia (E) convulsions superimposed on pre-eclampsia. Preeclampsia (PE) PIH in association with proteinuria (> 0.3 g/24 h) ± oedema Severe PE Significant proteinuria (1 g/litre) PLUS DBP ≥ 110 mmHg on 2 occasions OR SBP ≥ 170 mmHg on 2 occasions OR DBP ≥ 100 mmHg on 2 occasions & with at least 2 S or S of imminent E. HELLP syndrome: Variant of severe PET (haemolysis, elevated liver enzymes and low platelet count).ABOUBAKR ELNASHAR
  3. 3. Clinical features of severe PET in addition to hypertension & proteinuria: Severe headache Visual disturbance Papilloedema Liver tenderness Epigastric pain and/or vomiting Signs of clonus Platelet count <100 x 106/l Abnormal liver enzymes (ALT or AST rising to above 70 iu/l) HELLP syndrome. ABOUBAKR ELNASHAR
  4. 4. MANAGEMENT I. Maternal monitoring II. Foetal assessment III.Control BP IV.Prevention of seizures V.Control of seizures VI. Fluid balance VII.Delivery VIII. Postparum ABOUBAKR ELNASHAR
  5. 5. I. Maternal monitoring 1.BP: /15 m until the woman is stabilised and then /30 m in the initial phase of assessment. /4-h if a conservative management plan 2. Input and output chart. 3. Full blood count, liver function and renal function tests. Repeated at least daily when the results are normal but more often if the clinical condition changes •AST >75 iu/l or ALT >70 iu/l Significant >150 iu/l: increased maternal morbidity Uric acid should not be used for clinical decision-making. Platelet count<100x106: consideration for delivery. 4. Clotting studies not required if the platelet count >100 x 106/l.ABOUBAKR ELNASHAR
  6. 6. •Diagnosis of HELLP syndrome 1. Haemolysis: LDH levels, or blood film (fragmented red cells). 2. Platelet count: <100 x 106 ABOUBAKR ELNASHAR
  7. 7. II. Foetal assessment •In the acute setting: CTG •In labour: continuous electronic fetal monitoring. ABOUBAKR ELNASHAR
  8. 8. •In Conservative management: 1. US : F wt A FI 2. Umbilical artery Doppler 3. CTG ABOUBAKR ELNASHAR
  9. 9. III. Control BP: Antihypertensive treatment Indications: 1. SBP> 160 mmHg or DBP>100 mmHg. 2. SBP <160 plus severe disease : heavy proteinuria or disordered liver or haematological test ABOUBAKR ELNASHAR
  10. 10. •Drugs: •Acute , severe: Nifedipine: oral not sublingually IR cap:10 mg initial; repeat after 30 m if necessary IR cap: 10-30 mg tid; not to exceed 120-180 mg/d ABOUBAKR ELNASHAR
  11. 11. Hydralazine IV: 5 mg over 5 min, repeat /20 min until DBP 95 mmHg, No more than 4 doses. If not give Labetalol or Nifidipine. Maintenance: 10 mg/h Add 2ml NS to reconstitute 20 mg hydralazine. Withdraw 0.5 ml hydralazine solution and add 9.5 ml NS to give total 10 ml solution. ABOUBAKR ELNASHAR
  12. 12. Labetalol: IV: 20 mg; subsequent doses of 40, 80, 80 mg IV at 20-min intervals. Maintenance: 40 mg/h Oral: 100 mg BID ABOUBAKR ELNASHAR
  13. 13. Chronic, moderate Nifedipine SR tab: 30-60 mg qd; not to exceed 90-120 mg/d Hydralazine. Oral: 25 mg tds •Methyldopa was the most commonly used therapies in the UK. safe in long term follow-up of the delivered babies some studies have suggested some benefits of labetalol. •Atenolol increase in IUGR. •ACE inhibitors and ARBs contraindicated {unacceptable fetal adverse effects}. •Diuretics relatively contraindicated for hypertension should be reserved for pulmonary oedema. ABOUBAKR ELNASHAR
  14. 14. IV. Prevention of seizures Indications: 1. Severe PET: once a delivery decision has been made and in the immediate postpartum period. When conservative management of a woman with severe hypertension and a premature fetus is made it would be reasonable not to treat until the decision to deliver has been made. ABOUBAKR ELNASHAR
  15. 15. If Mg So is given: 1. It should be continued for 24 h following delivery or 24 h after the last seizure 2. Regular assessment of: a. Urine output: <20 ML/H: STOP b. Deep tendon reflexes: Loss: Stop c. Respiratory rate: d. Oxygen saturation Antidote: Ca gluconate 1 g (10 ml) over 10 m ABOUBAKR ELNASHAR
  16. 16. V. Control of seizures I. 1. Do not leave the patient alone. Prevent maternal injury during the convulsion. 2. Call for help and place a code blue call- Medical Emergency call. 4. Initiate resuscitation. 5. Turn the patient into left lateral position when able to do so. 6. Inform the consultant obstetrician and anesthetist on call. II. AIRWAY 1. Assess and maintain patency, using oral suction if necessary. 2. Insert a plastic oral airway if possible 3. administer oxygen therapy via face mask. ABOUBAKR ELNASHAR
  17. 17. III. BREATHING 1. Assess respiratory rate and ambubag using facial mask/laryngeal mask or endotracheal tube if necessary. IV. CIRCULATION 1. Evaluate Pulse and B P. If absent, initiate CPR. 2. Secure IV access as soon as possible with main line infusion, with three-way tap attached, of Hartmann's Solution, administered at a very slow rate, as fluid intake will be restricted to 1 ml/kg/h 3. Pulse oximetry is helpful. ABOUBAKR ELNASHAR
  18. 18. 2. Mg SO4 is the therapy of choice Loading dose: 4 g given by infusion pump over 5–10 min Maintenance: infusion of 1 g/h for 24 h after the last seizure. Prepare loading dose: Add 4g (8ml) of 50% MgS04 to 12ml of NS. Administer slowly IV over 10 m.  Prepare Maintenance dose: Add 50g (100ml) of 50% MgS04 to 400ml of NS (withdraw 100mls from 500ml bag of NS, prior to adding MgS04). Administer IV via volumetric pump at 10ml/h =1g/h. ABOUBAKR ELNASHAR
  19. 19. 3. Once stabilized plans should be made to deliver the woman but there is no particular hurry and a delay of several hrs to make sure the correct care is in hand is acceptable The woman’s condition will always take priority over the fetal condition. ABOUBAKR ELNASHAR
  20. 20. Recurrent seizures. 1. Increase the rate of infusion of Mg So4 to 1.5 g or 2.0 g/h 2. Diazepam or thiopentone may be used, but only as single doses, 3. Intubation 4. Transfer to intensive care facilities with intermittent positive pressure ventilation ABOUBAKR ELNASHAR
  21. 21. VI. Fluid balance 1. Total fluids should be limited to 80 ml/h or 1 ml/kg/h 2. The regime of fluid restriction should be maintained until there is a postpartum diuresis 3. If there is associated maternal hge, fluid balance is more difficult and fluid restriction is inappropriate. ABOUBAKR ELNASHAR
  22. 22. VII. Delivery When: •> 34W: Once the woman is stable •<34 w and delivery can be deferred >24 h: corticosteroids •Conservative management at very early gestations(26W) may improve the perinatal outcome but must be carefully balanced with maternal wellbeing, only be considered if the mother remains stable ABOUBAKR ELNASHAR
  23. 23. How? Depend on 1.presentation 2.fetal condition 3.likelihood of success of IOL after assessment of the cervix. •>34 w with a cephalic presentation: vaginal delivery should be considered. Discuss the mode of delivery with the mother. Vaginal prostaglandins will increase the chance of success. Anti-hypertensive tt should be continued throughout assessment and labour. •<32 w: CS is more likely as the success of induction is reduced ABOUBAKR ELNASHAR
  24. 24. The third stage: 5 u IM Syntocinon or 5 u IV Syntocinon given slowly. Ergometrine or Syntometrine should not be given for prevention of hge ABOUBAKR ELNASHAR
  25. 25. VIII. Postpartum management 1. . a. Women who develop hypertension or symptoms of PE postnatally (headaches, visual disturbances, nausea and vomiting or epigastric pain): referred for a specialist opinion and investigation to exclude PE. b. Women who deliver with severe PET (or E): close observation postnatally for 4 days or more c. Careful review to ensure improving clinical signs is needed before discharge. ABOUBAKR ELNASHAR
  26. 26. 2. Anti-hypertensive •Continued as dictated by BP. •BP should not be allowed to exceed 160/110 mmHg •A reduction in anti-hypertensive therapy should be made in a stepwise fashion. •Avoid alpha methyldopa •In breastfeeding: labetalol, atenolol, nifedipine and enalapril can be given ABOUBAKR ELNASHAR
  27. 27. 3. Follow-up and final diagnosis 1. An assessment of BP and proteinuria at the 6 w. If hypertension or proteinuria persists then further investigation is recommended. 2. Preconceptional counselling ABOUBAKR ELNASHAR
  28. 28. ABOUBAKR ELNASHAR

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