MANAGEMENT OF SEVEREPE/ECLAMPSIA IN DISTRICTHOSPITAL
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
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
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?
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)
Prevent Eclampsia MgSO4 Loading dose Maintenance dose In district hospital – What is the best route while waiting and during transfer?
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
Eclampsia: Principle ofmanagement Resuscitation To stop the seizures Prevent recurrent seizure Control BP Plan for delivery
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
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 ?
Control BP- what drug ? How fast ? MgSO4 ? Loading Maintenance Plan delivery How are you going to arrange Referral Transportation
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
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
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
Key take home messages Understand limitations of district hospital Know when to refer Management of PE in emergency situations