The document discusses the management of severe preeclampsia and eclampsia in district hospitals. It defines preeclampsia, severe preeclampsia, and eclampsia. It recommends referring patients with severe preeclampsia to critical care levels 2 or 3 depending on symptoms and conditions. It provides guidance on controlling hypertension, preventing eclampsia with magnesium sulfate, and planning for delivery. The document also reviews managing a case example of a pregnant woman with severe hypertension and discusses key considerations for her care and transportation to a tertiary hospital for delivery.

1. MANAGEMENT OF SEVERE
PE/ECLAMPSIA IN DISTRICT
HOSPITAL

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 of
management
 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