Essay 360

a)The patient has severe pre-eclampsia (PET) and I will take a history to establish if she is symptomatic increasing her risk of having an eclamptic fit. I will ask her if she has a headache, flashing lights, nausea and vomiting, sudden onset of oedema and epigastric pain suggesting she may be at a high risk of developing fulminant PET. I will ask her if has had reduced fetal movements as PET is associated with an increased risk of stillbirth and antenatal hypoxia. I will ask her if she has any unprovoked vaginal bleeding and associated abdominal pain suggesting placental abruption which is a possible complication of PET. I will ask her parity and previous mode of delivery and previous pregnancies complicated by PET. I will review her antenatal notes for any previous admissions with raised BP, note her booking BP and BMI and also review any recent growth scans that may suggest fetal growth restriction (FGR).

I will recheck her BP ensuring the appropriate cuff is used and commence a BP profile. I will check her HR, Temp, RR O2 sats. I will perform an abdominal examintion to assess RUQ tenderness suggesting a hepatic involvement or capsular rupture. I will assess fundal height suggesting FGR and palpate the uterus for any tenderness associated with abruption. I will check her reflexes and check for ankle clonus. Brisk reflexes and 3 or more beats of ankle clonus increase the risk of eclampsia and MgSO4 should be commenced. I will perform fundoscopy to look for papilloedema which is a sign of PET. I will listen to the fetal heart using a sonicaid and commence cardiotocography to assess fetal wellbeing. I will send bloods for FBC, UEs, LFTS, urates, clotting if platelets less than 100x109/L. I will send her urine for a protein creatinine ration to quantify her proteinuria or commence a 24 hour urine collection when her BP stabilizes.

B) I will pull the emergency buzzer and call for help. I will ask for the core midwife, obstetric SHO, most senior resident anaesthetist and ODP and for the consutlant anaesthetist and obstetrician to attend. I will place the woman in left lateral to increase utero placental blood flow to the fetus by releiving aortocaval compression. A guadel airway will be difficult to insert and high flow oxygen via a face mask at 15L should be commenced. Simultanously the her breathing should be assessed and intraveous access with two large bore cannulae secured. At the time of IV access bloods should be sent for FBC, UEs, LFTS, urates, clotting, and group and save. A loading dose of magnesium sulphate 4g IV should be given as a bolus to stop her fitting. Diazepam and lorazepam are contraindicated. A magnesium sulphate infusion needs to be commenced at 4g/hr continued for 24 hours. If she has another fit a further bolus of 2-4g of MGSO4 can be given IV or the infusion increased. She requires antihypertensives with a BP of 170/115 and this need to be given IV. A labetalol bolus should be given and an infusion commenced according to local guidelines. If the women has stopped fitting and then oral antihypertensives can be considered. Continous monitoring needs to be commenced to assess fetal wellbeing and corticosteroids administered for fetal lung maturation. The patient needs to be transferred to high dependency room, catheterized to monitor urine output hourly as oliguria/anuria can be a sign of acute renal failure , continuous blood pressure and HR. She needs to be fluid restricted at 80mls/hr to prevent pulmonary oedema. She need to have gruaduated compression stockings and pneumatic boots to prevent venous thromboembolism. When the patient is stable decision about delivery needs to be made by the consultant obstetrician as she is 32 weeks. The neonatal unit needs to be informed and a cot should be available. The neonatologist needs to be informed. At 32 weeks the mode of delivery is more likely to be by emergency caesarean section unless she is labouring then vaginal delivery is possible.

a)Admit this patient to stabilize her condition.Obtain a history of her parity if she is nulliparous(risk factor) or multiparous ?changing partner.Previous obstetric history of mode of deliveries in previous pregancy and the outcome.History of presenting complaint of headache,blurring of vision ,epigastric pain .This is a case of Pre eclamptic toxaemia however it's important to ask about any previous medical underlying pathology eg essential hypertension,any surgey in the past eg lower segment cesarean section.,any medication she is on already (antihypertensive dose, frequency ,duration of use) and any drug allergy as well as family history.Review case record of her booking blood pressure and presence of proteinuria on dipstick at antenatal visits.

Re check set of observation of blood pressure,pulse,temperature.Examine the woman abdomen of fundal hight ,presenting part and auscultate foetal heart by pinard or handheld dupplex.Examination of any neurological manifestation of  exaggerated deep tendon reflexes as it may indicate severity of condition.

CTG(cardiotocography) as well as ultrasound is needed to assess foetal wellbeing.Ultrasound for estimated foetal weigh,assess liquor volume and umbilical artery doppler as this baby is at risk of intra uterine growth restriction.

Obtain PET blood of FBC full blood count including platelet count,Liver function test,uric acid,urea & electrolyte and coagulation profile as this patient is prone to develop HELLP syndrome(haemolysis,elevated liver enzyme,low platelets).24 hrs Urine collection for proteinuria need to be started.

b)This patient needs to be nursed in high dependency unit as this emergency condition,Her care should be under multi disiplinary team  including senior obstetrciain(consultant),senior neurologist,senior midwife,anaesthist,paediatrcian and haematologist,,,). The first aim is to ensure clear airway prevent tongue bite,ensure that the patient is breathing properly and secured intravenous acess to mentain her circulation,Caution should be practised to restrict her i.v fluid intake as this patient is prone to develop pulmonary oedema.second aim  is to deliver this woman after stabilizing her condition,Mg sulfate should be started with intravenous 4 mg ,stat followed by 2 mg/hr for 24 hrs .Antihypertensive drug labetalol(trandate) 100 mg,IV needs to be given. MEWS score (modified early warning score) needs to used to follow up the woman condition if improvong or deteriorating .As the patient develops epileptic fit  immediate neurologist advice should be sought .Anti epileptic drug should be given to control her seizure .Tegretol and are mostly common used drugs to control epilepsy in pregnancy.

Review result of her PET blood.Decision should be made at higher lever consultant is to weigh between risk of expediting delivery with all the premaurity complication against benifits of continuing pregancy without compromising woman condition,

As the baby is only 32 weeks,Steroid injection of 12 mg Betamethazone ,2 doses 24 hrs apart should be given to enhance lung maturity.Neonatal intensive care unit should be contacted to make sure that facilities are available or ensure inutero transfer after stabilizing the condition to maternity unit where neonatal resuscitation facility is available. 

Explaination should be given to the mother and her partner about her condition to allivate her worries and concern and to answer her question.Discussion about the mode of delivery and the need to expedit delivery by the safest method for the mother and her baby which is most likely lower segment cesrean section.explaination of risk and complication of the procedure of trauma to bowl or bladder ,bleeding ,thromoembloism and infection.Informed consent should be obtained and signed.

Qn: A healthy 30 year old woman has been referred to the assessment unit at 32 weeks gestation because her BP is 170/115 mmHg and she has 3+ proteinuria on automated reagent stix testing. (a) Discuss your initial assessment [6 marks]. (b) During clinical assessment, she suffers a grand mal seizure. Discuss your subsequent ante-partum management [14 marks].

a) I will ask if she has symptoms of impending eclampsia such as epigastic pain, headache, blurred vision. I will also ask her about fetal movements. Then I will proceed to examine her abdomen, checking for epigastric tenderness - a sign of impending eclampsia, and measure her symphysial fundal height - may be small for dates if she has fetal growth restriction. I will check her reflexes for hyperreflexia and clonus which may suggest impending eclampsia.

Maternal investigations should include 24 hour urine total protein to quantify her proteinuria; full blood count, renal panel, liver function tests including uric acid and AST. I will order PT/PTT if platelet falls below 100x10(9)/L. I will assess fetal wellbeing by cardiotocography (CTG), fetal growth and liquor volume scan, with umbilical artery Dopplers if there is evidence of fetal growth restriction.

b) Eclampsia is an obstetric emergency. I will call for help from senior obstetrician, senior anaesthetist, senior midwife and labour ward team. I will first assess her airway, breathing and circulation. Give her oxygen supplementation, and insert at least 2 large bore IV cannulae. I will administer a bolus of 4mg intravenous magnesium sulphate over 5 min to abort the seizure, followed by a continuous infusion of magnesium sulphate 1g/hour. Recurrent seizures should be treated with repeat bolus of magnesium sulphate 2g or increase infusion rate to 1.5-2.0g/hour. I will also treat her hypertension with either labetalol (IV or oral), or oral nifedipine, IV hydralazine, and aim to maintain her blood pressure at or below 150/80-100mmHg.

I will order blood investigations including full blood count, renal and liver function tests including uric acid and AST, coagulation profile if platelet less than 100x10(9)/L, group and cross match. Fetus should be monitored with cardiotocography. Neonatologist and SCBU should be informed. Maternal blood pressure, heart rate and oxygen saturation should be monitored continuously. Invasive monitoring may be considered e.g. CVP, intra-arterial. Hourly urine output and strict fluid input/output chart, monitoring of reflexes - delayed reflexes and respiratory depression may suggest magnesium toxicity. Consultant obstetrician should discuss and document plan of management and delivery. Delivery is definitive treatment and in her case, emergency Caesarean section is recommended. Corticosteriods for lung maturity may be considered but in view of maternal symptoms, and if there is fetal compromise, uncontrolled maternal hypertension, delivery should be expedited.

(a) This patient has severe pre-eclampsia. I would confirm the diagnosis by rechecking her blood pressure, ensuring that she is sitting or semi-inclined with the arm to be used at the level of the heart. Appropriate sized cuff should be used. We need to quantify her proteinuria with a 24-hour urine total protein measurement. I would admit the patient to labour ward for further monitoring. I would ask her for any symptom of headache, epigastric discomfort or visual disturbances. I would check if her baby is moving well. I would check her BMI and also do an abdominal examination looking for epigastric discomfort and measure her symphyseal-fundal height. I would check her reflexes looking for hyperreflexia and clonus of more than 5 beats. I would do a full blood count specifically looking at the platelets, and do a coagulation profile if her platelet is less than 100. I would also check her renal and liver panel and uric acid. We should check her BP at 15 minutes interval initially then at 30 minute interval till she is stabilized Then we can monitor her at 4 hourly intervals. She needs an indwelling catheter to monitor her urine output. We need to monitor her fetal status initially with a cardiotocography, subsequently with an ultrasound for fetal weight, amniotic fluid index and Doppler when she is stable. We need to give her a course of intramuscular betamethasone as she is only 32 weeks gestation.

(b) She is having an eclamptic seizure and this is an obstetric emergency. We need to get help from the anaesthetic team and inform the obstetric consultant. Her airway needs to be protected by turning her to left lateral position to prevent aspiration. We should give her supplementary oxygen via face mask. She needs 2 large bore intravenous cannulae inserted. Intravenous diazepam should be considered if her seizure does not abort by itself. We need to start intravenous magnesium sulphate with a loading dose of 4g over 5 minutes followed by an infusion on 1g/hour over 24 hours to prevent seizure recurrence. We need to check the fetal status with a cardiotocography and deliver the baby via caesarean section once the mother is stabilized. The neonatologists should be informed as we are delivering the fetus prematurely and there is no time to complete the course of antenatal steroids. We need to keep the patient and her partner updated at all time and inform them of the management plans. We need to ensure that her blood pressure is under control and her mean arterial pressure should be less than 125mmHg, Intravenous labetalol should be started if her blood pressure remains high and there are no contraindications. We need to assess her risk for venous thromboembolism and consider thromboprophylaxis if necessary. We need to fill in an incident report form.

a)Initial assessment includes history of headache, visual disturbances, swelling of face/ fingers/legs, abdominal pain, urinary symptoms, change in fetal movements, past history of epilepsy. In relation to proteinuria exclude other conditions such as urinary tract infection, renal disease.  Examination is mandatory and look for general condition, facial oedema,  epigastric tenderness, ankle clonus, deep tendon reflexes of both upper and lower limb, fundal size assessment, fundoscopy. Put Early warning observatin chart. Note her Body mass index and repeat blood pressure with appropriate cuff. Dipstick urine and send for culture and sensitivity and spot protein creatinine ratio. Blood investigations include full blood count, liver function test, creatinine, urea and electolytes. Monitor fetus with CTG to ensure fetal well being at that point. In patient assessment required in view of BP>170/110. Persistent high blood pressure of >170/110 reuire antihypertensive agent, preferably labetalol.

b) Subsequent management as an in patient (high dependency bed in consultant led labour ward) is must until she delivers and remain stable. Supportive treatment for grand mal seizure. Involve consultant obstetrician, midwife in charge, anaethetist in further management. One to one midwife care essential. Ensure airway secured, breathing and circulation stable.Involve paediatrician in discusisng fetal outcome with patinets and check for availability of cots and their presence during delivery. Treat all seizure during pregnancy as eclamptic fit until otherwise proven. To prevent further seizure, Magnesium sulphate infusion (4g bolus followed by 1g/hour) started and maintained atleast for 24 hours after delivery or after last seizure episode, whichever later. Monitor Pulse rate, respiratory rate, blood pressure, oxygen saturation, clonus, reflexes. Maintain hourly urine intake output chart, intake output chart. Strict fluid balance (85ml/hour) including drug infusion is recommended in order to avoid overload (pulmonary oedema). Invasive monitoring (CVP) is individualised by anaesthetist. Continue antihypertensive agent, labetalol or hydralazine infusion (labetalol avoided in asthmatics and preload essential before hydralazine infusion). Sudden fall of blood pressure is not advisable in antenatal period so avoid sublingual nifedipine. Continuous blood pressure monitor until patient stable and blood pressure <160/100. Continuous CTG to assess fetus. Cervial assessment  to be documented. Consider induction of labour in the presence of favourable cervix (Bishop score>5), unlikely at 32 weeks gestation. Aim delivery once patinet is stable. At 32 weeks, highly likely to be abdominal delivery. All actios to be documented with time and person name. Incident form to be filled out for the seizure. Continue high dependency care atleast for 24 hours after delivery. Patinet remain high risk for eclampsia for up to five days after delivery so continue inpatient care until then.

A)

I will elicit symptoms of impending eclampsia- headaches, nausea, vomiting and visual disturbances. Abdominal pain below the ribs suggests stretching of Glisson’s capsule by a subcapsular hepatic haematoma seen in severe pre-eclampsia. Acutely increasing facial and generalized edema suggests worsening pre-eclampsia. Shortness of breath and chest pain suggests cardiac failure or a pulmonary embolism. Vaginal bleeding suggests placental abruption. Decreased fetal movement suggests fetal compromise.

I will note on clinical examination her Glasgow Coma Scale. Her blood pressure, pulse and respiratory rate and oxygen saturation should be monitored every 15minutes.

On cardiovascular examination pulmonary crepitations, abnormal heart sounds and an elevated JVP suggest cardiac failure.

 On abdominal examination, right upper quadrant and epigastric tenderness suggest a hepatic haematoma. A tender and tense uterus suggests a placental abruption. A symphisio-fundal height that is small for gestational age suggests IUGR. Determine fetal presentation by abdominal palpation.

A neurological examination is done. Pupil asymmetry with focal neurological signs such as hemiplegia suggest a CVA. Papiledema seen on funduscopy indicate severe pre-eclampsia. Hyper-reflexia and ankle clonus indicate impending eclampsia.

A vaginal examination would be done to assess the cervical Bishop’s score. If delivery becomes necessary, caesarean section may be needed if the cervix is unfavourable (modified Bishop’s score < 5) and induction of labour possible if the cervix is very favourable. Also blood seen on vaginal examination would suggest a placental abruption.

B)

This is Eclampsia, an obstetric emergency. The goal is to stop the seizure, stabilize the mother and achieve delivery urgently.

I will summon a multi-disciplinary team consisting of the senior anesthetic resident, consultant obstetrician, midwife in charge. Inform also the senior paediatric resident, haematologist, laboratory staff and obstetric theater staff. Transfer to HDU if immediately accessible.

Protect her airway by tilting her into the left lateral position to avoid aspiration. Suction any secretions that would obstruct her airway. Give oxygen, 15 L/minute by facemask. Insert 2 large bore intra venous cannulae and take blood for CBC, LFT, RFT,INR, Group and cross match 2 units of partially packed cells. Administer MgSO4  4mg iv over 5 minutes and commence a MgSO4 infusion at 1g/hour. If another seizure occurs give MgSO4 2g bolus to abort the seizure.

Commence continuous monitoring of her blood pressure, pulse rate, respiratory rate and oxygen saturation.

Aim for a mean arterial pressure(MAP)<125mmHg with hydralazine 5mg iv boluses. Do not exceed a maximum cumulative dose of 15mg. Start a hydralazine infusion if blood pressure not controlled, 40mg in 100mls normal saline, titrating the infusion rate to the MAP.

Commence intra venous fluids. Insert a urinary catheter for hourly output monitoring. Restrict input to the output measured over the previous hour plus insensible losses not exceeding 80mls/hr.

Administer betamethasone 12mg im ( reduces incidence of IVH, NEC, RDS and perinatal mortality associated with prematurity). A second dose of betamethasone for the purpose of fetal lung maturity will not be necessary in 24 hours because urgent delivery is required.

The fetus should be monitored with cardiotocography.

Correct any coagulopathy (platelets < 50 *10⁹/L, elevated INR) after consultation with the haematologist.

When the mother is stabilized or improving delivery should be prompt. Delivery should be by emergency caesaren section.

Counsel the patient and relatives regarding need for emergency delivery despite fetal prematurity and obtain written consent.

 Consider augmentation ( AROM and oxytocin infusion) with continuous fetal and maternal monitoring if in established labour and vaginal delivery is eminent.

A healthy 30 year old woman has been referred to the assessment unit at 32 weeks gestation because her BP is 170/115 mmHg and she has 3+ proteinuria on automated reagent stix testing. (a) Discuss your initial assessment [6 marks]. (b) During clinical assessment, she suffers a grand mal seizure. Discuss your subsequent ante-partum management [14 marks].

A) I would ascertain gestational age by dating scan or LMP if scan is not available. Findings are confirmed by repeating BP with appropriately sized cuff using a manual BP machine unless a validated automatic one is available. Enquires about presence of other symptoms suggestive of severe preeclampsia or impending eclampsia are asked for such as severe headache, blurred vision, epigastric pain, nausea, vomiting or sudden welling of face and hands. If any previous pregnancies I would ask whether they have been complicated by preeclampsia and what was the outcome the pregnancy and the mode of delivery. Patient is asked about perception of fetal movements.

I would palpate the abdomen to assess fetal lie and presentation and to assess presence of epigastric tenderness. I would commence CTG to assess fetal wellbeing. If BP value is confirmed then patient is admitted to LW and antihypertensive therapy is commenced to bring the BP value to < 160/100. Labetolol is the drug of choice which can be given orally or by iv. Infusion. Nifedipine slow release can be given and has the advantage of rapid action but should be avoided if MgSO4 is considered. i.v access is secured and bloods are sent for FBC, UE, uric acid and clotting screen if PLT less than 100k.Urine is sent for protein creatinine ratio and 24 hr collection is commenced. Arrangement for fetal USS for growth, Dopplers and AFI are made.

Steroids are given for fetal lung maturity.

b) I would ask for help and senior obstetric team should be called. Anaesthtetic registrar should be called and neonatal team is informed.

I would position the mother in left lateral position to avoid aspiration. Airway is maintained patent by placing a mouthpiece. O2 by facial mask is administered 15 l /min. I.V access is secured if not in place and bloods are taken for FBC, UE, G/S, urate and clotting. MgSO4 4 g is administered by slow i.v  infusion over 5- 10 min to control seizure. The dose ie repeated if  seizure is not controlled. Once the seizure is controlled patient is admitted to HDU. BP is controlled by i.v Labetolol or hydralazine. MgS04 iv infusion is set up at a rate of 1 g/hr. CTG commenced to assess fetal condition. BP is checked q 15 min until normal range and then q 4 hr. Urine catheter is inserted and hourly urometer is used to monitor urine output. Fluid is restricted to 85 ml /hr to prevent pulmonary oedema. Reflexes and respiratory rate are checked hourly to detect magnesium toxicity and if depressed the MgSO4 should be stopped and calcium gluconate 10 mg is given i.v. Steroids are given even if the delivery is expected to take place is less than 48 hr. Once patient is stable arrangement for delivery should take place. At this gestational age the IOL success rate is low and probably delivery will be by C/S. Neonatal team is informed and if there is no cot available arrangements for ex utero transfer should be implemented. 

A healthy 30 year old woman has been referred to the assessment unit at 32 weeks gestation because her BP is 170/115 mmHg and she has 3+ proteinuria on automated reagent stix testing.

(a) Discuss your initial assessment [6 marks].

Inpatient admission offered,  antnatal notes reviewd for  symptoms past  bp and any risk factors for high bp in pregnancy like primigravida, new paternity, twin pregnancy, previous preeclampsia- eclamspsia.

family history of pet ,eclampsia

personal history of seizures, hypertension, renal diseases.

asked about symptoms of  headache, blurring of vision, epigastric pain, nausea vomiting, right upper quadrant tenderness, decreased urine output.

bp measured  confirmed with patient at 45 degree angle to horizontal with appropriate sized cuff, with both paplaptory and auscultatory methods with koaotkoff phase v as diastilic mark of blood presuure measures frequenty 4 atleast 4 time a day when inpatient.

protien urine quantification with  24 hrs urine protien more han 300mg/ 24 hr or spot protien/ creatinine ratia more tha 0.03 mmol/l done every day while inpatient.

examination includes, pulse, blood pressure initially every 15 mins than 2 hrly than 6 hrly once condition is stabilized and inpatient, pallor due to bleeding , jaundice, icterus if liver function compromised, HELLP syndrome, adominal examintion for lie position, baby weight, symphysis fundal height. ankle clonus if more than 3 beats.

fetal assessment includes, cardiotocography for fetal wellbieng ,fetal ultrasonography for liqour, abdominal circumference, and if conservative management is planned than regular 1 weekly assessment of umbiccal essel doppler and fetal biometry for growth.

matrnal investigations include FBC  for decreased hemoglobin, hemoconcentration, platelet counts if less than 1 lac than to do coagulation profile.

liver function test to detect HELLP syndrome, whether increased  alt, bilirubin

renal function test , sr creatinine, sr urea.

b) During clinical assessment, she suffers a grand mal seizure. Discuss your subsequent ante-partum management [14 marks].

call for help, aim is to stablize patient initially. HDU admission and monitoring

senior anesthesist,obgy consultant informed, senior midwife called. folowwing steps shoukd occur simultaneously.

airway secured with mouth piece,

oxygen flow via facial mask.

two wide bore intravenous  cannula inserted and at that time 20 ml blood withdrawn for hematological and biochemical investigations.

to place patient in railed cot and any injuries prevented.

to give inj magnesium sulphate 4gm iv  bolus slowly over 10 to 15 mins and than to give MgSO4 infusion 1gm/hr for 24 after last convulsion or 24 after delivery. IN case of additional convulsion to increase the dose of infusion to 1.5 to 2gm / he iv infusion.

to monitor respiratory pulse, bp continously than every atleast 6 hrly when stabilized.

to look for tongue bite.

respiratory rate, falls less than 12 with magnesium toxicity, overdose.

ankle jerks, whether presence of clonus, decreses reflex with mgso4 overdose, first sign.

input output charting with catheter in situ and to monitor for urine output, should be more than 20ml/ hr. fuild should be given with cvp monitoring and kept at cvp pressures between 4-12 cm h2o, fluid replacement given with ringer lactate solution and detrose avoided.

pulse oxygen saturation to maintain above 96 % and while monitoring when inj mgso4 is given.

antihypertensive treatment  with inj or oral labetelol, oral nefiepine and iv hyrdralazine. labetelol to avoid in patient with asthma.

diuretics avoided unless evidence of pulmonary edema.

inj betamethasone to mother 12 mg 24 hrs apart for fetal lung maturity. routine antibiotics not given.

fetal assessment includes CTG and ultasound for liqour volume and fetal growth measurements., includes abdominal circumference. if conservative maangement planned than to do ctg twice weekly or more frequent with ultrasound to be done every weekly, not less than that.

definitive  treatment is delivery. 

benefits and risk of prolonging pregnancy for fetus upto 34 completed weeks of gestation  versus risk to the mother explained with blood pressure, protienuria, biochmeical and hematological investigation put in notes. further conservative Mx is planned than to put in notes fetal or maternal indication for delivery, corticosteriod administration,fetal monitoring and consultant opinion of  delivery mode and timing. anesthesist and neonatologiast informed of the case.

hospital delivery, delivery within 24 hrs - 48 hrs in case of refractory hypertension and deteriorating maternal and fetal conditions, or delivery palnned at 34 completed weeks of gestation.

vaginal examination done for cervical assessment , bishops score with scores favourable for induction is more than 5 to induce with vaginal prostaglandins.

cesarean section done for poor scores, failed induction or deteriorating maternal and fetal conditons.

A) From her notes I would briefly check her booking BP and clarify if she is known to be hypertensive or suffered from PET in previous pregnancies. I would check if she is on anti-hypertensives in this pregnancy and whether she was compliant with taking her medications. I would ask her about her past medical history; diabetes and SLE which put her at a higher risk of PET and I would also ask if she had any kidney disease as this can also be a cause of proteinuria as can a recent urinary tract infection.

I would ask her regarding symptoms of PET including visual disturbances, headaches and epigastric pain. The latter could indicate HELLP symptom.

On examination I would measure SFH as PET is associated with IUGR so she may measure small for dates. I would check for peripheral oedema and would listen to her chest for basal crepts would could indicate pulmonary oedema. A neuro examination would include reflexes to see if they were brisk. 

Investigations include repeating the blood pressure at 5 minute intervals and if still elevated above 150/100 she would need antihypertensive therapy such as nifedipine 10mg stat. Her BP would then be repeated 30 minutes later. Bloods would include FBC to check her platelet count as thrombocytopenia is associated with HELLP, U+E and LFT which can become deranged in PET and are markers of severity. Coagulation screen to rule out DIC if platelets are <100.

Urine PCR should be sent as it is more sensitive than a urine dipstix and MSU to rule out a UTI.

Initial fetal investigations include CTG and as an inpatient a US and dopplers should be arranged to check fetal condition.

(b) 

The emergency buzzer would be called and the patient should be managed with the help of the help of the obstetric consultant, anaesthetist and midwife. The patient would be put in left lateral position and 15L oxygen administered via a facial mask. The fits tend to be short lived so once it stopped IV access can be obtained and MgS04 4g over 5 minutes should be given immediately. This should be followed by a maintance dose of 1g an hour. If she has another fit 2g of Mgs04 can be given again. Bloods should be taken at the same time of cannulation including FBC, U+E, LFT, Coag and G+S.

IV antihyertensives should be administered according to the unit protocol eg hydrazaline or labetolol. Doses should titrated gradually until her BP is controlled and then a maintenance dose given to keep her BP <160/105. If with the initial antihypertensive if ineffective an alternative should be subsequently used.

She should be transferred to HDU and her BP, saturation, RR and HR should all be recorded on a MEOWS chart. Her BP should be recorded every 15 min until it is controlled and then every 30 minutes. A urinary catheter should be inserted and UO monitored hourly. Fluid balance should be strictly managed at 85ml/hr to reduce her risk of pulmonary oedema. Her reflexes need to be checked regularly as when reduced are suggestive of magnesium toxicity.

Once she is stable fetal condition should be assessed with CTG monitoring.

She should be debriefed and it explained to her what has happened as she is unlikely to remember the episode. It should be explained that definitive treatment of eclampsia is delivery. She should be given steroids for fetal lung maturity and then a discussion regarding timing of delivery made with the obstetric consultant and paediatricans. If there is no fetal compromise and the cx is favourable on vaginal examination there may be a case for induction of labour with PG. However at 32 weeks it is more likely that she will need a caesarean section.

Following the event a clinical incident form should be completed so that quality of care can be retrospectively assessed.

1. she should be asked about headache ,blurring of vision, epigastric pain and vomiting for the eminent eclampsia. She should be asked about fetal movement and any per vaginal loss. Her menstrual history should be asked to correlate for the gestational age ,although is should be better correlated with booking scan. Her obstetric history should be enquired about parity ,mode of delivery, history of miscarriage, history of hypertensive disease in last pregnancy ,preterm delivery due to preeclampsia, time interval since last delivery. Her family history should be enquired about hypertension ,and pregnancy induced hypertension in first degree relative ,chronic hypertension and renal disease ,connective tissue disorder and thrombophillia.

Her booking status in the current pregnancy should be checked and notes should be reviewed ,her blood pressure in previous visit should be noted ,whether she has any other high risk factor ,any prophylactic medicine like aspirin started or whether she is on any other antihypertensive medicine.

Her BMI should be checked along with pulse ,respiratory rate ,if there is any pedal oedema it should be documented in its grade along with deep tendon reflexes. On per abdominal examination she should be checked   for the epigastric tenderness, uterine size to estimate gestational age ,tone ,and any contraction palpable or not. ultrasound and the Doppler study for the umbilical artery for the fetal well being and growth and amount of liqour.

She should be planned for the admission in high dependency unit for the control of blood pressure by antihypertensive drugs like labetalol or hydrallzine ,investigation eg FBC, liver function test ,renal function test, and 24 hrs urine collection, and monitoring .

Consultant should be discussed about the management plan and patient and her relative should explained about the same.

2. Immediate call for the help should be summoned from consultant obstetrician, anaesthesit , physician and midwives. Most likely diagnosis is eclampsia , in which seizures are self limiting. Patient should be placed  immediately in recovery position to avoid aspirtain and falling of tongue behind ,her airway ,breathing and circulation should be checked ,two wide bore cannula should be inserted and blood should be taken for the investigation. Measure should be taken to avoid trauma due to fall and by putting mouth gag to avoid tongue bite .  oxygen should be started by mask.

Protocol for the management of preeclampsia should be followed and measure to terminate the seizure should in form of magnesium sulphate should be given intravenously 4 gm over 10 minute .diazepam injection iv can also be used but magnesium sulphate is superior to diazepam in case of eclampsia.

Magnesium sulphate should be continued as a rate of 1-2 gm per hour or 2 gm in case of further episode of convulsion and she should be monitored for the respiratory rate,spo2,hourly urine out put, and deep tendon reflexes for the monitoring of magnesium toxicity .monitoring by serum magnesium level not recommended.urine output should be 30-40 ml /hour. indication to stop mgso4 should be doccumented clearly in the notes and calcium gluconate  10% 10 ml should be given.

In initial phase of stablisation ,BP should be monitored every 15 minute along with other vital sign and antihypertensive should be started to control blood pressure to prevent cerebrovascular accident, as mgso4 is anticonvulsant .  assessment of the fetal wellbeing should be done after stablisation or simultaneously by CTG.

Patient should be seen in person by consultant plan of management should be disscuss with the involvement of the neonatologist about the timing of delivery ,mode of delivery ,type and frequency of fetal monitoring and indication for the immediate intervention like fetal distress, APH .

All her investigation should be reviewed and abnormality should be corrected by the involvement of the MULTIDISCIPLINARY TEAM. Patient should be monitored by modified early warning scoring system. Input and out put should be monitored and restriction of the intravenous fluids 80 ml /hrs as they are at increase risk of developing pulmonary oedema.

In the event of eclampsia delivery should be planned once the maternal condition is stablised depend on the cervical status if favourable by induction or LSCS in case of unfavourable or for the obstetric indication. Consideration to give steroid should be considered with the consultant . Anaesthetic review for the mode of anaesthesia and analgesia  ,in event of coagulation abnormality should be considered.

Patient and family member should be explain about the condition and  management plan and their wish should be respected in decision making.

Risk management should be in place ,incedent reporting should be done to improve the skill and training of the staff.

A) I will ask about obst. history gravidy asPG associated with increase risk, history of previous preeclampsia or PIH as this associated with increase risk , family Hx of pre eclampsia in a1st degree relative as this also increase the risk

new partener increase the risk, non barrier method of contraception decrease  risk

history of multiple pregnancy or molar pregnancy increase risk

Examination of vital signs( BP every15 min,PR,Oxygen saturation), abdominal ex for fundal level presentation of the fetus as this determine  mode of delivery if required

CTG should be conducted as this is high risk pregnancy

U/S for fetal viability, uterine artery doppler ,amount of liqour,placental perfusion,IUGR

Investigation should be done, CBC(low HB,haematocrits,platelets, may be present),LFT(elevated liver enzymes ), RFT(end organ faliure),serum  uric acid is increase

B)first air way should be kept patent with oxygen supply

OB consultant ,anashetist should be call

MAGNESIUM SULPHATE should be given immediately to abort seizure. 2g iv polus dose followed by infusion of 1-2g/hr

signs of magnesium sulphate toxcicity should b e observe lik absent pattelar reflex ,oligouria,respiratory reflex,in case of toxcicity calcium gluconate given as antidote

diazepam 10 mg iv can be used as alternative to magnesium sulphate

anti hyper tensive also started such as hydralazine 5mg iv polus dose rebeated till MAP <125 or 15mg dose, followed by infusion of 10mg doubling every 39 min till dose of 40mg.

colloid fluid shuld be given before anti hypertensive drug to protect fetoplacental circulation

fluid should be given with caution in aform of crystalloid as there is increase risk of pulmonary oedema due to low protein and increase capillary leakage,

the dose is 1ml/kg/hr ,urinary catheter should be inserted to monitor urine out put

steroid should be given for lung maturity of the fetus

termination of pregnancy should be conducted if BP fail to response to treatment, deteroration of mother condition, or non reassuring CTG.

GENERAL ANASTHESIA SHOULD BE AVOIDED as endotracheal intubation increase BP, reigonal blockage can be used for labour analgesia, insturemental delivery

mode of delivery is according to cerivical ex if servix is favourable induction of labour can be use with close monitoring 

if un favourable cervix C/S should be done

magnesium sulphate shold be continue post partum due to ioncrease risk of another attack of seizure

pt should be seen after six wks of discharge to measure BP,inves of LFT,RFT, refer to physician if persistant disease

discuss next pregnancy planning. 

(a) Discuss your initial assessment [6 marks

A previous obstetric history should be taken and any risk factors for severe pre-eclampsia identified. Booking BP should be recorded. Enquiry should be made about symptoms of severe pre-eclampsia including headache, visual disturbance, epigastric pain and nausea and vommitting.

The BP should be rechecked with the patient sitting, reclined at 45 degrees. The cuff should be of appropriate size, placed at the level of the heart and Koratoff phase 5 sound should be used. BP should be repeated every 15 minutes until treatment initiated.

The abdomen should be examined to assess fundal height which if reduced may raise the suspicion of an FGR baby; fetal lie and epigastric tenderness. Fundoscopy should be performed to rule out pappilodema and a neurological exam to check for clonus.

In this situation I would secure IV access in the assessment unit and at the same time would take bloods for FBC, clotting studies and renal and liver function tests. A urine sample should be sent for PCR.

Fetal well-being should be checked with CTG and an urgent scan for growth, AFI and dopplers should be organised.

The on-call consultant should be notified and their plan for delivery clearly documented in the notes.

(b) During clinical assessment, she suffers a grand mal seizure. Discuss your subsequent ante-partum management [14 marks].

I would call for help, specifically asking for a senior midwife, obstetric consultant and anaesthetic consultant.

Initial management should be with an ABC approach. The airway should be assessed and if necessary secured with a oropharengeal / nasopharengeal arway until it can be definitively secured by an anaesthetist. The woman should be positioned to prevent aspiration and high flow oxygen should be administered via a non-rebreath mask

Further IV access should be secured.

Every unit has an agreed protocol for the management of eclampsia and this should be followed. Diazepam (IV or PR) can be used to terminate the seizure if it does not stop spontaneously. IV magnesium sulphate should be started as soon as possible, this is used to prevent further seizures and stabilise the maternal condition. This should be given initially as a loading dose of 4g given intravenously over 5 minutes, followed by an infusion of 1 g/hour.

Her hypertension should be controlled with IV labetalol and if this is not effective, IV hydrazaline should be used.

The woman should be catheterised and hourly urine output measured.

CTG should be used to assess fetal condition and the first dose of steroids given.

Its important to liaise closely with SCBU, the anaesthetic team and the womans partner. The woman should be transferred to obstetric HDU with 1:1 care by an experienced midwife. Ongoing monitoring should include ½ hourl BP, HR and oxygen sats. Respiratory rate and tendon reflexes should be checked hourly to rule out magnesium toxicity. Urine output should be monitored hourly and input should be limited to 80ml/hr to prevent pulmonary oedema. All results should be recorded on ITU / high dependency charts.

FBC, U&E and LFT should be repeated 6 hours later if not delivered. If blood tests identify any ongoing coagulopathy, a consultant haematologist should be involved.

Delivery is dependent upon maternal condition;vaginal delivery could be considered if the woman was multiparous and favourable for induction or indeed the baby had not survived the eclamptic seizure otherwise delivery is likely to be by CS.

The mother, her partner and immediate family should be kept fully informed by the obstetric team and should also be counselled by members of the neo-natal team. 

This is a case of sever preeclampsia, My initial assessment includes going through patient notes (parity, singlton or multiple pregnancy, mode of delivery in previous pregnancies, any risk factors in this pregnancy), admission , quantification of protein in urine by spot urine protein/ creatinine ratio. History taking including symptoms of sever preeclampsia including sever headache, visual symptoms, pain just below the ribs, vomiting, any recent swelling of hands, feet or face. is the patient known to have chronic hypertension, any medications.

examination includes: rechecking her blood pressure manually using propper size cuff. reflexes and clonus, any abdominal tenderness.

investigations include: blood for full blood count, U&Es, LFT, Urate, coagulation screen. fetal wellbeing including CTG and Ultrasound sca for amniotic fluid volume, growth, presentation, umbilical artery Doppler.

(b) During clinical assessment, she suffers a grand mal seizure. Discuss your subsequent ante-partum management:

any seizure during pregnancy should be considered eclampsia until proved otherwise.

I would call for help (senior MW, anaesthetist) and inform the on call consultant, wait until seizure is over as its usually self limiting, put the patient in the left lateral position and secure air way, IV access. Oxygen by face mask, mesurement of blood pressure continosly. magnesium sulphate should be started, a bolous dose of 4 g IV over 5 minutes is given followed by 1 g/hour for 24 hours by IV infusion. any further seizure another bolous dose 2-4 g IV is given. a foley's catheter with urometer should be placed for monitoring of urine output. monitoring of signs of magnesium sulphate toxity including loss of patellar reflex, decreased urine output (<100ml over 4 hours), respiratory depression (respiratory rate < 14/min or O2 sat <95%). control of Blood pressure by Labetalol IV to avoid the risk of intracranial haemorrhage, target blood presure <150/80-100. alternative to labetalol include hydralazine, oral nifedipine. fluid restriction to 80ml/hr to avoid the risk of pulmonary oedema. Check the blood reults to detect any haematological or biochemical impairment. platelet count incase of considering regional anaesthesia during delivery (>100). monitoring of the fetus by continuos CTG. a course of steroids, betamethasone 12mg IM should be given after discussion with neonatologist. once the condition of the patient is stable and blood pressure is controlled delivery should be by caesarean section.

propper documentation and debriefing of patient and her partner.

I will take history from the patient asking her whether she is having headache,blurring of vision,epigastric pain or pain under the ribs,any bleeding per vaginum, any pain in the abdomen and the fetal movement.

Menstrual history.last menstrual period and confirm her gestation.

Obstetric history to know about the parity and if multiparous , i wil ask her if she had  high blood pressure in her previous pregnancies and any termination of her pregnancy because of that.

medical history inquiring whether she is hypertensive from before or if she developed high blood pressure during this pregnancy,also history of any renal disease i wil also inquire about the medicines she is taking and the dose. Also I will check the notes if she was following up in the hospital before.

Examination of the patient -Check the pulse ,SPO2,and repeat blood pressure manually  with the proper cuff, sitting position and the arm at 45 degrees.Check the patient reflexes and neurological examination.

Per abdomen  examination to know the sfundal height, lie ,position,presentation of fetus and check the fetus heart sound.

Send blood for liver function test,renal function,and complete blood count.  For the feus, ultrasound to see the fetal growth ,liquor volume and doppler.

(b)This patient is having eclampsia. I will call for help-call for the Consultant obstetrician,Consultant anaesthetist, Senior midwife and Haematologist.

Check the airway, breathing and Circulation. Patient to be placed in the recovery position.Oxygen to be given via the face mask,IV cannulae inserted and blood sent for complete blood count, renal function test and liver function test. Start magnesium sulphate at 4 gm loading dose over 15 min followed by maintenance dose of  1gm per hour. Every 4 hourly,reflexes shiould be checked and Magnesium level should also be checked. If signs of magnesium toxicity then 10%calciulm gluconate should be given.

IV labetolol for the blood pressure.Check blood pressure every 15 min till patient is stable followed by BP measurement every 30 min in the intial phase and then 2 hourly. Once patient is stable, transfer the patient to the high dependency unit.Input output charting should be done and the fluid should be given at 85ml perhour. the urine output should not be less than 30ml per hour.

Once patient si stable and inpatient BP should be checked four times a day,blood test should be done done thrice a week and protein to be checked daily.

Patient and her relatives should be fully informed her condition .

If the patient is still unstable,or the liver function test is deranged then we need to terminate the pregnanacy after giving a course of steroid and also afer consultation with the neonatologist.

If patient becomes stable the patient can be discharged home with follow up by the multidisciplinary team . scan should be done evey 2 weeks and CTG done weekly.

Delivery sould be planned by the consulatnt at 36 weeks and care plan should be documented in the notes about the place of delivery, analgesia and anaesthesia during labour. patient should be informed also and delivery should be planned at 38 weeks.

This patient needs prompt assessment and treatment as PET is associated with significant maternal and perinatal  mortality and morbidity.

senior obstetric, anaesthetic and midwifery staff must be involved in the assessment of women with suspected severe pre-ecclampsia.

h/o symptoms  like headache, visual disturbances,epigastric pain , nausea and vomiting would be  taken. These indicate severe disease.

BP is measured correctly and consistently.

Blood pressure profile – every 15 minutes.

If BP is rising or patient is symptomatic urgent treatment is required.

Reflexes are elicited to see for hyper reflexia, clonus.

Abdominal examination for Epigastric tenderness and uterine size .

A spot urine protein / creatinine ratio or 24h urine protein excretion to confirm proteinuria.

Investigations like FBC, renal function  and liver function tests. Repeated daily if normal and more often if abnormal or woman’s condition changes.

clotting profile is monitored if platelet count falls below 100 x10E9/L or abnormal LFTs.

Assess fetal well-being using CTG in the acute situation.

Subsequent assessment should be by growth scan for growth and liquor volume and umbilical artery Dopplers .

b)

Adherence to agreed unit guidelines is required.

Multidisciplinary care involving senior obstetrician,anaesthetist,midwives,ITU team.

haematologist and blood bank  to be alerted due to potential complications of  DIC.

Assess and maintain airway.

Position the woman in recovery position to prevent aspiration. Protect airway and administer oxygen .

MgSO4 is the drug of choice for Treatment / prevention of fits .
loading dose 4g given over 5-10minutes and a maintainance dose of 1g/hr to prevent further eclamptic fits ,given atleast for 24hrs after the last fit.

MgSO4 is used according to hospital protocol . She should be monitored for MgSO4 toxicity ..

Anti hypertensive agents  like intravenous labetalol or hydralazine  are commenced to control high BP.

maternal condition  is stablised ,  coagulopathy is  identified and corrected (If platelets < 50 *10⁹/L, elevated INR),  after consultation with the haematologist.

Ensure HDU care with 1:1 nursing and care by a single lead clinician.

Ensure good communication with SCBU, anaesthetist and the woman's family.

Obstetric early warning chart is used for monitoring.

Required monitoring of maternal condition which includes: BP, SO2, urine out-put & renal function, FBC,clotting, LFT, tendon reflexes, respiratory rate .
Fluid restriction recommended to minimise the risk of pulmonary oedema.
acceptable regimen would be: Total fluid in-put = previous hour’s urine out-put + 30ml.

prognosis is that maternal condition may deteriorate after delivery but full recovery is to be expected with supportive care .

Risk of VTE is assessed  and thromboprophylaxis provided.
Incident form is filled.

Once  woman is clinically stable , fetal condition is assessed by CTG and delivery is planned.

Senior obstetrician, anaesthetist and neonatologist are involved as baby is premature and a documented plan of management is arrived at.

The benefits of corticosteroids for fetal lung maturity are considered and weighed against the need to expedite delivery.

maternal well-being  takes precedence in timing delivery .

Delivery is the definitive treatment and in this case, emergency Caesarean section is recommended.

a)  There is a concern here that this lady has severe pre-eclampsia.  The BP would need to be re- checked to confirm previous reading(s).  I would do this with a manual spygmanometer.  I would use an appropriate sized cuff (x1.5 circumference of arm), with the arm at the level of the heart and the clothes removed from where the cuff is placed.  I would then like a quantification of her proteinuria and would send off an urgent protein:creatinine ratio.   I would also send off urgent bloods: FBC, UE, LFT, urates, G&S and coagulation if platelets come back < 100 x 10^9.  I would confirm salient points regarding the current pregnancy i.e. singleton or multiple gestation, whether the BP is known to be elevated/labile already,  whether there are any other problems this pregnancy or any issue  that has already necessitated steroids (for fetal lung maturity).  I would also ascertain information regarding placental site (i.e. possibility of placenta praevia) .   I would ask about any past medical +obstetric history: any history of BP /renal problems or autoimmune disease and any previous pregnancies and their outcomes/ complications (any previous pre-eclampsia, C/S etc).  I would ask  if she is currently taking any medication and if prescribed, what for.  I would ask how she is currently feeling: whether she has any symptoms suggestive of pre-eclampsia (headache, visual disturbances, epigastric pain, vomiting) and I would ask her if her baby is moving well.  I would examine her abdomen assessing the estimated size of the gestation via SFH (if singleton pregnancy) and I would then assess for any epigastric/RUQ tenderness, suggestive of hepatic involvement.  I would look for any marked peripheral oedema and ask the woman whether she thinks she is getting significantly more swollen of late.  I would check reflexes and also clonus looking specifically for hyperreflexia, clonus >3 beats or jitteriness indicating neuronal instability and possible impending eclampsia.  I would perform fundoscopy to exclude papilloedema and I would listen to the chest.   After maternal assessment I would arrange for a CTG for initial fetal assessment.

I would inform the consultant in charge of the possible diagnosis and the need for subsequent transfer to the obstetric ward for continued close monitoring, with observations in the 1^stinstance at 15 minute intervals.  If the woman does indeed have severe PET I would arrange for catheterisation and fluid balance monitoring.  MgSO4 would need to be considered along with IV anti-hypertensive (e.g. IV labetalol unless contraindicated). 

b)  This is eclampsia, an  obstetric emergency.  An immediate obstetric emergency code is to be put out which would include calling the senior obstetrician, anaesthetist and senior midwife in charge, along with other medical staff including paediatrician, additional midwives & members of the obstetric team.  The immediate management is ABC.  The lady must be placed in left lateral and an airway maintained/obtained, with airway adjuncts if necessary and then high flow O2.  IV access must be obtained with x2 large bore cannulae and repeat bloods requested.  Once IV access secured, commence immediate IV MgSO₄  as per the Collaberative Eclampsia Trial:  Loading dose of 4grams IV over 5 minutes, followed by an infusion of 1gram/hr maintained for 24hrs.  Recurrent seizures should be treated with a further dose of 2-4grams over 5 minutes.  Deep tendon refelexes must be monitored hourly whilst on MgSO4.  There should also be continuous pulse oximetry (aiming to keep SaO2 > 94%).  If RR dropping and deep tendon reflexes lost, stop MgSO4 and consider calcium gluconate.  An indwelling urinary catheter should be placed if not already done so.  The catheter bag should be placed on an hourly urometer and strict fluid balance with fluid restriction to a total of 85mls/hr in place.  Urine output should be ≥ 80mls/4hr blocks (i.e >20mls/hr over 4hrs).  If total input > 750mls excess of output,  give 20mg IV furosemide.  Observe over next 4 hrs, if output still low, senior obstetrician to be informed.  Lung bases to be assessed for signs of fluid overload.   Once patient stabilised, assessment of fetal status should be performed and plans made for delivery. Fetal assessment will include USS for growth, LV and umbilical artery dopplers in addition to the routine CTG.  Steroids for fetal lung maturity to be given if not already given.  Mode of delivery will be based on the individual clinical picture and the woman’s preferences.  If there are any additional conditions which recommend against a vaginal delivery then plans for a C/S to be made (i.e. placenta pravia, breech presentation). If there is suspected fetal compromise then again recourse to a C/S should be made. IF the woman and her baby are stable and very keen to try for a vaginal delivery, then vaginal assessment should be performed with the possibility of IOL if cervix favourable.  The risk of failure here at 32/40 is however high and this will need to be factored into the decision making.  Neonatal team to be requested to discuss delivery outcomes with the mother +/- partner. 

I will review  her referral letter & any antenatal documents regarding her BP, treatment hx eg antihypertensive, or aspirin  as a prophylactic .I will ask her any complaint like headache, epigastric pain,vomiting,blurring of vision etc which are signs of severe preeclampsia.I will ask her LMP ,regularity of period,datting scan to reconfirm her gest age. I will take her past obst  hx ,about parity, & if multiparous ,previous hx of preeclampsia,eclampsia,abruption,IUGR,preterm labour,IUFD etc should be asked & noted as it requires specific monitoring in this pregnancy.I will examine her BP,oedema(generalized or localized like pedal,or peri orbital) ,temp,RR & clonus for current status.as high bp with clonus more than 3 may lead to eclampsia.I will examine her abdomen to see the Ht of uterus to suspect or rule out IUGR as it is common in preeclampsia. Her fetal heart beat should be confirmed & If required  initial CTG should be taken. Her BMI should be noted.

b)Grand mal seizure,in pregnancy with high BP & proteinuria suggest eclampsia if not other wise proved as another cuse.I will try to stabilise her,& ask for help simultaneously.I will see her air way,breathing, & put her in semirecumbent postion or lateral position to prevent air way blockage.I will see her So2,& if required O2 mask should be started.I will establish her iv line for medication as well as for any iv fluid in future.At the same time I will send blood(20ml) FOR FBC,platelets,liver enzymes,urea ,creatinine, group  & save.I will stabilize her convulsion or to prevent further fits ,Mg So4 4gm iv loading dosei,n 5 minutes  followed by iv infusion 1 to 2 gm /hr for 24 hrs will be started. If  recurrent fits develop,2gm MgSo4 iv can be repeated.To controle BP & to prevent any intrcerebral haemorrhage ,antihypertensives labetolol iv will be started.Catheterisation of bladder will be done with Foleys catheter no 16,to monitor her output at the same time I will send her urine for protein –creatin level or dip stix for protein estimation.I will assess her any injury due to convulsion & if required treatment will be given.I will inform about rhe incident to the seniors & consultants,icu staff & aneasthesist & their help can be sought .

     Once she is stable,her further plan of management  should be done with consultant,senior mid wive,physician,anaesthesist & neonatologist. The plan of management should be documented. She & her partner should be informed about the further course of management. She should be hospitalized till her blood pressure is under controlled i.e (150/80-100). For her fetal monitoring purpse she will require weekly CTG & fortnightly growth scan & Doppler. If she is stable her mode & timing of delivery should be at or after 37 weeks with her wishes & consultant’s recommendation.

 If her blood pressure is refractory to treatment or recurrent convulsions develop delivery should be ideal. In this circumstances (32 weeks)cesarean section may be required. Similarly her clinical , biochemical or fetal wellbeing is under jeopardy delivery should be considered. In this circumstances if time allows even if less than 24 hours, corticosteroids Betamethasone 12 mg IM 24 hours apart should be given for fetal lung maturity.

She should be provided with information leaflet & contact number of hospital in case of an emergency.  

(A)

Rapid assessment of maternal and fetal wellbeing is necessary as maternal and fetal morbidity and mortality are high in severe PEt.i will Inquire about the sympotms  like headche , visual disturbances, episgastric pain and visual disturbances  suggestive of severe disease, fetal movements, review her antenatal record if available. previous pregnancies if any and their subsequent outcome. Check her B.p and monitor subsequently after 15 min. per abdominal examination for fundal height ,  epigastric and abdominal tenderness. tendon reflexes elicited to rule out hyperreflexia. Blood sample taken for full blood count, groupind and cross matching, LFT, serum urate and electrolyte levelsand coagulation profle. 24 hours urine sample is collected and sent for protein and creatinine clearance. Featl well being assessed by cardiotochography and ultrasonography for fetal biometry, liquor volume assessment ,placental localization, rule out fetal growth restriction. Doppler Usg done if indicated from Usg features. BP is monitered 15 minutes to half hour interval and antihypertensive therapy started if remained high.

B.

As pt develop grand mal seizures during initial assessment i will immediately call for assistance,  turns her to the side, maintain airway breathing and circulation. Inform senior obstetrician, anesthetic and neonatologist. consultant obstetrician and anesthetic als  informed. Hematologist and blood bank informed for the need of blood and blood products. I will check her BP , pulse , respiratory rate , oxygen saturation by pulse oximetry and monitor at 15 minutes interval.  Blood sample taken for Full blood count, grouping cross matching, LFT, serum urate and electrolyte levels, coagulation screening and urine collection for protein to creatinine ratio. Subsequent management aims for control of her blood pressure and seizures including prophylaxis for further fit prevention, correction of coagulopathy if any. For the control of seizures i will give her magnesium sulphate bolus dose of 4 grams in 5-10 minutes followed by maintainance dose of 1 gm/hr which is continued till 24 hours post delivery.. Magnesium toxicity is monitored by  checking her respiratory rate, oxygen saturation, tendon reflexes urine output initially after every 15 min for 2 hrs and then half  hourly.  serum Mg levels checked every 12 hourly.  Patient is catheterized and her intake output record is maintained at one hourly interval. fluid intake is restricted to 1 ml/kg/hr. intravenous antihypertansive labetalol or hydralazine started  and Bp monitored. once fits controlled  Fetal well being is assessed by cardiotocography and ultrasound if possible. Benefits of  steroid for fetal lung maturity outweight the need for imminent  delivery.definite treatment is delivery  after stabilizing maternal conditions, indications for imminent delivery are uncontrolled BP, deterioating  blood chemistry and coagulation profile or evidence of fetal compromise. at 32 weeks possibilty of delivery by caesrean section is high and i will invole the patient partner and neonatologist regarding her susequent delivery .

A healthy 30 year old woman has been referred to the assessment unit at 32 weeks gestation because her BP is 170/115 mmHg and she has 3+ proteinuria on automated reagent stix testing. (a) Discuss your initial assessment [6 marks]. 

This woman has severe pre-eclampsia (PET). She needs admitting to an appropriate unit with level 2 critical care and a MDT approach including consultant obstetrician, anaethetist and neonatologists. . Her blood pressure needs to be lowered as per the NICE guideline on hypertension in pregnancy. It should be ascertained if she has any allergies or suffers with Asthma. If not she should be given a stat 200mg of labetalol which is the first line option. One should ask about symptoms such as headache, visual disturbance, epigastric pain and oedema. A past medical history should be established as she may have underlying renal disease or diabetes or other factors associated with an increased risk of PET. A past obstetric history for parity, complications such as previou PET/IUGR and mode of deliveries should be established.

Whilst a history is being taken, intravenous access can be established silmutaneously. Bloods should be sent for FBC. U&E, LFTs, Coag, and G&S. The woman should be examined including repeat BP, PR, RR, sats and temp and these should be plotted on a MOEWS chart. The chest should be auscultated listening for signs of pulmonary oedema  and the abdomen palpated for SFH and RUQ or epigastric tenderness. She can be assessed clinically for oedema and for clonus. The urine should be sent to quantify the degree of proteinuria by either a spot urine PCR or 24hour collection. 

The woman should be asked about fetal movements and a CTG should be commenced. Ideally the woman should be given steroids if her BP can be controlled.

(b) During clinical assessment, she suffers a grand mal seizure. Discuss your subsequent ante-partum management [14 marks].

Eclampsia is an obstetric emergency. Most hospitals have a local protocol to guide management. Help should be sought from the MDT mentioned above and a senior midwife. A scribe should also be present. An ABC approach should be used. High flow oxygen should be given. The woman should be nursed in the recovery position, IV access gained and bloods sent as mentioned previously if this was not achieved pre-seizure. She should be given a loading dose of magnesium sulphate (4g over 5-10 mins). A maintence infusion should then be commenced at 1g/hr. If the woman has a further fit she can be given another bolus of 2g. The woman should be monitored for magnesium toxicity by respiratory rate and deep tendon reflexes. If she is oliguric magnesium levels can be checked. The magnesium should be continued until 24 hours post delivery. There is no role for benzodiazepines in the managment of eclampsia. 

Anti-hypertensives should be given according to the blood pressure aiming to keep in <150/100mmHg. Labetalol is the first line drug. Hydralazine can also be given. The blood pressure should be continuously monitored via an arterial line. A urinary catheter should be inserted to allow a strict fluid balance and fluids should be limited to 80mls/hour. TED stockings should be used.

The aim is to stabilise the woman and plan for delivery. The well being of the woman takes priority over the unborn fetus. If the SCBU does not have the facilities to care for this baby then extra-uterine transfer will be required as in-utero transfer is not appropriate. The neonatologists should be made aware. Delivery should not be delayed for antenatal steroids.

Severe PET is not an indication for delivery by caesarean section. The likelihood of successful induction needs to be weighed up with a caesarean section. In this case at 32 weeks it is unlikely the woman would be favourable for IOL and caesarean section should therefore be considered. 

A healthy 30 year old woman has been referred to the assessment unit at 32 weeks gestation because her BP is 170/115 mmHg and she has 3+ proteinuria on automated reagent stix testing. (a) Discuss your initial assessment [6 marks]. (b) During clinical assessment, she suffers a grand mal seizure. Discuss your subsequent ante-partum management [14 marks].

A)This is a case of severe pre eclampsia.Woman should be offered  hospital admission .Senior obstetrician,anesthestist and experienced mid wife should be involved in the Initial assessment ,aiming to assess involvement of other organs including placenta.

Pre eclampsia is associated with significant morbidity ,reduced by initial assessment followed by prompt treatment .

Enquiry is made of symptoms such as headache,visual diturbace ,nausea,vomiting  and epigastric pain,associated with severe disease and impending eclampsia.

Bp is measured ,every 15 min,till the woman is stabilized .Reflexes are checked and presense of clonus noted,associated  with risk of convulsion.

Abdominal examination –epigastric  tenderness is  noted  which reflects liver involvement.Fundal height is checked .Placental involvement in the disease would be reflected by size of the baby( smaller than gestation) and CTG for fetal well being.

 Inveastigations FBC,LFTs and Renal function tests.Low platelets would prompt clotting profile.

B) This is obstetric emergency which should be dealt promptly.First help should be summoned  from senior obstetrician ,anesthetist, and senior midwife.Unit protol should be followed.

Woman is approached safely,and placed in left lateral position.Airway is secured,preventing tongue falling back and obstructing airway.check for breathing  and Oxygen is administered.Pulse and blood pressure is checked.Pulse oximetry is helpful.

Ensure IV line is in place.Magnesium sulphate is given 4g iv over5-10min,followed by further 1g/hr for 24hrs

If the seizures recur ,magnesium sulphate bolus may be given,2g iv  or rate of infusion is increased.Woman closely observed for magnesium toxicity  by respirstory rate ,loss of tendon reflexes oxygen saturation.

Blood pressure is controlled by iv antihypertensives.labetalol or hydralazine is given iv,until the blood pressure is  less than 150 systolic or diastolic 80-100.

Once she is stable, she should be transferred to HDU/ITU  for 1:1 midwifery care and followup by single lead clinician.Further monitoring of BP, O2 saturation,respiratory rate and tendon reflexes.Obstetric early warning charts  are helpful.Labs repeated for LFTs,renal function clotting profile.Coagulopathy is corrected if there is evidence of DIC.

Woman is catheterized for close monitoring of urinary output.fluids given 85ml/hr,to prevent pulmonary edema.Risk of VTE is assessed and thromboprophylaxis given .

Incident reporting would be required.

Definitive treatment of preeclampsia is delivery.Neonatologist should be informed and NICU alerted.

Steroids given for lung maturity .Delivery at this gestation would be most probably by CS.woman should be counselled about mode of delivery and prognosis of her baby in liaison with neonatologist

A healthy 30 year old woman has been referred to the assessment unit at 32 weeks gestation because her BP is 170/115 mmHg and she has 3+ proteinuria on automated reagent stix testing. (a) Discuss your initial assessment [6 marks]. (b) During clinical assessment, she suffers a grand mal seizure. Discuss your subsequent ante-partum management [14 marks]

(A)

This is severe peeclampsia 

1would remeasure her BP,

then i would ask about personal history of chronic hyprtention,  and would review her antenatal follow up note looking for her baseline BP.

I would ask about  symptoms of impending eclampsia,such as ,severe headache,bluring of vision,or epigastric pain.

Iwould examine the abdomen for tenderness and regidity as severe pre eclampsia may cause abruptio placentae'

Then i would assess the fundal level and the viability of the fetus as the condition may be complicated by an IUGR, oligohydramnios, or even an IUFD

Also iwould assess the urine out put by inserting   a foley catheter.

(B)

The  pt developed eclampsia,a team is needed in her management  so i would call for help.

I would call the senior obstetrician,the anathetist, the ICU phisian,the hematologist,and the midwife and the neonatologist.

Her air way should be maintained patent and  respiratory aspiration should be prevented ,so,i would put the pt on her left lateral position  with an air way in place

I would give the pt magnesium sulphate as treatment  for the fit and in the same time as prophylactic from further fits but the urine out put  should be with in normal  rate to avoid  magnesium sulphate toxisity, and the pt should be followed by   checking tendon reflexes,RR,PR.

diazepam  also is good drug in aborting  convulsion 

The BP should be lowered using hydaralazine, labetalol, or indral as an emergent anti hypertensive treatment

A blood sample shoul be taken for gruoping and save,for RFT,LFT,CBC, and coagulation profile

(a)

The patient has severe pre eclampsia and needs assessment by senior obstetrician, anaesthetist and midwife.

I would ask for symptoms of pre eclampsia such as headache, blurring of vision, pain under the ribs, vomiting and sudden facial or limb swelling.

I would check for previous history or family history of pre clampsia, her antenatal progress and if it is a multiple pregnancy as these are risk factors for pre eclampsia.

On examination, I will recheck her blood pressure when she is at rest and sitting with a 45 degree tilt with appropriate size cuff at the level of her heart using Korotkoff phase 5.

I will check her height and weight for BMI.

I will examine for epigastic or RHC pain, check her fundal height as severe pre eclampsia can cause IUGR.

I will check fundoscopy for papilloedema, perform neurological examination and check for hyper- reflexia.

For investigation, 24 hour urinary total protein collection will be performed. Bloods such as FBC, uric acid, urea, creatinine and electrolytes and liver function test will be done to look for HELLP syndrome and severity of pre eclampsia. Clotting screen should only be done when platelets are less than 100x10⁹.

Fetal well being can be assessed with CTG, ultrasound growth, AFI and umbilical artery dopplers.

She needs to be admitted and started on antihypertensives such as labetalol. BP is monitored every 15 minutes then every 30 minutes when stable.

(b)

This is an obstetric emergency. I will call for help from a multidisciplinary team consisting of senior obstetrician, anaesthetist, midwife and haematologist.

I will put her on left lateral at a 15degree tilt to minimise aortocaval compression. I will secure her airway and breathing. 2 large IV cannulas will be inserted and circulation secured. Bloods tests such as FBC, uric acid, urea, creatinine and electrolytes and liver function test will be performed if not done earlier.

The seizure is usually self limiting but bolus IV magnesium sulphate can be used to abort the seizure. IV magnesium sulphate infusion should be continued for 24hours after delivery or after last seizure, whichever is later. IV diazepam may be considered if recurrent seisures.

IV antihypertensives such as labetalol or hydrallazine should be started to prevent cerebral complications from uncontrolled blood pressure.

She needs close monitoring in the ICU for blood pressure, pulse rate, respiratory rate, SpO2. Complications of magnesium sulphate overdose must be looked out for such as loss of tendon reflexes and decreased urine output. There must be strict I/O chart to prevent fluid overload and pulmonary edema. As she is high risk for VTE, prophylaxis with TEDs and LMWH is required if there is no contraindication.

Fetal wellbeing is assessed with CTG, ultrasound growth, AFI and umbilical artery dopplers. Delivery should be performed after mother’s blood pressure has been stabilised, after discussion with the neonatologists as the fetus is still premature. Steroids for lung maturity may be considered before delivery.

An incident report form should be filled up. The patient and partner should be kept updated with the events and management plans when she is stable.

1. Stabilization of patient and control of blood pressure is the most important thing. She should be admitted to HDU. Brief history enquiring about symptoms such as headache, visual disturbances, epigastric or hypochondriac pain, nausea and vomiting be enquired. Ask about the fetal movements. Abdominal examination is done to assess fundal height, presentationof presenting part and any tenderness. Extremities assessed for reflexes and clonus. MEOW chart should be started. I/V access obtained and bloods sent for FBC, U&E, LFT, Group and save, clotting and uric acid. Foley’s catheter inserted and urine should be sent for PCR and 24 hour collection started. Anti-hypertensives be given in the form of labetalol 200 mg stat provided there are no contra-indications such as asthma or allergies. Blood pressure be monitored continuously. CTG should be started. TEDS applied. On call consultant and anaesthetist should be informed of admission
2. I will crash bleep obstetric team including anaesthetist, consultant obstetrician, senior house officer, ODP, senior mid-wife. Will get the emergency trolley and give patient 2 grams of intravenous MgSO4 over 10 minutes. I will ask mid-wife to check patient’s BP, Pulse and sats and monitor them every 5 minutes. I will ask the anaesthetist to take bloods for FBC, U&E, LFT, Clotting and uric acid. I will ask the nurse in charge to prepare MgSO4 infusion and start patient on it at the rate of 1 g/hour. If the patient develops further seizure. I will give her stat dose of 1 gram intravenous MgSO4. Will ask the porter to take bloods urgently and ask SHO to contact lab to process them urgently. I will insert foley,s catheter, if not inserted before and put her on hourly output chart. Pneumatic compression stockings applied to reduce risk of thrombosis. After patient is stablized, I will start her on anti-hypertensive infusion. She should be kept on restricted fluids at the rate of 85mLs/hr. I will check the blood results and plot them on flow chart. Bloods will need repeating every six hours or earlier if indicated. I will then speak to Radiologist and request imaging in the form of CT scan of brain. I will auscultate chest and request chest X ray if there is suspicion of pulmonary oedema. Corticosteroid should be started in the form of betamethasone 12mg every 12 hour for 2 doses, however, steroids should not delay delivery if required. Once patient is stable, discussion regarding delivery should take place. Urgent USS will be requested to check growth, liqour volume and dopplers. Neonatologist should be informed and ensure cot is available in case of delivery.  Patient and family is given chance to discuss short and long term morbidity with neonatologist if baby is born at this gestation. Mode of delivery depends on how stable the patient is. Caesarean section should be done for obstetric indications. Once decision for delivery has been made, I will assess the patient vaginally and give her prostaglandins depending on bishop score.

After acute management I will debrief patient and family and will fill incident form. Further ante-natal management depends how well patient has recovered. I will start her on oral anti-hypertensive and keep her in the hospital until delivery which very likely will be before 38 weeks. She will also have serial growth scans until delivery 

I would enquire on  symptoms of headache, blurring of vision epigastric pain or vomiting which may indicate impending eclampsia, inquire on her perception of fetal movements. I would re-check her Blood pressure using appropriate sized sphygnomanometer cuff, check for reflexes and asess fundal height for fetal growth and send urine sample for spot protein creatinine ratio.. Bloods should be sent including Full Blood Count , Urea and electrolytes, uric acid and liver function tests.

When the seizure happens, i would call for help and call anaesthetist and senior midwife .I woud put her in recovery position, maintain airway and try to avoid aspiration,maintain ventilation, gain IV access send blood for group and save, and administer loading dose of 4 g magnesium sulphate slow IV to stop seizure , then continue infusion of magnesium sulphate at a rate of 1 g per hour until 24 hours after delivery.consultant obstetrician and anaesthetis should be informed and neonatologist alerted.  I will insert a foley's catheter to monitor her urine out put and fluid balance. i will administer labetol 200 mg orally stat dose or IV depending on her condition, and recheck her blood pressure regularly and evaluate the need of anti hypertensive infusion or regular oral antihypertensive. Fluids should be restricted to 85 ml/hour to avoid the risk of pulmonary edema.respiratory rate, reflexes and urine output should be checked regularly to detect signs of magnesium toxicity .

once stabilised, i will assess the fetal well being by ctg, and assess the fetal position. i would administer first dose of steroid and asess cervix by vaginal examination if favourable for induction or not. I would explain to the woman and her family what had happend and counsel them on  the risks of continuing pregnancy and offer induction if cervix is favourable for induction or caesarean section if it is not. At 32 weeks it is more likeley that the cervix will not be favourable for induction and delivery is more likely to be by Caesarean section.

a)The patient needs to be admitted in the ward and requires close monitoring of maternal and fetal wellbeing. Assess the severity of PET by symptoms and signs and appropriate investigations. History has to be taken regarding symptoms of headache, visual disturbances, oliguria, epigastric pain, nausea and vomiting. Detailed physical examination must be done including vitals; pulse, 24 hr BP monitoring , (>170/100 BP on 2 occasions suggest severe PET) general examination look for obesity( risk of PET increase by 3 fold), petechiae( may suggest thrombocytopenia, feature of HELLP).Systemic examination must include CNS examination – examine for hyperreflexia, ankle clonus  and chest / CVS examination to look for signs of pulmonary edema, congestive heart failure, right hypochondrial tenderness.

Abdominal examination must be done and examine the uterine height (may be decreased if FGR), contractions present or not, fetal heart present or not, distension due to ascites( feature of CHF).Fetal well being is assessed by conducting CTG and then obstetric  USG to look for FGR, amniotic fluid volume. Color Doppler of uterine artery, MCA, umbilical artery, ductus venosus must be done to look for the evidence of fetal hypoxia and decide the intervention to be taken. Investigations must be done to assess the severity; FBC( esp. thrombocytopenia correlates with the severity), 24 hour urinary protein, LFT ( aminotransferase, AST/ ALT), renal function test, coagulation screen and  fundus examination. Past history has to be taken of diabetes, chronic hypertension, thrombophilia and connective tissue disorder which aggravates the severity of PET.

B) Ring the emergency buzzer and call for help. Call consultant obstetrician, anaesthetist, midwife, SHO for help. Inform hematologist regarding the blood/FFP requirement.Ensure airway, breathing and circulation of the patient. Raise the rails of the cot and remove the sharps from nearby. Turn the patient to left lateral position and maintain airway by inserting the Guedel’s airway so as to prevent the tongue from falling backward and blocking the airway & being bitten during another fit. Do oral suction so as to clear the secretions from the air-passage. Adminster oxygen at high flow rate. Intravenous  access is sited and send the blood for cross-match, FBC, LFT, RFT and coagulation screen. MgSO₄ is administered 4gm in 20% dilution i.v over 15-20 minutes with 5gm in 50% dilution i.m in each buttock as the loading dose followed by 1gm / hr infusion as maintenance dose till 24 hr after last fit or delivery whichever is later.Put the indwelling urethral catheter so strict input output monitoring may be done. Anti-hypertensives like i.v.hydralazine or labetalol may be considered depending on the BP.

The ultimate treatment of eclampsia is delivery of the baby and placenta. Steroid (Betametasone 12 mg i.m) is administered to promote the fetal lung maturity. Immediate fetal monitoring should be done by CTG. If fetal distress is there assess contractions by abdominal examination and do vaginal examination to assess the state of cervix. If cervix is favourable, augmentation must be done with oxytocin and if cervix is not favourable; LSCS must be expedited. Epidural anaesthesia should be used during LSCS if coagulation screen is normal as it lowers the BP. Look for the availability of neonatal ICU as neonate may be preterm, growth restricted and LBW. The patient needs to be monitored in High dependency unit/ Intensive care unit so vacancy of bed must be ascertained .

Paul,

I have just noticed that you have possibly suggested  to several people that delivery following an eclamptic fit must be immediate, without waiting for steroids.  I may have misinterpreted this, but I would be really crateful for some clarification.  I did think that the NICE guidelines stated that if the woman is "stable" after her eclamptic seizure then it may be feasable to wait 24hrs for delivery in order to administer steroids.  I appreciate that in practice we may just go on a deliver for fear of further deterioration and they generall are 'unwell' if they have indeed developed eclampsia, but the guidelines do actually say we could wait.  What is the correct thing to say in the exam?

I would be really grateful for clarification on this query

Thank you in advance

Dear Paul,

please mark my answer.

Dear Paul,

some of the answers are not marked, including mine..