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MRCOG PART 2 SBAs and EMQs

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Essay 305 - PET

PET Posted by Maili Q.

(a)

I will ask about symptoms indicating severe pre-eclampsia or impending eclampsia, including headache, epigastric pain with vomiting, blurring of vision, and sudden onset of swelling in face, feet or hands. Fetal movement should be ascertained.

On physical examination, body mass index should be recorded. General consciousness should be assessed. Blood pressure should be repeated. Fundal height would be measured to exclude fetal growth restriction. Abdomen should be palpated to look for epigastric tenderness (liver involvement) or uterine tenderness (abruptio). Neurological examination should be performed to look for hyperreflexia and clonus. Fundoscopy may be of use to detect papilloedema.

Initial investigation should include full blood count, kidney function and liver function to assess end-organ damage. Urine protein:creatine ratio or 24 hour urine protein to quantify proteinuria. CTG will be conducted to monitor the fetus. Growth scan may be indicated if growth restriction suspected.

 

(b)

Help should be called for immediately, involving senior and consultant obstetricians, senior and consultant anaesthetists, and senior midwives.

The patient should be positioned left laterally. Airway should be secured and facial mask applied for oxygen supply. Intubation might be required.

IV access should be obtained with blood drawn for FBC, kidney, liver and clotting function as well as group and crossmatch.

Although eclamptic fits are usually self-limiting, IV magnesium sulphate with 4g loading and 1g/hr infusion for 24 hours should be started to abort and prevent further seizure. A repeat dose of 2g bolus may be considered if recurrent seizure. Patient should be watched for symptoms and signs of magnesium toxicity, including confusion, loss of reflex and respiratory depression. Monitroing of serum magnesium level should be considered in patient with kidney impairment or oligouria.

Continuous monitoring of blood pressure, pulse rate, respiratory rate and oxygen saturation is required. Antihypertensive e.g. intravenous labetolol should be administered to maintain BP < 150/100.

Fluid should be restricted to 80ml/hr to avoid overloading and pulmonary oedema. Indwelling catheter should be inserted to monitor urine output and manage fluid balance.

The fetus should be on continuous monitoring by CTG and be delivered once patient is stable. Emergency caesarean section is usually performed if cervix not favourable and neonatologist should be standby at delivery in view of prematurity.

Following delivery, patient should be transferred to intensive care/high-dependency unit for further monitoring. Risk management and incident form should be filled. Events should be explained to the patient, and general practitioner should be informed for follow-up. Advice regarding recurrence (1 in 4 in this case) in future pregnancy and indication for aspirin from 12 weeks should be given.

Please ignore the previous answer Posted by Maili Q.

(a) Initial assessment

I will ask about symptoms indicating severe pre-eclampsia or impending eclampsia, including headache, epigastric pain with vomiting, blurring of vision, and sudden onset of swelling in face, feet or hands. Fetal movement should be ascertained.

On physical examination, body mass index should be recorded. General consciousness should be assessed. Blood pressure should be repeated. Fundal height would be measured to exclude fetal growth restriction. Abdomen should be palpated to look for epigastric tenderness (liver involvement) or uterine tenderness (abruptio). Neurological examination should be performed to look for hyperreflexia and clonus. Fundoscopy may be of use to detect papilloedema.

Initial investigation should include full blood count, kidney function and liver function to assess end-organ damage. Urine protein:creatine ratio or 24 hour urine protein to quantify proteinuria. CTG will be conducted to monitor the fetus. Growth scan may be indicated if growth restriction suspected.

 

(b) Principles and management

Communication

Help should be called for immediately, involving senior and consultant obstetricians, senior and consultant anaesthetists, and senior midwives.

 

Resuscitation

The patient should be positioned left laterally. Airway should be secured and facial mask applied for oxygen supply. Intubation might be required.

IV access should be obtained with blood drawn for FBC, kidney, liver and clotting function as well as group and crossmatch.

 

Stop and prevent further seizure

Although eclamptic fits are usually self-limiting, IV magnesium sulphate with 4g loading and 1g/hr infusion for 24 hours should be started to abort and prevent further seizure. A repeat dose of 2g bolus may be considered if recurrent seizure. Patient should be watched for symptoms and signs of magnesium toxicity, including confusion, loss of reflex and respiratory depression. Monitroing of serum magnesium level should be considered in patient with kidney impairment or oligouria.

 

Monitoring

Continuous monitoring of blood pressure, pulse rate, respiratory rate and oxygen saturation is required. Antihypertensive e.g. intravenous labetolol should be administered to maintain BP < 150/100.

Fluid should be restricted to 80ml/hr to avoid overloading and pulmonary oedema. Indwelling catheter should be inserted to monitor urine output and manage fluid balance.

The fetus should be on continuous monitoring by CTG.

 

Definitive treatment (delivery)

Delivery should be planned once patient is stable. Emergency caesarean section is usually performed if cervix not favourable and neonatologist should be standby at delivery in view of prematurity. Following delivery, patient should be transferred to intensive care/high-dependency unit for further monitoring.

 

Risk management

Risk management and incident form should be filled. Events should be explained to the patient, and general practitioner should be informed for follow-up. Advice regarding recurrence (1 in 4 in this case) in future pregnancy and indication for aspirin from 12 weeks should be given.

 
Posted by shreya S.

A. I will take a history to establish severity to pre eclampsia and ask for symptoms like headache, blurring of vision or epigastric pain. I will ask about medical history like renal disease or diabetes which could pre dispose to preeclampsia or hypertensive disease. If she is on any medication including anti hypertensives. Check for symptoms of UTI like burning, increased frequency or micturition causing proteinuria. I will enquire about fetal movements and any symptoms of abdominal pain or pv loss as pre eclampsia can cause complications like pre term labour and placental abruption.

On examination i will repeat the blood pressure, check pulse and record BMI. I will check reflexes and do fundoscopy if visual symptoms to check for papilloedema to establish severity of pre eclampsia. I will check fundal height to rule out fetal growth restriction and establish lie and presentation in case of impending delivery.A CTG for fetal well being and plan to admit.

B. The principles will be to treat this episode, resuscite, stabilise to prevent further seizures and plan for delivery. For this seizure, I will call of help first ( senior obstetrician, anaesthetist, senior midwife and paediatricians made aware).

First establish safety for both patient and staff, clear airway and resusicate in left lateral postition. 100% oxygen delivery and iv access ( FBC, LFT, U&E, Clotting profile). Start magsulph regime with 4g iv loading dose followed by maintenance dose of 1g per hour. Admit to HDU , joint care between obstetric and anaesthetic team is needed. Will need close monitoring for magsulph toxicity by checking reflexes and respiratory rate. Blood pressure control not below 140/90 and close fluid Input output monitoring limiting to 80mls per hour.

After stabilising her,review clinical condition and blood results to make a decision about delivery. It has to be carefully made balancing the risks of preterm delivery at 30 weeks and maternal health.MDT decision involving senior obstetrician, anaesthetists and paediatric team ( SCBU awailability) and further discussion with the patient taking her wishes into account time for delivery has to be decided.Risks of preterm birth should be discussed by paediatric team with patient to help her make an informed decision. Deranged clotting profile and low platelets may need correction with platelet transfuion or FFP before attempting delivery.

Mode of delivery at this gestation is more likely to be cesaren section unless cervix very favourable, goes into spontaneous preterm labour or patient declines cesarean. Recovery post op in HDU and Magsulph should be continued for 24 hours atleast after delivery as risk is even higher in the immediate post natal period. Incident form should be filled.

PET SAQ ANSWER Posted by vijay D.

A)

Elicit history of high blood pressure before this pregnancy.High blood pressure in past pregnancies,need for treatment and outcome.History of symptoms of severe pre-eclampsia including headache , visual disturbance,epigastric pain,reduced urination.I would review handheld notes for booking blood pressure , BMI, other risk factors,previous scans for placental location.history suggestive of UTI

Examination including repeat blood pressure,look for swelling of legs and abdomen.I would check the reflexes auscultate chest.Measure symphysio-fundal height ,check lie and presentation and auscultate fetal heart.

Investigations i would perform include blood tests for full blood count,clotting profile,LFT,U&E,urine PCR,group & save.fetal CTG trace

B)

The management principles include initially arresting the convulsions and safeguarding the airway.Followed by measures to prevent further convulsions.Stabilising her airways , breathing  circulation and blood pressure.Arranging care in high dependency unit and involving anaesthetic team , consultant obstetrician,midwife,neonatologyteam and hematology/blood transfusion team.Appropriate restraint to prevent fall or injury.Monitoring blood pressure , urine outout,saturation.

The initial convulsion would be managed by preventing aspiration and IV Mgso4 loading dose 4gm diluted in saline over 10 minutes.Tongue guard to prevent tongue bite.Inform consultant obstetrician and anaesthetist.Arrange trabsfer to high dependency care.Review blood tests to detect onset of HELLP syndrome.

Once she is conscious to apprise her of the situation and offer induction of labour after explaining merits and demerits of delivery.inform her of risk of severe morbidity to herself and baby if pregnancy continues.

Involve neonatology team to counsel regarding consequences of preterm birth and arrange a cot for baby.assess cervix for suitability of induction.offer caesarean section if unfavourable.

Continue Mgso4 infusion untill 24 hours after delivery.regular blood tests every 6 hours.

PET Posted by rasheeda B.

a)initial assessment.I would ask her,about symptoms of severe preeclampsia, if she has recent history of headache,epigastric pain,visual disturbance,and sudden onset swelling .If she percieves foetal movements.On examination,I will check bp every  15 mins until diastole <110,check the fundal height, to look for growth restriction,check for epigastric tenderness as this indicates stretching of glissons capsule,,check fundoscope for pappiloedema,and reflexes for hyperreflexia.Hyperreflexia indicates irritation of cns.For investigation to do protein creatinine ratio/24 hrs urine protein. to investigate full blood count,renal function test, liver function test.,to do ctg,and ultrasound if growrth restriction is suspected. and check liqor volume,and umbilical artery doppler .b) principles underlying subsequent management.(fits).To call for help,,need midwife ,senior obstetrician,eclampsia pack..To resuscitate,keep pt. in left lateral position,secure airway,-prevent tongue biting,give oxygen by face mask.Secure iv,send blood for fbc,U E,LFT,clotting ,group and save. Although seizures are self limiting,to give magnesium sulphate loading dose of 4 gms iv -push slowly over 5 mins.Maintainance dose of 1 gm per hour to be infused for 24 hrs.In case of recurrent seizure a furter dose of 2 gms over 5 mins.To treat hypertension with iv labetolol or hydrallazine.Dosage of labetolol-bolus of 20 mg iv,followed by 40 mg increase,every 10 minsupto a total dose of 220 mg.Aim is Mean Arterial Pressure should be <125mm Hg..once this achieved infusion of 40 mg/hour.

Monitoring .One midwife exclusively for this patient..Check FHR,BP every 15 mins.ECG during magnesium therapy and 1 hour after loading dose.Check urine output. Fluid balance 80 ml/hr.O2 by face mask .If oliguric, to check serum magnesium levels.FBC ,U&E,,clotting,LFt to be repeated.

Once stabilised to deliver this patient.Preferrably caesarean as cervix would be unfavourable for induction at 30 weeks gestation.To inform the patient as well as her relatives about decision to deliver as soon as possible by caesarean and also the fact that baby being premature needs admission to scubu.

Risk management clear documentation,involve gp,and fill incident form.

PET Posted by rasheeda B.

I want to add in monitoring check urine output hourly should be > 25 ml,resp. rate and deep tendon reflexes-(detects magnesium toxicity)

PET Posted by MRCOGPASS P.

a) I would ask for history suggestive of pre clampsia such as blurring of vision, headache, epigastric pain, nausea and vomitting. I will ask her antenatal history for any similar episodes and ask about the presence of fetal movements. On physical examination, I will retake the vital signs, blood pressure, pulse rate and calculate the BMI. I will perform a fundoscopy to check for papiloedema and examine the abdomen for lie , presentation and check symphysial fundal height to check for any intra uterine growth retardation. I will also perform a speculum and vaginal examination to check if she is in labour as well as examine bilateral calves for any swelling or edema I will also check the reflexes for hyperreflexia and clonus more than 5 beats. I will perform the following investigations to rule out pre clampsia. Full blood count, coagulation profile, urea electrolytes and Uric acid as well as a spot protein creatinine ratio or a 24 hour Urine protein collection as well as chart her input and output over 24 hours daily. I will admit her to the labour ward for monitoring and inform my consultant obstetrician and anaesthetist and neonatologists. I will ensure that there are sufficient beds in the high dependancy unit as well as the neonatal intensive care unit in the event of delivery. I will start her on IV anti hypertensives such as IV labetalol and recheck her blood pressure every 15 min . I will put her on a MEOWS chart for monitoring.

 

b) I will call for help, activate the consultant obstetrician, anaesthetist, neonatologist . I will resusitate the patient. Put her in a left lateral position. I will commence a loading dose of intravenous magnesium sulphate 2 g followed by a maintenance dose. If she fits again, I will give her another dose of intravenous magnesium sulphate. Her blood pressure should also be controlled with intravenous labetalol loading dose followed by a maintenance dose. I will admit this patient into the high dependancy unit for further monitoring. She should be put on the MEOWs chart and pre clampsia monitoring. She should also have electronic continuous fetal monitoring while she is admitted. Blood investigations such a full blood count, coagulation profile, Uric acid, urea and electrolytes should be sent. Magnesium levels should also be monitored as long as she is on intravenous magnesium sulphate therapy as they can cause toxicity such as respiratory depression . Intramuscular steroids should be given in the form of Bethamethasone 12 mg 24 hours apart. Fluid balance should also be charted in this patient and urine output charted.

Mode and timing of delivery will depend on obstetric indications or if blood pressure is not well controlled, patient should be delivered by caesearean section. Post delivery, the patient should be debriefed and the diagnosis explained. She should be counselled regarding the need to stay in hospital till her blood pressure is well controlled. Contraception and breastfeeding advice should be given before discharge and she should be adviced to book early for her next pregnancy as she will benefit from aspirin early in the pregnancy.

Posted by Tarannum Rukhsa K.
I would ask about symptoms of pre eclampsia such as headech ,blurring of vision ,epigastric pain or dyscomfort ,sudden increase in weight .i would ascertain eftal viability by asking fetal movement .i would like to ask about previous pregnancy does she has this problem is previous pregnancy lead to early delivery or history pre eclampsia or intrauterine growth retardation .i will measure her blood pressure BMI and spot protien cratinin ratio to quatify the protienurea .i will check for hyperreflaxia (sign of pre eclampsia )she needs to have fundoscopy to rule out any pappiloedema .i will examine her abdomen to feel any epigastric tenderness and fundal height to have a rough idea of fetal growth and fetal heart sound .i will send investigation cbc ,ALT and AST ,low platelet and deranged liver enzyme indicate impending pre eclampsia .she should have ctg to monitor fetal condition and growth scan to rule out any fetal growth retardation . Principles of management , Eclamtic fit is an obstetric emergency . Involment of senior obstetrician ,senior midwife is necessary Keep airway patent ,keep her on left lateral position (reduced risk of aspiration) Maitain i/v line with two large bore cannula size14 Monitor vitals pulse ,blood pressure ,respiratory rate and check for oxygen saturation .initially every 15 min. Catheterise the patient to monitor urinary out put . Control of fits by mgso4blus dose and start maitainance dose afterword. Maintaing the blood pressure below 150/100 by giving labetalol infusion first line antihypertensive Blood investigation Cbc to look for deranged platelet (hemolysis) ,Alanine aminotranferase and aspartate . Ctg for fetal monitoring . Corticosteroid for fetal lung maturity as early delivery suspected . Definate treatment is termination of pregnancy after discussion with obsteric consultant and neonatologist . Mode of delivery depending upon the cervical status if bishop score is good induction of labour .otherwise delivery by cesarean section . All events should be recorded in the notes and incident form must be filled . Councelling of family as they must be anscious. General practioner should be informed .once patient is stable she should be explained the condition and risk of recurrence in future pregnancy . Encourage breast feeding councell about post natal followup and risk in future pregnancy .
Posted by Tarannum Rukhsa K.
I wrote second part with heading of priciple of management but it mixed up.second part is from that written pricipal of management .thanks .
PET SAQs. Answer Posted by mamta S.
a) I will admit this patient in consultant led care as she is a case of moderate preeclampsia , repeat her bp after half hour , if persistently high will start her on labetolol tablet 100-200 mg BD ,, asses her general condition,ankle reflexes , clonus, ask her about any symptoms of headache , vomiting , epigastric pain, blurring of vision as it indicates impending eclampsia , I will check symphysiofundal hieght for fetal growth , will get KFT , LFT,uric acid , FBC , quantitative analysis of urinary proteins . I will advise ultrasound for fetal growth and liquor amount , umblical artery Doppler velocimetry . Any deranged parameter in blood test indicates severe condition of the woman . I will also inform the consultant obstetrician , anaesthetist , neonatologist as she may require urgent CS , delivery . I will also give her injection betamethasone 12 mg I'm stat and repeat after 12-24 hrs . I will inform the condition and risk to the patient and her partner b)as she is throwing fit she has developed eclampsia , I will call for help , inform consultant obstetrician , anaesthetist and neonatologist , will make the patient lie in recovery position , ensure her airway is clear and breathing maintained . I will give her magnesium sulphate 4 grams slow IV as loading dose , followed by mgso4 IV infusion at a rate of 1 gram per hour . I will transfer the patient to HDU/ Intensive care for good monitoring . If seizure not controlled then repeat the dose 2-4 grams SOS . I V fluids to be given at a rate of 40-60 ml per hour . I will monitor her urine output , maintaining it at a rate of minimum 30 ml per hour as poor output can cause magnesium toxicity . Magnesium level monitoring is required for prevention of respiratory and neuromuscular depression .fetal condition to be reassessed by CTG , Doppler though transient bradycardia may be seen. Magnesium sulphate will also require neuroprotection to the premature fetus as preterm delivery will happen . Risk assesment for VTE to be done as she will be hospitalised for long . Once the general condition is stabilised decision for delivery to be taken after discussing with neonatologist , consultant obstetrics and anaesthetist . If intensive neonatal services not available then in utero transfer to tertiary care may be considered after stabilising the condition of the mother as the baby is less than 34 weeks . Woman to be kept on magnesium sulphate in postnatal period for 24 hours and anti hypertensive to be continue if bp is not normal . Medical / specialist review is required at 6-8 weeks .
Posted by toothless ..

(a) I would ask the patient for symptoms of headache, visual blurring and epigastric pain to exclude impending eclampsia. I would proceed to ask about her current pregnancy, booking date and blood pressure at booking visit. I would enquire about results of down syndrome screening and fetal anomaly screening scan results. In her past obstetric history, I would for antenatal problems of pregnancy induced hypertension or pre-eclampsia, gestation at delivery, mode of delivery and any complications. I would ask the patient if she has been feeling normal fetal movements. On examiation, I would check the patient's blood pressure with a manual sphymomanometer with an appropriate sized cuff at the level of the heart. I would check her height, weight and calculate her body mass index. I would do an abdominal exam for epigastric tenderness, measure the SFH ensuring appropriate growth for dates and do a doptone for fetal heart assessment. I would check for pedal edema, hyper-reflexia and clonus. I would do a 24 hour urinary total protein to quantify her proteinuria and consider admiting the patient to hospital if her blood pressure is persistently >140/90mmHg.

b) I would call for help. I would assess the patient's airway, breathing and circulation and turn her to a left lateral position while awaiting spontaneous seizure abortion. Simultaneously, I would coordinate helpers to secure intravenous access, take bloods for full blood count, PT/PTT, renal panel, liver function test, uric acid and group and save. I would give the patient a loading dose of intravenous magnesium sulphate 4g stat over 5 minutes and infusion at 1g per hour. Meanwhile I would seek anaesthetist and consultant obstetrician input and arrange for transfer to the high dependency unit for monitoring. She requires frequent monitoring of blood pressure, insertion of indwelling catheter with in-out charting and continuous CTG for fetal monitoring. Intravenous antihypertensives such as IV labetalol or IV hydralazine should be given to maintain blood pressure <160/100mmHg. Expeditious delivery after discussion with the anaesthetist, neonatologist, patient and family is required upon stabilization of the patient. Delivery should be via emergency caesarean section. Post operatively, the patient should be continued on IV MgSO4 and pre-eclampsia bloods monitored. The patient's blood pressure should  be checked regularly and anti hypertensive medications titrated accordingly. The patient and family must be debriefed about the events of eclampsia requiring immediate resuscitation and emergency delivery for maternal safety. The events must be carefully documented and an incident report form raised for audit. The coupld should be counselled on increased risk of pre eclampsia (1:4) next pregnancy and the role of aspirin. On post natal follow up, blood pressure and urine must be checked.

Posted by Purnima D.

 

  1. I will get the blood pressure (BP) checked at maternity assessment unit with an appropriate size cuff sphyngomanometer, preferably manual as automatic machine can give low readings. Will also repeat urinalysis. High BP and proteinuria makes diagnosis of preeclampsia. I will enquire about symptoms as headache, visual disturbances, right upper quadrant pain & sudden swelling. Obstetric history and past history of high blood pressure needs enquiring to assess possible complications. I need to admit her to be able to monitor closely as she will need BP checking about 4 times in a day based on readings. Will organise for her to have full blood count, urea and electrolytes, LFT, coagulation tests, and send urine for PCR. Will review her notes for booking BP, get details of scan.  I will note allergies and medical conditions if any, which could guide use of anti hypertensive medication. I will start her on antihypertensive (based on unit protocol) and recheck BP after to decide appropriate dose.

 

Examination: BP repeated to get a profile. Check for reflexes (if brisk) and clonus

       Chest (rule out  Pulmonary oedema) and abdominal examination ( assess tenderness, organomagaly)

Speculum examination : if having abdominal pain & to assess cervical favourability

 

b) Fits in a pregnant women is due to Eclampsia unless proven otherwise.

It is a medical emergency which necessitates calling senior help as consultant obstetrician, consultant anaesthetist, labour ward lead, intensivist. Management needs multidisciplinary team  involvement.

Priority is as per ABC & simultaneous preparation of  MgSo4 and anti hypertensive infusions. Airway checked for presence of foreign body, a Guiedal airway inserted to avoid tongue falling back and causing obstruction, Breathing assessed followed by circulation. 2 wide bore intravenous lines inserted and bloods taken for FBC, U&E, LFT, coagulation, G&S.   

MgSo4 4gm given over 5 minutes as loading dose followed by 1gm/litre every 24 hour infusion as maintainence. MgSo4 reduces cerebral irritation thus helps in stopping fits , avoids recurrence and has been shown in studies to reduce maternal mortality risk.

Anti hypertensive as hydralazine, nifedipine , labetolol ( as per unit protocol) needed to reduce BP and should be fast acting. Side effect with Hydralazine is immediate drop in BP which can cause fatal distress so have to be given slow over 5- 10 minute infusion and repeated as per BP charting.

The vitals (P,BP,urine output) need monitoring so HDU charting commenced to stabilise BP, avoid recurrent fits and void complications as pulmonary oedema. Urinary catheter inserted so strict input/output charting can be done and restrict fluid intake to 80ml/hour.

Monitoring of respiratory rate (>16/minute), urine output (>100ml/4hour) , patellar reflexes and magnesium levels checked to avoid Magnesium toxicity. Infusion continues till 12 hours postpartum or 24 hours of commencing whichever is later.

Chest examination is done to rule out pulmonary oedema which results as a consequence of fluid overload.

Speculum/ Vaginal examination to assess if cervix favourable.

Repeat PET bloods done to ascertain improvement and identify complications as HELLP.

Anaesthetist review needed as she will need delivering once blood pressure stabilises. Epidural preferred as it will keep her pain free (pain can precipitate fit) and also reduce BP.

Paediatrician review as once BP stabilises mum needs delivery after 2 doses steroids given, she needs to know risk of preterm delivery.

Maternal condition needs stabilising first and so fetal monitoring only done once BP stabilises.

Definitive treatment is to deliver. She is 30 weeks pregnant and steroids are needed to mature lungs.

Vaginal delivery is preferred if cervix favourable,  fetal position and condition  does not necessitate LSCS.

ITU/ HDU admission may be needed if monitoring at labour ward not feasible

Postpartum time needs to be kept aside to debrief her and relatives regarding eclampsia, future pregnancy management (recurrence risk 1 in 4, need of aspirin as soon in next pregnancy)  and implications.

  Staff training is paramount in form of simulation/ skills drills session.

IR1 form needs filling 

PET Posted by gunjan S.

PET

Initial Assessment

I will ask for symptoms of severe pre eclampsia like severe headache, epigastric pain with vomiting, visual disturbances and sudden onset swelling of hands, feet and face. Enquire about the presence of fetal movements. Note Obstetric history for raised blood pressure in previous pregnancy. Review her notes for booking blood pressure, previous scans for fetal growth, placental location.

I will examine her pulse, Blood pressure every 15 minutes [until less than 150/100] and measure BMI. Abdominal examination for fundal height to rule out growth restriction. Note epigastric tenderness [liver involvement] or uterine tenderness [placental abruption].Auscultate fetal heart and confirm presentation, contractions. I will do Fundoscopy to rule out papilledema and Neurological examination for hypereflexia and clonus.

I will do a Urine protein creatinine ratio or 24 hour urine protein to assess proteinuria. Perform Full blood count, Baseline Renal function tests, and Liver function tests to assess end organ damage. CTG and Ultrasound scan with Doppler will be performed for fetal well-being, growth, liquor volume.

B.] Principles of management -:

Communication –This is an obstetric emergency so obstetric crash call for help including senior obstetrician, anesthetist, labour ward coordinator, senior midwife, neonatologist and porter. Eclampsia pack is arranged.

Resuscitation –I will quickly position the patient in left lateral position and secure airway. Facial oxygen is started and intubation done if required. Intravenous access secured with two large bore cannula as soon as she stops fitting. Blood will be sent for FBC [haemoglobin, platelets],liver and renal function[urea,creatinine] tests, rates ,clotting profile and group & save.

Prevent further seizures - Loading dose of intravenous Magnesium Sulphate 4g over 5 minutes is administered to prevent further seizures though eclamptic fits are usually self-limiting.Maintainence dose of 1g/hour in an intravenous infusion for 24 hours is started. For recurrent seizure, a bolus dose of 2g over 5 minutes can be given.

 Control blood pressure – Adequate control of hypertension to prevent stroke or cardiac failure [secondary to hypertension] by antihypertensives.Intravenous Labetalol or Hydralazine is given depending upon the local protocol to keep systolic less than 150 and diastolic blood pressure between 80-100mmHg.

Monitoring -- Close monitoring in HDU ward with one to one nursing care. Monitor Blood pressure [every 15 minutes], respiratory rate and oxygen saturation. Signs of Magnesium toxicity identified by checking deep tendon reflexes, urine output [hourly] and ECG. If repeated seizures with oliguria or rising urea, creatinine check for magnesium levels and central venous pressure monitoring indicated. Strict intake and output chart [hourly]. Restrict intravenous fluids to a total of 85 ml/hour to prevent fluid overload and pulmonary edema. PET blood tests [FBC, LFT,RFT,Clotting profile ]repeated every 6 hourly depending on the clinical status and previous results.

Delivery Plan –Once the patient is stable, she should be delivered. Induction of labour with vaginal prostaglandins is done if not contraindicated. Caesarian Section is preferred if the cervix is unfavourable.Neonatologists must be present at delivery for preterm birth and SCBU informed. Magnesium therapy is continued for 24 hours to cover up the risk of postpartum eclampsia.PET blood tests repeated and monitoring continued in HDU ward.

Risk management –Debriefing the woman, filling of the risk management and incident forms will be done. She will be advised about Contraception and risk of recurrence in future pregnancy .Inform GP for postpartum blood pressure monitoring after discharge.

Posted by ASB A.

obgat

(A)

This is a case of preeclampsia ( hypertension and proteinuria after 20 weeks gestations ) . 

During history , symptoms of severe preeclampsia ( e.g headache , blurred vision , epigastric pain , vomiting) should be enquired about . Ask about maternal perception of fetal movements .

During examination , assess tendon reflexes for hyperreflexia . Fundoscopy should be performed for papilloedema . Abdominal examination for assessment of fundal height , fetal lie and presentation ; epigastric tendereness and auscultation of fetal heart beats .

Investigations include 24-hour urine collection or spot testing for protein : creatinine ration to quantify proteinuria .Blood tests for full blood count , seum creatinine and  transaminases . If platlets are less than 100,000  , then coagulation screening should be carried out . ultrasound for fetal biometry , amniotic fluid volume and umblical artery doppler .

 

(B)

A patent airway must be secured immediately and the patient positioned in the left lateral position to avoid aspiration .

Obstetric crash call as it is an obstetric emergency and its managment should involve consultant obstetrician , anaethetist and experienced midwife .

There should be a unit protocol for managment of eclampsia and this protocol should be followed .

Insert 2 large iv line and obtain blood for full blood cound , urea and electrolyte , transaminases , group and save blood , fibrinigen and fibrin degradation products .

Fits should be controlled by intravenous Mg SO4 ( 4 grams loading dose over 10-15 minutes , followed by 1 gram/hour maintenance dose for 24 hours ) . Do not use diazepam or phenytoin as an alternatives to Mg SO4 in eclampsia managment .

Blood pressure should be controlled to avoid cerebrovascular accidents . if mean arterial pressure is persistently high ( > 125 ) , then intravenous antihypertensive ( labetalol or hydralazine ) should be started to control blood pressure . labetalol should be avoided in asthmatics . 500 ml or less of crystalloid should be considered before or during the first dose of hydralazine .

Maintenance fluid managment should be limited to 80 ml/hour unless there are ongoing loss (e.g haemorrhage ) . strict input /output chart should be used to identify any significant imbalance between input and output which could preceed pulmonary oedema .Do not use volume expansion (e.g before epidural ) unless hydralazine is used antenatally .

Regarding monitoring ,the patient should be nursed in level 2 critical care ( level 3 if ventillation is needed ) . blood pressure should be monitored continously . close monitoring ( every 15 minutes ) of respiratory rate , oxygen saturation , tendon reflexes and urine output to identify signs of Mg SO4 toxicity  . blood tests ( FBC , creatinine and transaminases ) should be repeated every 6 hours . invasive monitoring ( central venous pressure )  is indicated in women with renal damage ( oliguria , anuria with rising urea and creatinine ) , pulmonary oedema and cardiac failure .

Assessment of fetal wellbeing with ultrasound ( fetal biometry , amniotic fluid volume and umblical artery doppler ) and cardiotocography .

Once the patient is stabilised ( seizures controlled , hypertension treated and hypoxia corrected ) , she should be delivered  . Vaginal delivery may be considered , however , ceasarean section is the best choice if gestational age is less than 32 weeks , especially with unfavourable cervix .

control of hypertension and seizures as well as restricted fluid managment should be continued postpartum until recovery is apparent .

 

Posted by Ja A.

A) Enquire about symptoms of impending eclampsia such as headache, blurring of vision, epigastri pain or vomiting. Enquire about current medications and her compliance to them. Presence of abdominal pain with vaginal bleeding may suggest abruptio placenta. Presence of reduced fetal movements suggest fetal compromise. Abdominal examination to assess uterine irritability and symphysio-fundal hight to assess estimated uterine size. Fundoscopy to look for papilloedema. Repeat BP montoring half hourly with correct sized cuff to ensure BP controlled. Blood investigations such as FBC to determine haemoglobin and platlet levels. Liver function test to look for raised enzymes. Serum uric acid to determine severity of pre-eclampsia. Urine protein-creatinine ratio to quatitate proteinuria. CTG to assess fetal well-being.

B) Patient has eclampsia which is an obstetric emergency. Ensure surrounding of patient is safe to prevent self harm during fitting. Place patient in left lateral position to prevent aspiration of vomitus. Facial oxygen supplementation to reduce risk of hypoxia during seizure. Most eclampsia is self-limiting but IV MgSO4 4gm bolus is to be given followed by maintainance of 1gm/hour. Multidisciplinary approach involving consultant obstetrician, consultant anaesthetist and midwifery team. Neonatologist to be notified as fetus is premature. Sequence of events to be scribbed accurately by a midwife. IV anti hypertensives such as iv labetolol or iv hydralazine if mean arterial blood pressure raised above 125mmHg. Post-ictally, aim is to stabalize BP and to prevent further fitting. Arrange to deliver via category 3 Caesarean section. Continous CTG monitoring to ensure fetal well-being. Assess for focal neurological deficit , if present CT brain is required to look for intracranial bleeding. Involvement of neurosurgical team will be required if CT scan of brain shows intracranial bleeding. Post Caesarean section, patient will be placed under level 2 critical care with continuous BP monitoring and MEOWS charting. PET bloods repeated to ensure resolution and absence of coagulopathy due to HELLP syndrome. IV MgSO4 to continue for 24 hours after the last fit. Arrange debriefing session for patient and partner. Administer medical thromboprophylaxis when risk of bleeding is low. Incident reporting for risk management assessment.

Posted by Di T.

            a) This woman is having severe pre eclampsia (sever PET).  I will enquire regarding if she has symptoms such as headache, blurring of vision, epigastric pain and nausea and vomiting.  If she does not have those symptoms, I will proceed to ask regarding risk assessment for PET such as her parity (nulliparous has higher risk), inter-pregnancy interval (more than 10 years are at increased risk), past obstetric history of hypertensive disorder in pregnancy (increased risk of recurrence and severity in current pregnancy).  I would also ask for fetal movement and if there is associated pre vaginal bleeding.

          On examination, body mass index should be noted as >35 have increased risk.  Her BP should be measure using appropriate cuff size using Kurotkoff phase V.  Pulse rate and oxygen saturation should be measured.  Lung should be listened for any crepitation to look for sign of overload.  Sympysio fundal height should be measure as severe PET is associated with fetal growth restriction and abdomen should be palpated to look for sign of liver tenderness and uterus for sign of abruption placenta.  Neurological examination should be performed to look for hyperreflexia and clonus.  Fundoscopy may be perform to detect papilloedema. 

          Initially assessment should include full blood picture (FBC), liver and renal function (LFT, RFT) to assess end organ involvement and any laboratory deranged to detect HELLP.  Coagulation profile should be asked for if palate level less than 100x109/L.  Urine protein should be quantified using spot protein: creatatine ration or 24hour urine protein.  CTG should be done to assess fetal well-being and growth and amniotic fluid scan should be done if fetal growth restriction is suspected. 

          b) Help should be soughed as she is having eclampsia involving senior obstetrician, anesthetic and midwifes staffs.  Airway should be maintained to have adequate oxygenation and to prevent aspiration.  Fits should be aborted using IM or magnesium sulphate 4mg over 5 min followed by infusion 1g/hour for 24hour after delivery or from the last fits.  Blood pressure (BP) should bring down to the aim of systolic less than 150 and diastolic between 80-100 using IV labetalol, oral nifedipine or IV hydralazine.  Initially BP, PR, oxygen situation should be measure 15min once until stabilized then half an hourly.  Once she is stabilized she should be transferred to High dependency care.

          Fluid balance should be monitored closely to avoid fluid overload with urine output of more than 5ml/kg body weight/hour and maximum input of 80ml/hour.  FBC, LFT, RFT and coagulation profile if palate is less than 100x109/L, tendon reflexes and respiratory rate should be monitored and to detect for HELLP syndrome. 

          Delivery (likely to be caesarian section as bishop score may not be favourable) should be planned after discussion with neonatologist, senior obstetrician and anesthetics and after a course of corticosteroid and correction of coagulopathy if they are deranged.  Third stage should be managed actively with oxytocin.  Ergomtrine should be avoided.  If conservation management to prolong pregnancy is planned, it must be balanced again maternal well-being. 

          Incident form should be filled up for eclampsia.

Posted by ixi C.

a) Take a history for symptoms of impending eclampsia, including blurred vision, headache, epigastric pain, sudden onset of edema. Ask if there is a prior history of high blood pressure in current and previous pregnancies. Ask for drug history and if she has been started on any antihypertensives. Ask for symptoms of reduced fetal movements which may suggest fetal compromise. Ask for symptoms of possible complications of hypertension in pregnancy such as constant abdominal pain and vaginal bleeding which may suggest abruption. On physical examination, check blood pressure and body mass index. Check for hyperreflexia, presence of clonus and evidence of edema. Measure symphyseal fundal height which may be less than dates in fetal growth restriction. Do urine dipstick for proteinuria. Also send urine sample for urine protein-creatinine ratio. Significant proteinuria of more 30mg/mmol confirms diagnosis of preeclampsia. Alternatively, 24hr urine collection for total protein can be started. Significant proteinuria is defined by a level of more than 0.3g over 24hrs. Send blood for full blood count and liver function test, looking for low platelets and raised transaminases in HELLP syndrome. Check urea, electrolytes and creatinine for baseline renal function. Also check coagulation profile and uric acid levels.

b) Management of eclampsia by a multidisciplinary team is vital. This should comprise of a consultant obstetrician, anaesthetist, senior midwife, neonatologist and should also include available operating theatre staff. Aim is to stabilize the mother and expedite delivery. Assess airway, breathing and circulation. Lie patient in left lateral recovery position and provide oxygen with facemask at 10-15ml/hr. Insert two large bore intravenous cannula and ensure blood are sent for full blood count, urea electrolytes and creatinine, liver function tests, coagulation profile and type and screen. Most eclamptic fits are self-limiting. Start intravenous magnesium sulphate 4g slow bolus over 20-30 minutes, followed by a continuous infusion at 1-2g/hr. Repeated boluses may be needed if seizures recur. Start intravenous hydration with crystalloids such as Hartmann's solution, at infusion rate of 80ml/hr, being careful to avoid fluid overload. Monitor blood pressure every 15 minutes and start IV labetalol or hydralazine. Aim for blood pressure under 150/110mmHg. Insert indwelling catheter to monitor urine output. Ensure urine output at least 0.5mg/kg/hr. Monitor patient on modified obstetric early warning chart. Watch for signs and symptoms of magnesium toxicity such as oliguria, delayed tendon reflexes, decreased respiratory rate. Mg levels should be monitored. Antenatal steroids should be given in view of imminent preterm delivery. Assess fetal wellbeing by continuous cardiotocogram. Bedside scan should be performed to confirm placenta localization and fetal presentation. Delivery via caesarean section should be planned once the patient is stable, unless the patient is in established labour. If established labour is confirmed, allow normal vaginal delivery if no contraindications. If there is evidence of fetal distress, expedite delivery via caesarean section. Ensure blood tests are normal with no coagulopathy or thrombocytopenia before proceeding with anaesthesia and caesarean section. The patient and family should be informed about indication for premature delivery and risks of prematurity to fetus. Neonatologist should be on standby for neonatal resuscitation. 

PET Posted by Aliwal S.

(a) A detailed history should be taken, including her past medical history, any previous hypertension, renal disease, or autoimmune conditions. Antenatal history including any previous hypertensive episodes, the growth of the fetus thus far and ultrasound scan findings should be obtained. Any previous obstetric history and details including complications like hypertensive disorders, placenta abruptio and preterm birth should be enquired. Further signs and symptoms of impending eclampsia such as blurring of vision, epigastric pain, headache, as well as complications such as swelling of hands and feet, patient perception of decreased urine output, and difficulty breathing must be ascertained. Examination includes retaking of the blood pressure to confirm hypertension using an appropriately sized cuff. An abdominal examination for symphysial-fundal height to ensure adequate growth of the fetus, and a fetal doptone done to check the fetal wellbeing. Abdominal tenderness especially in the epigastric and hypogastric region must be looked for, and uterine tenderness could indicate potential complications such as placental abruption. A neurological examination should be done checking her reflexes and presence of clonus. Investigations include bloods for full blood count looking for anemia, platelet count looking for thrombocytopenia, liver function test looking at albumin levels as well as AST and ALT levels. All these could indicate severe hypertensive condition such as HELLP syndrome. Renal function test should be done, and uric acid levels may be useful. A coagulation profile must be done if there is evidence of thrombocytopenia. Quantification fo proteinuria with either a 24 hour urine total protein, or urine protein-creatinine ratio must be done. Treatment of her hypertension is necessary. She should be admitted and labetalol oral given as a first line agent if there are no contraindications such as asthma. Monitoring of the fetus with continuous cardiotocography should be done if fetal movements are abnormal. An ultrasound should be done with doppler monitoring to check fetal growth. Consider antenatal steroids if preterm delivery is expected within 7 days. Monitor her blood pressure hourly until it is less than 150/100mmHg, then at least 4 times a day thereafter.

(b) The patient is having an eclamptic fit and this is an obstetric emergency. Initial resuscitation and management of the seizure is required. The patient should be placed in a left lateral position till the seizure is aborted, and a call for help is needed immediately. The consultant anaesthetist, senior obstetrician, senior midwife, and intensivist should be alerted. Her airway should be secured and oxygen given via face mask. 2 large bore intravenous (IV) cannulas should be inserted and bloods taken for full blood count, renal panel, electrolytes, liver function tests, and coagulation screen. To prevent further seizures, IV magnesium sulphate should be started at 4 grams(g) per hour over 10 minutes as a bolus dose, followed by 1g/hr as a maintenance dose. The neonates should be informed and a plan made for immediate delivery. Antenatal steroids should be given in view of preterm delivery necessary. The patient should be examined after the seizure has stopped for residual neurological deficits. A urine catheter should be inserted for strict input-output monitoring. Fetal wellbeing must be ascertained and she should be on continuous fetal monitroing. Transfer of the patient to level 2 critical care unit is needed for further monitoring. A set of vital signs recording blood pressure, pulse rate, saturation should be taken, and antihypertensives given as necessary. IV antihypertensive agents such as labetalol or hydralazine might be necessary. She will need continuous blood pressure monitoring. The patient and family should be debriefed about the events and the need for delivery as it is the definitive cure for eclampsia. Counselling about fetal outcome at this premature gestation should be given by neonatologists. The implications on her subsequent pregnancy needs to be emphasized, with the need for aspirin 75mg OM from 12 weeks onwards to decrease the risk of preeclampsia. Recurrence in the next pregnancy is high, about 1 in 4.  

Posted by XX ..

(a)

Take a history for symptoms of severe pre-eclampsia including blurring of vision, headache, pain under her ribs and sudden onset of pedal swelling. Ask for previous obstetric history and presence of any hypertensive complications or early delivery. Take a history of current pregnancy and ask for any complications with hypertension. Check her gestational age as early delivery may be considered. Check her booking blood pressure and urine test results to rule out essential hypertension or pre-existing disease with proteinuria. Ask for history of medical disorders including renal disease and systemic lupus erythematosis which may be associated with proteinuria. 

Check her blood pressure using an appropriate sized blood pressure cuff and dipstick her urine for protein. Perform a neurological examination and assess for any hyperreflexia or clonus which may suggest severe pre-eclampsia or impending eclampsia.Examine her abdomen for right upper quadrant tenderness and measure her symphysial fundal height, plotted on customised growth chart to exclude fetal growth restriction.

Do blood tests for full blood count, renal panel, clotting profile, liver function tests including uric acid to assess for severity of pre-eclampsia, rule out HELLP syndrome and check for end-organ damage. Order a 24hour urine total protein collection. Depending on clinical assessment above, perform  cardiotocogram for assessment of fetal well-being at dagonosis severe pre-eclampsia. Arrange for ultrasound of fetal growth, amniotic fluid volume and umbilical doppler.

 

(b)

Call for help from consultant, midwives and anaesthetist. Call for the pre-eclampsia kit. The initial principal is to resuscitate and stabilise the patient. Place the patient in the left lateral position and secure her airway breathing and circulation.  Secure venous access with 2 large bore intravenous cannulas and draw blood if not already done so for group cross match, full blood count, clotting profile, renal panel and liver function tests. Abort the seizure by giving intravenous magnesium sulphate 4g loading over 5 mins and repeat dose of 2g if recurrent seizure. Continue maintenance dose of 1g/hr infusion over 24hrs. If unable to obtain venous access quickly, consider rectal diazepam. 

Once the fit is aborted and patient stabilise, the next principal is to monitor the patient and fetus. Monitor the patients vitals continuously using a modified early warning obstetric chart, including blood pressure, heart rate, respiratory rate and oxygen saturations. Keep patient fasted. Indwelling catheter should be inserted and fluid balance monitored. Restrict fluid to 80ml/hr to avoid pulmonary oedema. Monitor the fetus with continuous cardiotocogram. If there is any signs of fetal distress, category 1 caesarean section should be arranged.

The next aim is to control blood pressure. Oral or intravenous labetalol may be given, aiming to keep BP <140/90. Once blood pressure is stablised, inform anaesthetist, neonates and operating theatre to plan for delivery via caesarean section.

Following delivery, patient is still at high risk of eclampsia and close monitoring is needed. She should be placed in a high dependency unit and monitored with a modified obstetric warning chart. Monitor fluid balance and restrict fluid to less than 80ml/hr. Ensure thromboprophylaxis is given with low molecular weight heparin and TED stockings. Antihypertensives can be stopped if blood pressure is less than 140/90 but continue intravenous magnesium sulphate for 24hrs. Repeat her pre-eclampsia blood tests as clinically indicated. Provide breastfeeding support as patient is likely separated from her newborn. 

Last principal is clinical governance and risk management. The events of fit leading to delivery should be documented clearly with a incidence report form filled in. Patient and spouse should be debriefed of events and informed of  increased risk of pre-eclampsia in her next pregnancy. Advise to take aspirin in her next pregnancy. Inform her GP and provide a follow-up appointment. 

 

PET Posted by Shilla Mariah Y.

a) I would take a quick history for symptoms of impending eclampsia namely headache, blurring of vision, nausea, vomiting and epigastric pain. I would ask for any swelling of the arms and legs. I would ask for fetal movement to assess fetal wellbeing. I would ask for any abdominal pain or vaginal bleeding to assess for abruption. I would do a quick examination for signs of impending eclampsia namely epigastric tenderness, hyperreflexia and clonus more than 3 beats. I would check her BMI and recheck her BP. I would do a symphysial fundal height measurement to look for small for gestational age fetus. I would do an abdominal palpation to check for tenderness and uterine tenderness. I would admit her to hospital. I would take bloods for full blood count, renal panel and liver panel. I would do a 24hour urine protein collection. I would give her an immediate dose of oral labetalol 200mg . I would monitor her BP every half hour as well as reflexes and clonus. I would update a senior obstetrician, neonatologist and anaesthetist. I would ask for availability of a neonatal bed, and if it is not available, consider transfer to another hospital when stable. I would consider giving a course of steroids for fetal lung maturity. I would consider starting magnesium sulphate if she has signs and symptoms of impending eclampsia. I would put on cardiotocography for fetal monitoring.                                                                                           b) I would recognise that this is an obstetric emergency. I would call for help - senior obstetrician, midwife, anaesthetist. I would give an intravenous bolus of magnesium sulphate 4g loading dose to abort the fit, and repeat boluses of 2g each time until the fit stops. Once the fit has stopped, I would assess and secure her airway and breathing by giving supplementary oxygen or intubation if she is unable to maintain her airway. I would insert 2 large bore IV cannulae. I would put her in recovery position, in left lateral. I would transfer her to intensive care. I would send bloods for full blood count, renal panel, liver panel, clotting screen and group and save. I would monitor her BP every 15 minute initially, then every 30 minutes when more stable. She needs delivery when she is stable. I would continue magnesium sulphate infusion to prevent fitting. I would complete a course of steroids for fetal lung maturity. I would put on electronic fetalmonitoring to assess fetal well being. I would restrict fluids to 80ml/hour. I would insert a catheter and monitor intake/output strictly. I would start intravenous labetalol to keep BP between 140/90 to 150/100. I would start thromboprophylaxis by either calf compressors, thromboembolic deterrent stockings of low molecular weight heparin, depending on other risk factors. I would expedite delivery when she is stable. I would call the neonatologist to be present at delivery to attend to baby. Delivery will be by Caesarean section. After delivery, I would debrief her and give her written information. I would also give her a medical review at 6 weeks to check her BP, check for proteinuria as wll as warn her that she is at risk for pre-eclampsia in future pregnancies and would benefit from antenatal prophylactic aspirin. I would also warn her that she is at risk of cardiovascular disease in later life.

Posted by rahul G.

a)

Initial assessment of a pregnant woman with high blood pressure with significant proteinurea should be done by a senior obstetrician and should begin with detail history of premonitory symptoms of pre-eclapmsia i.e. headache, change in vision - blurring / flashes, right upper abdominal pain, naussea & vomittings and increased swelling over face, hands & legs. One should also ask for alteration of fetal movements, per vaginal bleeding or painful distension of abdomen. These suggests severity & complication of pre-eclampsia.

Detail obstetric history should be asked - whether she is primiparous or multiparous, if so, then whether previous pregnancies were complicated by pre-eclampsia and the fetal & maternal outcome of previous pregnancies. Also interpregnancy interval should be noted. Also detail history should be sought for this pregnancy i.e. her prepregnancy health status looked for whether she was hypertensive prenatally? and if so, which medications was she taking? and also if these medications were changed once she became pregnant this time? If this is the new onset hypertension in this pregnancy she should be asked about the gestation of onset of it and its progression and the treatment recieved so far. All her investigations should be reviewed which includes FBC, LFT, RFT, clotting screen, PCR, ultrasound scans for fetal growth & doppler studies.

After this, she should have thorough clinical examination. Her vital signs, i.e. pulse, blood pressure, respiratory rate should be checked continuously. Her weight & BMI should be noted. Oedema should be looked for, for the site as well as grade of the oedema. Her deep tendon reflexes at elbow and knee joints, and the clonus at ankle should be checked.

b)

Eclampsia is an obstetric emergency (code 2222) and should involve multidisciplinary team approach involving an obstetric consultant, senior midwife , anaesthetist, hematologist & neonatologist. There should be written local policies available for dealing with such emergencies.

Primary management should focus on stabilising the woman by securing her airway by turning her on one side and using the tongue depressor, which also helps to prevent tongue bites. Oxygen mask should be used and oxygen saturation should be maintained. Her breathing should be secured. Intravenous access with two wide bore cannulae should be secured and simultaneoulsly the blood sample should be sent for FBC, LFT, RFT, Clotting screen, PCR (protein creatinine ratio), serum uric acid, and group & save. She should have indwelling catheter with hourly urometer.

Her blood pressure should be stabilised with IV hydralazine or labetalol or sublingual nifedipine, according to the  local policies and BP should be monitored continuously. Aim should be to keep BP at 150 / 80-100 mm of Hg, and the antihypertensive medication should be titrate accordingly. If IV hydralazine is used, then simultaneous IV infusion of 500 ml of crystalloids is recommended to avoid sudden hypotension. IV fluids should be restricted to 85 ml / hr to avoid fluid overload.

Seizure prevention shoud be obtained by magnessium sulphate (MgSO4). MgSO4 is currently unlicesed in UK and its use in eclapsia should be with the documented consent.  RCOG recommends IV bolus of 4 gm of magnessium sulphate over 5-10 min followed by 1 gm / hr infusion until 24 hrs after the last fit or the delivery of baby, whichever later. Monitoring of MgSO4 toxicity includes respiratory rate, deep tendon reflexes, hourly urine output measurement and serum magnessium levels.

Fetal monitoring should be done with CTG and Blood investigations shuld be repeated every 6 hours to assess the progress and severity.

Optimal treatment of eclampsia is the delivery of baby, aiming to improve maternal & fetal outcomes. In the situation of severe hypertension not responding to the medications or recurrent fits or CTG evidence of fetal distress and cervix being unfavourable, optimum treatment would be to deliver baby by emergency caeserian section. Womens preference should also be taken into account and documented. In case of favourable cervix with stabilised patient, one can still deliver the baby vaginally with Inj Betamethasone prophylaxis to minimise complications of prematurity. Post-delivery, she may need HDU/ITU care for intense monitoring. She should recieve antiDVT stockings & thromboprophylaxis.

Patients with eclampsia should be monitored throughout the hospitalisation (antenatal, intrapartum,postpartum) as they are likely to develope serious maternal & fetal complications like HELLP syndrome, Cardivascular stroke, renal failure, DIC, VTE, PPH, Abruption, sudden IUD, psychological cosequences and maternal death.

In postpartum period, the debriefing should take place with empathy and the woman should be well informed & supported by the team. Antihypertensives should be continued. Medical review should be arranged at 2 weeks and again at 6-8 weeks later. She can breast feed the baby, as there is no evidence of neonatal harm by labetalol, atenolol & nifedipine given postnatally. ACE inhibitors, Angiotensine receptor blockers & amplodipine are contraindicated by NICE guidance. She should be discharged from the hospital with contraception advise & proper counselling.

For her future pregnancies, she should be informed about the recurrence risk of pre-eclampsia & eclapsia upto 10-40 % and should be advised role of low dose aspirin 75 mg (from 12wks untill birth for next pregnancies)  in prevention of pre-eclapmpsia.

Her long term health cosequences like, chronic hypertension, neurological problems, psychological issues should be taken care by appropriate local health personnel. Her case should be notified to the National Eclampsia Registry.

 

Posted by Anoop R.

(a) I would first take a history, asking about symptoms of headache, visual disturbance, nausea and vomiting, epigastric pain and worstening headache. This is to identify any features of pre eclampsia. I would then examine the patient by first measuring symphysio-fundal height in order to ensure the fetus is not growth restricted. I would assess the degree of oedema and check a JVP to rule out severe fluid overload. I would check her reflexes and attempt to elicit any clonus as this would indicate severe pre eclampsia. I would assess any epigastric tenderness as this is a feature of severe pre eclampsia.  Investigations I would perform are regular blood pressure measurements to elicit a trend, send off a urine for protein-creatinine ratio to quantify the degree of protein. I would secure IV access and take blood for FBC, U&E, LFT and urate. These may be abnormal if there is a component of HELLP syndrome. I would take a group and save sample in case delivery of the fetus may be needed. I would assess fetal wellbeing by doing a CTG, and request an ultrasound scan for fetal growth, liquor volume and doppler velocimetry. This would indicate any degree of placental insufficiency caused by the disease. As the diastolic BP is >110mmHg this is severe pre-eclampsia and I would consider escalating her level of care if this did not settle,

(b) I would call for help and expect a consultant obstetrician, anaesthetist, obstetric SHO and core midwife to be present. I would lay the woman onto her left side to optimise her venous return and ask the anaesthetist to secure her airway. I would secure a second IV access and administer a 4g bolus of magnesium sulphate, followed by an infusion of 1g/hr. If she were to fit again, a 2g bolus would be given. The principle behind this is that magnesium sulphate is neuroprotective. I would measure her BP every 5 minutes and give antihypertensives to keep it <150/80mmHg. If she was not already in a level 2 critical care bed then I would transfer her to one providing she is stable enough. Once the mother's condition is stable I would assess fetal wellbeing by doing a CTG. I would consider administering steroids in case the fetus needed delivering. I would restrict her fluid intake to 85ml/hr to prevent fluid overload. I would prescribe anti-embolic stockings and thromboprophylaxis if indicated.

PET Posted by farzana S.

This woman has severe PET.She should be admitted in hospital and assessment  should be done by a senior member.History is taken  if she has symptoms of headache ,blurring of vision ,epigastric pain  ,nausea and vomiting This would indicate impending eclampsia.She should be enquired about fetal movements.

Reflexes are tested and ankle clonus noted.Funduscopy is done  for papiloedema.

Abdominal On examination height, weight BMI is noted.BP is measured, every 15min till it is 150/80-100.

 examination is done .Any abdominal tenderness is checked.Fundal height is noted and plotted against cutomised chart ,for size of baby.PET is associated with growth restriction.Presentation is noted. CTG is done for fetal well being.

Investigations include 24hr urine protein for quantification Bloods should be taken for FBC, platelet level,grouping and Rh factor.Coagulation screen,Liver function tests and Renal function tests ,urea ,electrolytes ,done to assess organ damage. USS is done for fetal biometry. Amount of liquor.

B) This is obstetric emergency.I will attend to it immediately and follow local protocol.Underlying principles for further managemnent include,

Communication- with multidisciplinary team,including senior obstetrician,senior midwife,anesthetist and neonatologist.

Resuscitation –I will place patient in lt lateral position.I will secure airway and give facial oxygen by mask. IV line is secured.IV crystalloids are started to maintain adequate circulation.

 Control of seizures-Most seizures are self limiting.MgSO4 4g i.v is given over 5min followed by infusion of 1g/hr maintained for 24hr for control and prevention of seizures.In case of recurrent seizures,further dose of 1-2g is given over 5min.

Control of blood pressure-IV  labetalol or Hydralazine is given aiming to keep Systolic BP below 150  and diastolic below 80-100 .

Monitoring –She should be transferred to HDU/ITU  for further monitoring.Vital signs,SO2 are   continuously monitored and recorded on MEOWS chart. Indwelling urinary catheter inserted and strict input output chart maintained.Hematological and biochemical investigations are repeated every 6hrs or as required.levels of MgSO4 are monitored if evidence of renal impairment.IV fluids should not exceed 80ml/hr.as there is risk of pleural effusion.

Fetal wellbeing is monitored by CTG.

Delivery is planned after 24hrs,as it is definitive treatrment for preeclamsia.Corticosteroids are given and neonatologist and SCBU informed.Mode of delivery would be CS.

Postpartum woman should be closely monitored in HDU as there is risk of postpartum eclampsia.Vitals are recorded on MEOWS chart and with strict urine input- output chart.Thromboprophylaxis is given.

Woman should be debriefed  of the events and management,and this should be documented.

An incident report is made.She should have a follow up appointment at 6-8wks .BP control and need for antihypertensive drugs is assessed.She should be counseled about risk of recurrence and encouraged to book early in future pregnancies.

severe PET Posted by Yuliya A.
a) Initial management will be based on patient's symptoms. This lady is clearly having a severe pre-eclampsia (highly raised BP and significant amount of proteinuria) at presentation, therefore if she were complaints on additional symptoms of fulminating PET such as severe headache, visual disturbances, epigastric pain, vomiting the delivery after stabilisation of patient will be the right decision. The patient has to be admitted to the hospital after assessment and examining as a matter of urgency at DAU, the presence of peripheral or generalised oedema and reflexes, uterine muscle tone (uterine tenderness may represent placental abruption) have to be recorded, IV access to be obtained and PET bloods (FBC, U&E's, LFT's, Uric acid, clotting screen), urine PCR to be sent urgently. Well-being of foetus has to be also established (FHHR and CTG). Full medical and obstetric history has to be taken, although being a primigravida is already an independent risk factor for PET, if the past obstetric history was contained PET the risk of developing of PET is around 30% in the future pregnancies. Current BP has to be rechecked at least 20 min apart, if it's still raised the first line anti hypertensive medication has to be given ( labetalol 200mg), with rechecking in 30 min. Patient needs to be thoroughly counsel about the possibility of early delivery if became symptomatic as her condition can deteriorate rapidly. Steroids for fetal lung maturity to be offered as may need to be delivered before 37/40. Record SFH and to arrange USS for growth, LV, Doppler. b) Eclamptic fit in this scenario is more likely to be diagnosis, emergency maternity alert for Help should be initiated, obstetric consultant, consultant anaesthetist, midwife coordinator, registrar, SHO, scriber, in some hospitals cardiac arrest team may be alerted over this event. Left lateral tilt with aBCDe management, started with secure of airways and given mask Oxygen on 15l/min, on arrival of Anaestetist patient is more likely need intubation, two large bore cannula as with IV fluids (80 ml/hr restricted to avoid pulmonary oedema) should be initiated, bloods (FBC, U&E's, LFT's, Uric acid, clotting screen) sent urgently including G&S and crossmatch for 4 ui with alert of haematologist. First step from medical treatment will be to be MgsO4 a loading dose of 4 g, bonus infusion given over 5 min, following by maintenance dose of 1g/h though a pump. Vitals signs such as BP, reflexes, Ps, urinary output (insertion of urinary catheter with urometer is mandatory). If continue fitted repeated dose of 2g of Mg SO4 and also diazepam can be also incorporated into treatment of this lady. BP has to maintained not lower than 150/80-90 may required IV labetalol or hydralazine infusion, however avoiding a rapid drop of BP which can cause acute fetal distress. Aim to stabilise and transfer to theatre for delivery, VE to assess cervical dilatation if in labour, otherwise the mode of delivery will be C/S. If relatives are presented at fit ask about the precious fits, medical hx, explaining that her condition is called PET. In case of delivery the iatrogenic risk of prematurity is high, but the delivery will be a life-saving. Paediatricians have to be informed to present at delivery (at least registrar grade). After delivery Patient will required HDU bed for intensive monitoring and treatment, MEOWS chart, MGSO4 infusion will be continue for 24h, observations to exclude magnesium intoxication should be made, drowsiness, feeling sleepy, absence of reflexes, low RR, the level of MgSo4 to check in blood. Incident report has to be filled promptly, following by presentation of case at perinatal multidisciplinary meeting for discussion and awareness.
Posted by MADHURI S.

initial assesment consist of history , examination and investigation.

history of headache, vomiting, blurring of vision, vomiting , epigasric pain should be asked to exclude the comlication of severe preeclampsia as empending eclampsia which affect 1% of patients. right hypogastric pain is associated with subcapsular liver hematoma, should be inquired.

history of pain in abdomen, bleeding per vaginum, perception of fetal movements asked.

past history of chronic hypertension or diagnosis of preeclamsia inquired, also asked is she is on any medicine for the same and compliance checked.

examination is done to assess maternal and feal well being.

maternal bp is checked with appropriate size cuff( small size overestimate while large size underestimate , but sitt large is preferred over small) koratkoff phase 5 is used to measure diastolicbp which correspond more correctly to mean arterial pressure. abdominal palpation done to assess fetal growth with use of customised growth chart( single measurement below 10th centile is indicator of iugr), aseessment of uterine tone, any tenderness is done.

deep tendon reflex checked, clonus ruled out . fundocsopy may be helpful in cases of chronic hypertension superimposed on preeclampsia

fetal assessment done with ctg and usg for fetal growth and umbilical artery study.

blood investigation such as full blood count which will show heamoconcetration with falling platelet count , liver function test may show elevated liver enzymes in case of HELLP syndrome.blood Urea , creatinine , elecrolyte may show end organ damage. uric acid may be elevated but not a guide to take decision for termination.

quantification of protenuria by 24 hr urine protein or protein creatinine ratio is done. there is no need to repeat. patient shoul be monitored in high  dependancy unit until her bp is less than , 150/80-100 after starting oral labetolol.steriods given if possiblity of pretern delivery after discussing with women..

criteria for termination decided by senior obstetrician and plan written

principles-

to control the fit, prevent recurrence , avoid fall and prevent injury to patient, to control blood pressure to prevent cerebrovascular accident which is most common cause of death.

preeclamsia is second most common cause of  maternal death in last triennium after sepsis.

protocal should be in place , shoudl involve consultant obsterician , aneasthesist, senior midwife and paediatricin.

the condition of women communicated to her family and partner.

women is put in left lateral position , head turned to one side to prevent aspiration, mouth gaginserted to prevent toungue bit . suctioning of mouth secretion to prevet aspiration.

drug of choice magnesium sulfate 4 gm iv bolus over 10-15 min after dilution with normal saline and followed by maintance of 1-2 gm per hour for 24 -48 hr whichever is longer.

recurrent seizure should receive bolus of 2 gm.

ctritical level 2 unit management . use of early obstetric warning chart for further monitoring .

2 iv  line , catheterr inserted for measuring urine output.

magnesium  toxicity measurement with respiratory rate(12-16 N), DTR, urine output(minimum 30 ml per hr)

no need to monitor serum magnesium level unless renal impairement*(mapie trial)

control bp by parenteral labetolol

assess fetal condition with continous ctg.

decision to delivery , most likely lscs due to unfavourable cervix.

regional anasthesia more safe if no coagulopathy, but ga can be therapeutic in case of continous seizures

consider thromboprophylaxis in post op period, anticoagulant 4 hr after removal of  epidural catheter, do not remove till 12 hrs after last dose.

monitoring fluid intake output. may need central line in case of pulmonary edema or oliguria

debriefing.

incident reporting.

discussion regarding contraception wth information to monitor bp with commmunity midwife and gp

arrange follow up after 2 weeks

 

 

extension of subscription Posted by dr uzma F.

 dear  sir ,

        i am appearing in RCPI  exam is it possible to extend my subscription 4  days more till  9 th of september