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MRCOG PART 2 SBAs and EMQs

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EMQ1480
SBA2068
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PET

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.