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MRCOG PART 2 SBAs and EMQs

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Essay 305 - Pre-eclampsia

Posted by Sophia Y.
(a) Justify your initial assessment of this patient [9 marks].
This is a case of severe pre-eclampsia. It is associated with high maternal & perinatal morbidity & mortality.

Initial assessment will include taking a history, asking her about classical symptoms of pre-eclampsia including headache, visual disturbances, nausea & epigastric pain and their duration. I need to establish the number of fetus as multiple pregnancy has a higher risk of developing pre-eclampsia than singleton. I will also ask her about presence of active fetal movement as it can be diminished or even none in fetal demise due to severe pre-eclampsia. I will ask about any urinary symptoms such as dysuria & frequency as urinary tract infection (UTI) can also cause proteinuria. I will ask about previous obstetric history (if any) as this might be a recurrent early onset of pre-eclampsia. I will ask about previous pregnancy outcome. I will also ask family history of pre-eclampsia as it is a risk factor.

On examination i will recheck her blood pressure manually, using Korofkoff phase 5 for diastolic blood pressure (BP) . Abdominal examination may show tenderness in epigastric region and symphysial fundal height less than 27 cm, suggesting intrauterine growth restriction (IUGR). Brisk deep tendon reflex & presence of clonus will highly suggest pre-eclampsia. Fundoscopy is performed to exclude papilloedema.

CTG should be commenced to ensure fetal well-being.

Blood should be taken for full blood count, baseline renal & liver function tests. Thrombocytopenia, raised liver transaminase, raised urea & creatinine & urate are seen in pre-eclampsia. In addition clotting should be checked as disseminated intravascular coagulopathy can be complicated in severe-pre-eclampsia. Group & save is needed as she is likely to have a caesarean section.
24 urinary protein collection should be commenced to quantify amount of proteinuria. Definition of pre-eclampsia is proteinuria over 0.3g/ 24 hour. Mid-stream urine should be sent for microscopy, culture & sensitivity to exclude an UTI.
Ultrasound scan should be arranged to exclude IUGR, oligohydramnios seen in pre-eclampsia. Reversed or absent end-diastolic flow in umbilical artery indicates early delivery. indicates Caesarean section is likely if malpresentation.

(b) Two hours later, she is found fitting. Discuss the principles underlying your subsequent management [11 marks].

The likely diagnosis is eclampsia. It is important to stabilise mother before delivering baby as mother is the priority. Delivery should not, however be prolonged to reduce risk of perinatal morbidity & mortality associated with prematurity.
I will immediately call for help to stabilise the woman. I will call obstetric, anaesthetic & midwifery on call team including consultants and senior midwives. She needs to be placed at left lateral recovery position. We need to ensure her airway is patent, presence of breathing & circulation. We will put a facial oxygen mask & given her 10L/min oxygen to improve oxygen saturation. She needs two intravenous (iv) cannula (14gauge) inserted. Magnesium sulphate (MgSO4) is the treatment of choice to control her seizure. 4g of iv MgSO4 is given slowly for 15minutes as loading dose. This is following by maintenance dose 1g/hour. If her seizures recur, the rate can be increased to 1.5g/ hour or further 2g bolus should be given. Her blood pressure, pulse, oxygen saturation should be monitored every 15 minutes continuously and recorded on the \"modified obstetric early warning score\". She should be catheterised. Urinary output & temperature should be recorded hourly. Her fluid input/output should be recorded. If hypertension (more than 160/ 110) persists despite MgSO4, anti-hypertensives such as iv labetalol should be given. MgSO4 should be continued for 24 hours or 24 hours after last seizure. She should be nursed at the high dependency unit.
Once mother is stabilised, delivery is indicated as it is the ultimate cure for eclampsia & pre-eclampsia. She should receive beta-methasone (12mg two doses 24 hours apart) to improve fetal lung maturity & reduce risk . Neonatalogists should be informed & present at delivery for advanced neonatal resusciation. Caesarean section is likely to take place for safe delivery at this gestation. She and family should be debriefed about events regarding the seizures before discharge.
Posted by Akanksha G.
A healthy 35 year old woman is referred to the maternity assessment unit at 30 weeks gestation because she had a blood pressure of 155/110 mmHg and 4+ proteinuria. (a) Justify your initial assessment of this patient [9 marks].
findings are suggestive of severe preeclampisa. initial assessment would include, enquiring about symptoms of headache, nausea and vomitting, epigastric pain, blurring of vision which are suggective of imminant eclampsia. her assessment of urine output, whether she is appreciating fetal movements well. a past history of chronic hypertension, diabetes, autoimmune diseases like SLE, thrombophilia. obstetric hiistory would include history of preeclampsia/ eclampsia in her previous pregnancies and their outcome. family history of preeclapmsia/eclampsia in the siblings. her examination would include noting her BMI, BP (preferably with a sphygomanometer) a value more than 160/110mm of hg indicates severe preeclampsia. extent of edema, involvement of upper limbs and periorbital edema indicates renal involvement. hyperreflexia especially clonus indicates imminant eclampsia. epigatric tenderness, papiledema also indicate imminant eclampisa. obstetric examination would include, symphysiofundal height, any tenderness of the uterus(indicates conceled abruption), presentation of the fetus (since this would influence the mode of delivery). investigations 24 hr urine protein, FBC, clotting screen if platelet less than 100X106/L, LFT ( elevated enzymes with low platelet constitutes HELLP syndrome), urea and electrolytes, s.creatinine( renal involvement usually occurs late in the disease process) s.uric acid . fetal assessment would include a CTG, if decision is for conservative managemnt then a detailed ultrasound examination for assessing fetal growth, presenation, liquor, umbilical artery doppler if IUGR is noted.
b)Two hours later, she is found fitting. Discuss the principles underlying your subsequent management [11 marks].
call for help and involve consultant obstetrician and anesthetist. teh patient is put in left lateral position and and mouthpiece inserted ,administer oxygen and secure 2 intravenous lines, a continuous pulse oximeter to oxygen saturation helps in identifying pulmonary edema early.draw 20 ml blood for investigations. an indwelling urinarycatheter is inserted. principles of her further management are, controll of further fits with magnesium sulphate(mgso4) controll of hypertension,monitoring, delivery and fluid management. mgso4 is the drug of choice for eclapsia, an initial loading dose of 4g is given in an infusion pump over 10 min followed by an infusion of 1g/hr. repiratory rate and deep tendon reflexes and urine output should be monitored to check for mgso4 toxicity. in the event of recurrent seizures, a futher dose of 2g slow IV can be given or the infusion incressed to 1.5-2g/hr. mgso4 should be continued for 24 hrs from last fit or delivery whichever is later. controll of blood pressure would be with intravenous hydralazine or intravenous labetelol or oral nifedepine, unit protocol should be followed. advantage of labetelol is that once BP is controlled with intravenous dose it can be switched over to oral dosing. ACE inhibitors, atenelol are contraindicated in pregnancy, use of diuretics is justified only in the presence of pulmonary edema. monitoring of BP should intially be every 15mins once stabilized every half hour. input output chart should be maintained and IV fluids restriction to 80ml/hr or 1ml/kg/hr is recommended, since inadvertant fluid overload leads to pullmonary edema. this may not apply in the event of hemorrhage when a central line should guide fluid management. steriods for fetal lung maturity may be administered for whatever benefit it can confer, hoeever delivery should not be delayed for this purpose. eclampsia is an indication to deliver the lady once she is stabilised. pediatrician should be informed. the mod eof delivery would depend on the fetal
presentation and cervical score. if patient is not in labour and an unfavourable cervical score induction is unlikely to be successful. a non vertex presentaion, unfavourable cervical score and nonreassuring CTG are an indication for cesarean section. careful monitoring in the immidiate post partum period helps in titering the anti hypertensive doses.anti hypertensives should be continued and reviewed by GP at 6 wks. a persistant hypertension at 6 wks should prompt investigations for secondary hypertension. a formal postnatal review should be arranged for discussion of the events. a preconceptional counselling before next pregnancy would probably help in discussing reduction of risks and improvement of future pregnancy outcome.
Posted by Nur Sakina K.
NSK

From A:
Symptoms of headache, visual disturbances, epigastric pain suggestive of pre-eclampsia (PET) must be elicited. Other symptoms of oedema may support PET, although non specific and can be present in normal pregnancy. Her obstetric (obs) notes are reviewed for booking blood pressure, parity, timing and mode of other deliveries or other previous obs complication. A personal or family history of PET increases her risk. Previous scan results are important to assess fetal growth for intrauterine growth restriction (IUGR) and Doppler studies if done. Past surgical history will assess difficulty of caesarean if needed in this pregnancy.
Observations for blood pressure, pulse, temperature and respiration rate for baseline is required. The face is examined for facial oedema which can be seen in severe PET. Her blood pressure should be monitored every four hourly initially or more frequent if labile. Abdominal palpation for symphysis- fundal height to screen for small for gestation age, fetal presentation, liquor volume and any site of tenderness identified. This helps decide siutablity for vaginal delivery if needed. The limbs are examined for clonus and hyper reflexia suggesting impending eclampsia and for oedema.
Bloods for full blood count (FBC) assessing hemoglobin (hemolysis) and platelets (reduced) for possible HELLP syndrome is needed. Renal and liver function is assessed for derangements which are affected in PET. A coagulation profile is required if platelets are abnormal. A urine sample for protein/ creatinine ratio is vital in PET to assess severity of proteinuria. CTG for baseline fetal heart rate along with an ultrasound scan to assess growth, presentation, well being, liquor volume and dopplers to identify IUGR is necessary. She should be admitted for monitoring of blood pressure and worsening of any symptoms for at least 24 hours.

From B:
The mother will need to be stabilized 1st and placed in the left lateral position. I would call for help from the anesthetist, obstetrics team, including informing the consultant oncall, charge and other midwives, a scribe and porter. The airway should be secured, 15L/ min of oxygen is administered via facial mask and 2 large bore I/V cannulae is inserted. Bloods for group and save and repeat PET bloods can be taken at the same time. If earlier investigation confirms PET, magnesium sulfate (MgSO4) should be given to stop the fitting. The local hospital protocol for MgSO4 administration should be used. A catheter is inserted to monitor urine output and I/V fluids (Hartmanns) should be restricted to 85mls/ hr. Observations should be done every 15 minutes.
Once the fitting has been stabilized, she should be transferred to HDU or ICU for close monitoring of PET and for further eclampsia. Anti-hypertensives such as I/V labetalol or hydralazine is given for elevated blood pressure control. Betamethasone is given to aid fetal lung maturity and the NICU team should be informed. CTG should be done to assess fetal wellbeing. Observations can be done every 4 hourly once blood pressure has stabilized. Oral anti-hypertensives with labetalol, methyldopa or nifedipine may be needed for the remainder of this pregnancy for blood pressure control.
The decision re timing of delivery should be made in conjunction with the paediatric team. If blood pressure is well controlled and no further episodes of eclampsia has occurred, conservative management would be reasonable to try prolonging the pregnancy and reducing complications associated with premature delivery. However, this risk must be balanced with the possibility of compromising maternal health. If delivery is required to control PET, this should be discussed with the couple including mode of delivery. At this gestation, a caesarean delivery is most likely.
Posted by shipra K.
a)The patient is having severe pre-eclampsia,the patient should be asked for the duration of her high BP records ,any medication for high bp records,any history of headache, blurring of vision,epigastric pain, excessive vomiting,(symptoms of imminent eclampsia)If she passing urine adequately,if the patient is having multiple pregnancy .
Detailed obsterical historyincluding the number of children, regarding similar history in the past pregnancy,any history of previous losses,any history of preterm deliveries because of hypertension.(for antiphospholipid antibodies as they are associated).Previous deliveries whether normal or by caesarian as pregnancy would need to terminated and her previous obstetrical history would be important in deciding the mode.
Menstrual history including LMP,previous menstrual history, her dates need to be confirmed.
Her previous antenatal records need to be reviewed,which would show duration of her high bp,medication,serial ultrasounds which could show IUGR,or multiple pregnancy.
Detailed examination for pulse rate bp,respiratory rate,temperature.Any pallor icterus ,pedal edema.respiratory system and cardiovascular status need to be examined.Neurological examination especially for deep tendon reflexes ,if clonus present increased chances of patient having fit.Obstetrical examination to note the fundal height,fetal presentation,fetal heart present or not.Per vaginum examination to note dilatation and effacement of cervix and bishop scoring done.
Immediate investigations should be sent and early reports asked for .these include FBC,platelet count,urea & electrolytes,serum creatinine, coagulation screen,liver function tests,fundus examination should be arranged for .An ultrasound should be done to see gestational age ,amount of liquor,biophysical profile. Umbilical artery doppler studies if possible to be done to see fetal well being .
B)Teatment of eclampsia includes immediate resuscitative measures ,effective control of fit ,control of blood pressure and termination of pregnancy. Senior obstetrician should be informed.
Patient should be placed in left lateral postion,oropharyngeal suctioning done,a mouth gag placed would decrease the chances of tongue bite.Clonazepam can be given to abort the fit.oxygen ginen through face mask at 10 l/min.
Anticonvulsant of choice is magnesium sulphate,4 gm , IV bolus over 20 min to be given, then either drip with 5 gm in 500 ml at 26 drops which gives a dose of 1gm per hour or 5 gm deep intramuscularly at 4 hourly interval.Strict montoring is required when magnesium sulphate started which includes respiratory rate,deep tendon reflexes,urine output, hourly and bp every 15 minutes .In case patient has a fit on this regime an extra 2 gm to be given slow iv bolus..Magnesium should be continued for 24 hours from the last fit,or 24 hours from delivery whichever is later. if urine output less than 40 ml,or absent deep tendon reflexes then magnesium sulphate to be stopped or delayed.If respiratory depression ie respiratory rate less than 16 per min is a sign of toxicity then calcium gluconate to be given.
Blood pressure can be controlled by either labetalol(20mg bolus upto 220mg)hydralizine(5 mg bolus uptil 15 mg),or nifedipine(10mg orally.)
Strict input output chart to be maintained as these patients have chances of pulmonary edema.crystalloids at a rate not more than 75ml per hour should be given better still to give fluid under CVP monitoring.
If patient having HELPP syndrome she might need platelet transfusion also DIC a known complication would need to manged in consultation with a heamatologist.
Termination of pregnancy should be done the mode decided by previous obstetrical history,her P/V findings condition of fetus and mother. In case Caesarian section needs to be done the anaesthetist has to be informed that patient has recieved magnesium sulphate. Neonatalogist to be informed .patient needs intensive monitoringand after stabilization should be transferred to high depency unit.
Posted by Johnson  O.
A/
Pre-eclampsia/eclampsia is one of the leading causes of maternal morbidity and mortality in UK. I will repeat the blood pressure, if it is still the same or higher, I will give her oral labetolol 200mg start becuase she is at increase risk of eclampsia.
I will take a detailed history including symptoms of headache, visual disturbance or epigastric pain which may be an indication of imminent eclampsia. I will ask about any previous history of high blood pressure and the medication she is on. If she is multiparous, previous obstetric history, how many children and mode of deliveries. Previous history of pre eclampsia, intrauterine growth restricition[IUGR] or preterm delivery due to complication of blood pressure.
There is increase risk of IUGR, abdominal fundal height will be measured. Presentation of the fetus to exclude breech. Fetal monitoring with CTG because there is risk of fetal distress.
Presence of clonus is an indication of imminent eclampsia, her reflexes and clonus will be checked.
I will do baseline blood investigations. Full blood count to check haemoglobin and platelet which will be low and Liver function test high in HELLP syndrome, a complication of pre eclampsia. Blood urea and electrolyte including Urate for renal function. Clotting factors if platelet is below 100X10^9/l. Group and save.
B/
Help should be summoned, senior obstetrician, anaesthetist, paediatrician. It is important to alert the haematologist.
She should be approached when it is safe to do so, to prevent injury to staffs. To reduce the risk of aspiration she should be placed in left lateral position.
ABC of resuscitation should commenced. Airway should be checked. Oxygen by face mask. Blood pressure every 5minutes. IV access for medication.
Unit protocol for management of eclampsia should be followed. To stop the convulsion or prevent repeat episode, magnesium sulphate[mgso4] should be given, 4g Iv bolus over 5 to 10minutes. She will also require mainatainace dose of 1g/hr for minimum of 24 hours from the last convulsion.
Her blood pressure should be controlled with antihypertensive according to unit protocol. IV labetolol or IV hydrallazine.
Foley\'s catheter to monitor the urine output becuase there is increase risk of oliguria. IV fluids should be maintained at 80mls/hour or 1ml/kg/hour to reduce the risk of pulmonary oedema.
Definitive treatment is delivery when the woman is clinically stable most likely by Caesarean section[C/S] at this gestation. Vagina delivery is possible if cervix is favourable for artificial rupture of membrane. Paediatrician should discuss with her about the noenatal care and possible complication.
Senoir obstetrician should be doing or supervising the C/S becuase the lower segment may not have developed well and making the operation difficult.
Ergometrin worsen blood pressure and should be avoided in 3rd stage. Post operatively,she should be managed at high dependence unit until stable.
She is at increase risk of venous thromboembolism, therefore thromboprophylaxia as per unit protocol, also TED stocking.
Incident report should be completed. Patient and her family should be debriefed about the care and the reason for the interventions.
After delivery there is still risk of eclampsia and worsen blood pressure, she should be in patient for a minimum of 4days and continue oral antihypertensive drugs. Breast feeding should be encouraged. Apropriate discharge letter to community midwife and GP. Effective contraception should be offered. Follow up arrangement by her consultant and to review her medication and discuss future recurrence.
Posted by Leen K.
LEEN
A healthy 35 year old woman is referred to the maternity assessment unit at 30 weeks gestation because she had a blood pressure of 155/110 mmHg and 4+ proteinuria.
(a) Justify your initial assessment of this patient [9 marks].

I would enquire about any headaches, visual disturbances, epigastric pain or shortness of breath - all of which may be associated with pre-eclampsia (and HELLP Syndrome). I would ask about her previous obstetric history, including previous pre-eclampsia or eclampsia, gestation and mode of deliveries ( and reasons if preterm delivery) as well as outcomes of each pregnancy. Current medications (including anti-hypertensives) will be enquired and as well as any antenatal problems or concerns ( such as fetal growth restriction or blood pressure concerns).

I would examine the patient and assess the the fundal symphyseal height (to check for signs of small-for-dates or growth restriction), as well as check the patient\'s relexes and presence of clonus (hyperreflexia and presence ofmany beats of clonus is a sign of imminent eclampsia) and listen to the lungs for signs of pleural effusion or oedema. I would also perform an ophthalmic examination to look for oedema. A cardiotocograph should be done to check on fetal wellbeing and a formal scan arranged to check fetal growth (with Doppler of umbilical artery and liquor volume if growth restriction is suspected).

I would obtain IV access and take bloods for full blood count, urea and electrolytes, livery funtion test and clotting studies - renal and liver function may be compromised in pre-eclampsia , as well as to look for signs of HELLP syndrome.

Regular monitoring of her vital signs (including BP) should be done every 15 minutes initially, until her BP stabilises. I would give her an anti-hypertensive if her BP remains raised, to reduce her risk of cerebro-vascular accident (especially if her Mean arterial pressure is above 125). Labetalol is an anti-hypertensive of choice due to availability of long term safety data in pregnancy. I would also give the patient steroids (IM betamethasone 12mg, 2 injections, ideally 24 hours apart) to help mature the fetal lungs and improve neonatal outcome, should preterm delivery is required. I would inform my consultant, anaesthetist as well as the neonatal team of her admission and condition. I would also enquire about the availability of neonatal intensive care facilities should the patient needs preterm delivery - and make sure arrangements are prepared for an intrauterine transfer if needed, extrauterine transfer if the patient is not stable enough to be transferred.
If her BP settles, I would arrange for a 24 hour urine collection for protein quantification. She needs to stay inpatient for BP monitoring. If her BP deoes not settle down despite oral anti-hypertensives, IV antihypertensives will be required - hydralazine or labetalolmay be used; and consider delivery soon.



(b) Two hours later, she is found fitting. Discuss the principles underlying your subsequent management [11 marks].

I would call for assistance/help from ,my consultant, anaesthetist, midwives. I would put her in the left lateral position to reduce conmpression of venous return. I would make sure she is in a position where she cannot harm herself or other staff. Oxygen (15L/min) should be given through a facemask to inprove maternal (and fetal) oxygenation of tissues. IV access should be gained (of not done so already) and bolus magnesium sulphate (MGSO4) 2g given over 5-10 mins. MGSO4 is effective in preventing further eclamptic fits and may reduce the BP, however if used alone is not effective as an anti-hypertensive. If she has recurrent fits, another bolus MGSO4 2g can be given IV; diazemuls IV being another alternative. MGSO4 continuous infusion should be commenced to reduce the risk of further fitting.
CTG should be perfomred once the patient has stopped fitting, to check on fetal wellbeing.
The only treatment for eclampsia is delivery of the fetus and placenta, and the patient should be prepared for delivery - bloods taken for platelets, haemoglobin levels and clotting studies and group and save. The neonatal team should be informed and explanation given to the patient and family. Delivery should be by caesarean section, as induction of labour at such a situation is inappropriate. She shoould be nursed in a high dependency area/room (in the delivery suite), as she required intensive monitoring. Fluid restriction (usually to 80mls/hr) is required to prevent fluid overload in the third space, and accurate fluid monitoring(input-output chart & catheterisation) done, Her bloods should be taken to check her renal and liver function and clotting; and be repeated regularly (iinitially at least every 6 hours until stabilised). Regular monitoring of her vital signs (every 15 mins initially) is appropriate to monitor. These are to monitor for improvements of deterioration of her condition.
Explanation should be given to the patient and her family of the situation and management plans. Clear documentation on the notes are important to reduce litigation risks and is good practice. An incident form should be filled in as soon as is appropriate for risk management.
Posted by robina K.
(A) The findings are suggestive of severe pre eclampsia associated with risk of eclampsia ,maternal and fetal morbidity and mortality . I will ask her about headache, vomiting, visual disturbance and pain below the ribs, as these symptoms indicates severe pre eclampsia or imminent eclampsia. Parity ,previous pre eclampsia/ eclampsia,previous obstetric outcome like IUGR , mode of delivery as previous caserean section for preeclampsia/eclampsia or associated IUGR may have underlying renal disease, thrombophilias and antiphospholipid antibodies with risk of recurrence. Pre existing medical conditions like hypertension and diabetes should be asked as these are associated with increased risk of recurence and complications. History is taken about fetal movements , constant abdominal pain or vaginal bleeding as these indicates abruption . I will ask about any antihypertensive medications she is on because immediate anti hypertensives should be started if she is not taking or dose my need to be modified .
I will check her BMI and B.P in a comfortable 45 degree sitting position with an appropriate size cuff and preferably with a mercury sphygmomanometer. An abdominal examination is performed to elicit hepatic tenderness which indicates HELLP syndrome or hepatic rupture, fundal height to correlate with period of gestation for the detection of IUGR , Fetal lie and presentation to decide the mode of delivery. I will perform a fudoscopic examination to asses optic disc for severity of the condition.I will check her clonus which indicates imminent eclampsia and magnesium prophylaxis may be needed .I will perform CTG to asses fetal condition .An ultrasonography is offered to asses fetal wellbeing, to perform biometery and centiles for IUGR , and liqour volume .If CTG and sonography is abnormal I will arrange for dopplers study .

(B) Principal of management includes rescucitation , stopping the fits if do not stop spontanously , prevent further fits, stabilise and monitor and deliver .
A multidisciplinary team (MDT) care is provided by calling senior obstetrician, senior anesthetist, senior midwife and neonatologist . Unit protocol should be followed . Patient is put in left lateral position, airway checked and secured . Drug of choice to control fit is magnesium sulphate. A loading dose of 4gm diluted in normal saline ( 20 ml of 20% solution) is administered I.V slowly in 5-10 minutes . Fits should diminish in 20 minutes if not a further dose of 2 gm given I.M or an infusion started at the rate of 1 gm/hr. Mg SO4 toxicity is monitored by respiratory rate, tendon reflexes, urinary ouput every 15 minutes and continous O2 saturation by pulse oximetry . Mg SO4 is continued for 24 hrs after delivery or after the last fit which ever is the last .
There should be good communication among the health professionals .Relatives should be kept informed .
A strict fluid balance is maintained by keeping one hourly intake and outpt record to prevent fluid over load and pulmonary oedema ., Fluid should be administered at the rate of 1 ml/kg or urine output in the preceding one hr + 30 ml . .Oliguria indicates renal damage . B.P is controlled by hydrallazine 10 mg slow I.V or Labetalol 50 mg slow I.V. Labetalol should be avoided in asthmatics . Baseline investigations like 24 hrs urine proteins, FBC including platelets, RFT Including U&E, Serum uric acid , creatinin clearance and LFT should be performed. Clotting profile is only advised if platelets count is less than 100,000 X 9/ L .Monitoring for HELLP syndrome is carried out by measuring liver enzymes(AST, ALT) , LDH and Platelets . Steroids should be administerd for fetal lung maturity however it is not going to effect if delivery is indicated in 24 hrs . Once patient is stabilised delivery is planned . At 30 weeks mode of delivery is most likely by casearian section unless women is in established labour or Bishops score is favourable for induction provided maternal and fetal condition is stable . Casarean section should be performed by senior obstetrician due to risk of exessive bleeding ,lower segment is not formed , vertical or delee incision may be needed . Senior anesthtist and ITU physican should be involved since the begining as she may need invasive monitoring. Postnataly women should be cared in HDU/ICU with 1:1 care . Complete recovery is anticipated however women should be investigated for cardiac, renal and CNS complications . Prophylactic antibiotics and throboprophylaxis should be given . Incident report form is filled . Once women is stabalised debriefing and councelling should be carried out by senior obstetrician .At discharge contraceptives are discussed .Followup appointements and GP letters are made to check her B.P regularly.
Posted by Bee N.
I will calm the patient and try to reassure that she will be offered appropriate management. I will then take a history to enquire about presence of severe headache, epigastric pain, nausea or vomiting, facial edema, visual sypmtoms like blurring of vision and flashes of light to further assess severity of symptoms . I will ask if their are other medical conditions like pre existing hypertension, renal disease and diabetes mellitus to determine the presence of secondary causes of illness and probability of compromised fetus. I would ask about family history of pre eclamsia and hypertension as well as parity of patient and number of gestation in this pregnancy to further assess risk for pre eclamsia. I will ask about history of medical disorders like asthma which will determine which anti hypertensive I would be using. then I will ask if she is on any medication or treatment as well as history of any allergies.

I will the repeat the BP with patient relaxed and using the appropriate cuff size and KorotKoff V. This will ensure accurate determination of BP. This will and checking of pulse and oxygen saturation will be done every 15 minutes initially and the every 30 minutes if BP settles.This will help detect worsening or deterioration of condition. I will then do an opthalmoscopy to check for pappilloedema. I will do a complete neurological examination to detect transient ischeamic attack or cardiovascular accident. This must include checking for reflexes which will also guide the use of MgSO4 if needed.I will examine the patients abdomen to check for tenderness (abruption)fetal presentation and growth. I will do a vaginal exam to assess for cervical ripening as delivery will be considered.

I will then take bloods for Full blood count, electrolyte and urea and creatinine, liver function test, urate and coagulation screening. This will help determine severity of condition, rule out HELLP syndrome and guide management. I will do a Cardiotocograph to assess fetal well being and will scan fetus for growth if in any doubt about appropriateness for gestation, Liquor volume or presentation. I will then insert a urinary catether to check for 24 hour urine protien collection and monitor input and output of fluid.

I will inform the consultant Obstetrician, anaesthetist, paediatrician and labout ward midwife as delivery will be needed. I will commence the patient on bethamethasone 12mg to be taken two doses 24 hours apart. I will commence antihypertensive such as labetalol oral or iv, oral nifedipine. Sublingual nifedipine should be avoided. I will consider seizure prophylaxsis with MgSO4 and monitor respiratory rate and reflexes for MgSO4 toxicity. Patient will be admitted and thromboprophylaxis considered.


B)As She is most likely having an eclamptic fit, I wll assess for Airway, Breathing and Circulation. I will commence O2 by face mask 6L/min. I will place in the left lateral position and ensure patient safety from surroundings. I will call for help from the consultant Obstetrician and Aneasthetist and inform the pediatricians. If fit does not stop spontanously, I will administer 5-10 mg of diazepam IV. I will take bloods for investigation if not taken yet for FBC, LFT, EU, urate and coag screen. I will use the unit protocol for treatment of eclampsia. Patient should be managed in labour ward high depenndency unit and BP, Pulse,O2 sats monitored every 15 minutes. Frequency can be reduced once BP settles.This often involves administration of Labetalol 50mg bolus over 5 minutes and then commencing an infusion of 5mg/ml. Other drugs that can be used instead is nifedipine or hydralazine. I will restrict IV fluid to 85 mls per hour while monitoring input and output of fluid. I will commence MGSO4 giving a loading dose of 4 mg IV over 5 minutes and maintenance dose of 1 g/hr for 24 hours while monotoring reflexes and respiratory rate. I will give steroids(betamethasone) for Fetal lung maturation. I will
monitor baby using CTG abd deliver once patient is stable by ceasarean section. I will keep patient, partber and relatives of management plan. I will consider thromboprophylaxis both pre and post delivery with thrombophylaxis elastic stockings and clexane. I patient will be debriefed as soon as poosible after delivery and monitored in hospital for at least 5 days. I will consel before dischrage about contraception and the risk of similar occurence in future pregnancy.
Posted by H H.
Initial assessment is justified to manage this high risk pregnancy (pre eclampsia + preterm gestation) which is associated with high maternal and perinatal morbidity and mortality. I should detect severity of condition and balance risk of early delivery to that of contiuation of pregnancy.
Will take history , headache,visual disturbances, epigastric pain,which indicate severe condition. Would ask of her feeling of fetal movement and if reduced. Obstetric history including parity , previous pregnancy induced hypertension and outcome of pregnancies. Family history of hypertension and pre eclampsia. Current treatment for hypertension during this pregnancy. Review her antenatal notes for antenatal progress and her hypertension control.
Examination include pulse, remeasure blood pressure, temp, respiratory rate, elicit reflexes. Would do abdominal examination for fundal hight, epigastric tenderness , laxity of uterus , feel fetal movement and exclude a tender rigid woody firm uterus of abruption .
Would do investigations including, FBC (platelet count), blood film for hemolysis, liver function tests for elevated aspartate amino transferase AST and alanine amino traansferase ALT , urea and electrolytes and serum creatinine for renal function, and clotting screen.
Would do tests for fetal wellbeing CTG and Doppler for umbilical arteries.

B)
There should be local guidelines and protocols in every medical facility to manage these situations.These should be regularly rehearsed and audited.
Call for help from midwives, porters, anaesthetists, inform consultant obstetrician, inform lab,hematologist and neonatologist.
Put patient in left lateral position and start resuscitation ,airway,breathing and circulation.
Apply wide bore IV canula,send bloods for investigations.
Control of fitts and prevention of reccurence, by IV magnesium sulphate 4gm loading dose over 10-15 minutes, then 1gm IV every hour.
Control of blood pressure using IV labetalol according to unit protocole.
Fluid balance using input output fluid chart after applyng a urinary catheter and CVP.Should know that there is a contracted intravascular volume.
Know that treatment would include delivery of the fetus ,but need to stabilize the patient first , see if available cots at NICU , neonatologist to be available and anaesthetist to decide regarding anesthesia.
Inform neonatologist no time to adminster corticosteroid for fetal lung maturity to be effective.
Montoring for magnesium sulphate toxicity ( reflexes, respiratory rate and urine output should be >30ml /hr)
Monitoring and treatment continued in post partum period knowing that fitts can recur .Mag sulphate should be continued for 24 hr after delivery.
Thromboprophylaxis in consultation with hematologist.
Debriefing and patient assurance of full cure,but can recure in future pregnancy.There risk of hypertension in later life.
Incident reporting and risk management.
Posted by SANCHU R.
Sanchu
A healthy 35 year old woman is referred to the maternity assessment unit at 30 weeks gestation because she had a blood pressure of 155/110 mmHg and 4+ proteinuria. (a) Justify your initial assessment of this patient [9 marks]. (b) a)She is admitted immediately to the labour ward suite and assessed. Symptoms of complications of pre-eclampsia are asked for namely headache, visual disturbances, epigastric pain shortness of breath and oliguria. Past history of Hypertension or renal problems are asked for.
Her obstetric examination, examination of abdomen looking for epigastric tenderness (hepatic subcapsular haemorrhage) auscultation of chest (pulmonary edema), deep tendon reflexes and clonus(impending eclampsia) are done.
The vital signs, her BP, pulse rate, RR and SATS are done and continuously monitored. Fluid balance chart is maintained. If there is oliguria, she needs catheterisation and hourly output monitoring since renal failure is a known complication of severe pre-eclampsia.
An IV cannula is sited with blood for U&E, Urates, FBC, LFTs are done. Urates may be elevated, there may be thrombocytopenia and abnormal renal and liver functions indicating the severity of the condition and indicating appropriate management. If platelets are <100X10 9/l, Coagulation profile is done. urine protein creatinine ratio is done.
CTG is done to assess the fetus. An ultrasonography for growth, AFI and doppler may be done after she is stabilised.

b)Two hours later, she is found fitting. Discuss the principles underlying your subsequent management [11 marks].
The senior midwife, the anaesthetist and the SHO are called for help. Airway is inserted and she is put in the recovery position, suction of secretions is done if necessary.
100%Oxygen is administered through a facemask at 15 l/min.
Magnesium sulphate 4 g iv, 8 ml of 50% solution diluted with 16 ml of normal saline is given over 20 min followed by a continuous infusion at 1g/hr. If there is recurrent fits , a further bolus of 2g is given. If further fits, Diazepam 5mg iv is given and other causes like intracerebral haemorrhage are considered. Reflexes, RR and urine output are monitored to avoid Mg toxicity. The infusion is continued for 24 hrs after the last fit or after delivery.
IV labetalol is the drug of choice to control hypertension . 25 mg ofis given IV, same dose repeated every 15 min for a max of 8 doses until BP is controlled. Maintenance infusion of Labetalol is started. The next drug of choice would be IV Hydrallazine if there is no response to labetalol.
Delivery should be planned. The cervix is assessed. If unfavourable or a delay is expected with induction, emergency caesarean section is done. If very favourable, induction is done by ARM and syntocinon infusion.
Posted by C P.
A healthy 35 year old woman is referred to the maternity assessment unit at 30 weeks gestation because she had a blood pressure of 155/110 mmHg and 4+ proteinuria. (a) Justify your initial assessment of this patient [9 marks]. (b) Two hours later, she is found fitting. Discuss the principles underlying your subsequent management [11 marks].
C
(a)
The diagnosis is suggestive of severe pre eclampsia. I will explain to the mother that she need admission to the ward and need investigation and appropriate treatment. In the history I will ask whether she has any symptoms of headache, epigastric pain, nausea, vomiting or visual disturbances. Specially seeing any black spots in her vision. Severity of the symptoms would suggest that she may get eclampsia or other complications of pre eclampsia. These include cerebro vascular accident, pulmonary oedema and HELLP syndrome.
I will ask the midwife to monitor her blood pressure every 15 minutes along with blood pressure I will monitor SO2, respiratory rate. Further I will listen to her lungs for any sings of pulmonary oedema, I will check whether she has any clones if present, she had the risk of eclampsia.
I will measure her symphysis fundal height. In established pre eclampsia the foetus will be small for date. I will listen to the foetal heart.
Further I will request for FBC, LFT, U/E, uric acid, creatinine and coagulation profile. In HELLP syndrome platelet count will be low and liver enzyme will be elevated. Elevated uric acid will reflect advers outcome to the patient and the foetus. Serum creatine will give some idea about her renal function. Following creatine protein ratio, if it is more than 1, I will perform 24 hours urine protein. More than 300 mg./ 24 hours denotes maternal and perinatal morbidity.
It is important to arrange growth scan of the foetus. In pre eclampsia the foetus will be IUGR. If so AFI and Doppler need evaluation.
(b)
While having the fit that patient must be kept flat on her side and 45 degree tilt position This is to avoid any aspiration of gastric contents and improve the after load. While doing this need to call for help specially senior anaesthetist, consultant obstetrician and senior midwife for resuscitation of this patient.Further I will secure the air way,give 10 to 15 lit O2 by mask and make sure her breathing is normal. If her breathing is not normal I will insert a airway and with the help of the ambubag ventilate the patient. Her circulation must be secured by inserting tow large bore ventflown. Meanwhile blood must be taken for FBC, LFT, U/E, uric acid, creatinine, and coagulation profile. This will reveal the severity of the condition and help us to decide the management profile.
Hospital protocol for eclampsia should be strictly adherent in managing this patient. Magnesium sulphate is the drug of choice. 4 gm given slow IV to control the fits and 1g/hours should be infused to prevent further fits.
Fluid balance is very important. Fluid overload will lead to pulmonary oedema. This has serious consequences.
Toxicity of Magnesium sulfate will be assessed be urinary output, respiratory rate, and assessing the deep tender reflexes. Magnisium sulphate must be stopped and Calcium glugonate 10 ml should be given over 10 minutes as a antidot.H
aematologist should be involved when haematology reports are deranged. For an example if she has HELLP syndrome.
Once the fits are controlled the delivery of the foetus should be planned. At 30 weeks gestation caesarean section is the option. Neonatologist must be summoned. Prior to the delivery it is mandatory the neonatologis talk the patient and her partner about the outcome of the baby at this gestation.
After the delivery she should be managed in the ICU. Clear documentation is essential. Further risk assessment form should be filled in .
Debriefing is very important after such event. This will reduce the changes of post natal depression.
Posted by Manoj M.
M
(a)A history of severe headache, visual disturbances, vomiting, epigastric pain may be associated with this clinical picture of severe preeclampsia. History of any bleeding vaginally or abdominal pain currently may suggest underlying abruption with preeclampsia. History of fetal movements to ascertain fetal viability. A past obstetric history may suggest previous preeclampsia in previous pregnancies.
Examination include BP assessment every 15 minutes untill BP is stablilised to reduce risk of cerebral haemorrhage associated with high blood pressure. Also examination of pulse and saturation as severe preeclampsia with risk of eclampsia. Examination of deep tendon reflexes and clonus as hyperreflexia and clonus may suggest impending eclampsia. Papilloedema may also suggest severe preclampsia with impending eclampsia.
Abdominal examination to ascertain any tenderness that may suggest underlying abruption. Symphysis fundal height may suggest growth restricted fetus with preeclampsia. CTG for fetal condition with severe preeclampsia.
Investigations including full blood count, liver function , renal function , uric acid as this may suggest severity of preeclampsia and may suggest underlying HELLP syndrome. A group and save should be done as she may need caesarean delivery. A 24 hour proteinuria to quantify her protein loss. Ultrasound scan for fetal growth, liquor volume and umbilical artery Doppler as may provide fetal condition and may allow timing for delivery.

(b)This is an eclamptic fit and an obstetric emergency. She should be attended promptly to reduce maternal mortality.
Help should be obtained immediately from obstetritian, midwives, anaesthetist. Airway, breathing and circulation should be assessed and maintain high flow oxygen at 15litres/min with with face mask, large IV acess obtained and bloods taken for investigations.
Prevent any injury to patient with fitting and keep her in left lateral position. Most eclamptic fits are self limiting and MgSO4 with loading dose 4g given over 5-10minutes and a maintaince dose of 1g/24hrs to prevent further eclamptic fits (given atleast for 24hrs after the last fit). She should be monitored for MgSO4 toxicity while using MgSO4 with local hospital protocol followed. Anti hypertensive agents commenced to control high BP like intravenous labetalol or hydralazine.
Urine output monitored with foley indwelling catheter and hourly urometry as risk of renal impairment and to maintain fluid balance.
Fluid intake should be restricted to 80ml/hr or 1ml/kg/h to reduce risk of pulmonary oedema.
Once she is stablised she should be delivered as increased risk of recurrance of eclampsia and treatment for preeclapmsia.
At 30 weeks she will need caesarean section as mode of delivery and inform neonatalogist as preterm.
Her care should be on delivery unit with one to one care and after delivery continued on HDU unit for further monitoring.
She should be fully informed of her care and informed consent obtained for caesarean delivery.
A critical incident form should be filled in for risk management.
Posted by Mohamed A.
a)
Diastolic pressure 110 or more and 4+ proteinuria indicate severe pre-eclampsia with high risk of eclampsia, placental abruption, intrauterine growth restriction (IUGR) and multi-system involvement Prompt assessment and treatment is required to minimize maternal & perinatal mortality & morbidity.
Enquire about headache,vomiting, visual disturbance, abdominal pain if present which may indicate worsening condition or impending eclampsia. If she is experiencing contractions or any bleeding per vagina for a suspected abruption or HELLP syndrome.

General condition assessed for drowsiness or restlessness which may precede eclampsia. Blood pressure should be rechecked using mercury sphinomanometer or another validated device using Korotokoff phase 5 for diastolic blood pressure. Should be checked every 15 minutes until the woman is stabilized then every 30 minutes in the initial phase of assessment.
Pulse, respiratory rate and oxygen saturation monitoring for early signs of pulmonary oedema.

Abdominal examination for hepatic tenderness if subcapsular bleeding or rupture, fundal height for suspected IUGR, uterine tenderness in case of abruption and check for contractions, fetal lie and presentation should be assessed together with auscultation of fetal heart.
Blood sent for FBC, liver and renal functions, clotting tests are indicated if platelet count < 100,000/ml. Blood film for fragmented red cells if HELLP is suspected.
Fundus examination should be arranged for papilloedema.
Indwelling catheter fixed and fluid balance with charting of input and output is essential. 24 –hour urine collection for proteinuria if conservative management is adopted.
Initial assessment of the fetus using CTG should be undertaken, if conservative management is planned, ultrasound for fetal size, liquor volume and umbilical Doppler should be performed.


b)
Help should be sought from senior obstetrician, anesthetist and midwife. Unit guidelines should be followed. Check breathing, airway and circulation and measures should be taken to prevent the patient from falling down or biting her tongue. She should be placed in the left lateral position and provided facial oxygen, venous access and send for group and save.

If fits is persistent Magnesium Sulphate 4 gm loading dose using IV pump over 5-10 minutes then a maintenance infusion of 1g/hr, if convulsions persists either to repeat magnesium sulphate 2g bolus or increase rate of infusion to 2g/hr, alternatievely Diazepam 10 mg Iv or Thiopentone 50 mg IV should be used. If failed to control convulsions intubation is likely to be necessary to protect airways and maintain oxygenation and transfer to ITU.

Once seizure stop the priority is to prevent further convulsions by maintaining mg sulphate infusion 1-2 g/hr for 24 hours, and to control blood pressure using Hydralazine or Labetalol IV. Then to initiate delivery once the patient is stable. The woman should be transferred to a delivery suite where 1:1 care is provided.
Fluid input/output chart is mandatory with fluid restriction, total fluids limited to 80 ml/hr or (total fluid in = previous hour urine out + 30ml) until there is postpartum diuresis. However, fluid restriction is inappropriate if associated maternal hemorrhage.

Fetal monitoring should be commenced using CTG, SCBU should be informed. In-utero transfer is inappropriate and if facilities are not available, ex-utero transfer should be arranged.
Blood pressure should be checked every 15 minutes, urine output hourly (should be >30ml/hr), respiratory rate should be>16/min and tendon reflexes checked.
If any sign of magnesium sulphate toxicity including urine<20 ml/hr, lost tendon reflexes and respiratory depression, infusion should be stopped and give Ca gluconate 1g over 10 minutes IV.

At 30 weeks cesarean section is more likely as success of induction is reduced. Neonatologist should be informed and once blood results are available and there is no coagulopathy or platelet count <80,000/ml, cesarean section under general anaesthesia should be performed after obtaining written consent. Platelets should be given if count < 50,000. Thromboprophylaxis should be considered.

keep under close observation in an HDU for 48 hours after delivery for the risk of recurrence, anti hypertensive should be continued as dictated by the blood pressure, may take 3 months to return to normal. Avoid methyldopa for the risk of depression An incident report form should be filled.
Posted by SUNDAY A.
SOS, answers.

I will ask about history of headaches,visual symptoms such as flashing lights, spots in the eyes, epigastric or right hypochondrial pain. History of nausae and vomiting, feeling unwell, pedal or facial oedema may all indicate severe disease. The onset, severity, relieving or aggaravating factors of the above symptoms would be relevant in determining the severity of disease. I would also ask about reduction in fetal movement. I will repeat the BP using appropriate cuff and serial reading afterwards, pulse rate and oxygen saturation. BMI would be checked if not recorded in the hand held notes. Cardiovascular system would be checked and a abdominal examination to check the symphysiofundal height, fetal heart beat and rule out any abdominal terderness would be carried out. Reflexes and clonus would be checked as well. Subsequently patient should be admitted on the labour ward and a 24 hour urine collection commenced with request for urgent FBC, U/Es, LFT, Clotting and urates and USS for growth,Liqour volume and umbilical artery dopplers requested as soon as possible.

b) I would call for help from the senoir obstetrician, anaesthetist and senior midwives. My aim would be to stop the fit and prevent recurrence and stabilize the patient. Initial management would be to secure the airway by lying the patient in the recovery position, check breathing and apply oxygen by face mask and 2 large bore cannular to repeat bloods for FBC, U/Es, LFT, Clotting profile, urates. Monitoring of BP,oxygen satuaration, Pulse rate and temperature should be commenced simultaneously. I would commence magnesium sulphate therapy - 4 gm ( 20%)IV starting with the loading dose and continuing with maintenance dose once the fit is abolished or a repeat dose ( 2gm) if required with the agreement of my consultant and anaesthetist. Strict input at 80mls/hr and urine output ( a urometer) to be commenced and BP to be kept below 160/100 or MAP below 125mmHg and if higher to commence on iv antihypertensive- labetalol may be used. IM steroids should also be given and once patient is stabilised with review of her bloods in particular LFT, U/E, urates and platelets and taking advice from the heamatologist if necessary, then delivery can be planned at the most appropriate time, place and date - the decision been made by the senoir obstetrician. The patient and relatives should be constantly informed of progress and plan of management.
Posted by Ron C.
RnRn

A.
Being otherwise healthy, most likely she developed severe pre-eclampsia. History of previous pregnancy with pre-eclampsia makes this more likely. Visual symptoms such as blurring, frontal headache, nausea and right upper abdominal pain may be signs of impending eclamptic seizure. Presence of fetal movements gives an indication of fetal wellbeing. Blood pressure series (minimal 4 at 10-minute interval) and mean arterial pressure (MAP) gives a better representation of the hypertension.
Examination may reveal leg swelling as well as facial oedema or swollen hands. Reflexes of legs may be brisk. Right upper abdomen / epigastric region may be tender. Abdominal palpation and measurement of fundal height gives an indication of fetal size and clinical liquor. Funduscopy may show retinal edema.
Proteinuria is quantified with protein-creatinine-ratio. I.v. access is obtained, bloods are taken and may show changes seen in pre-eclampsia or HELLP and include full blood count, renal function (incl. urate), liverfunctions and coagulation screen with fibrinogen + D-dimeres.
Fetal condition is assessed with CTG and Doppler flow + amniotic fluid index and growth is measured to identify intra-uterine growth restriction.

B.
An eclamptic seizure is most likely. This is an obstetric emergency requiring team input; additional help is sought, involving senior midwives and senior colleagues as well as anesthetist. One person will keep records of events. Consultant on call will be informed as well as neonatal unit.
Patient is put in left lateral position, airway is secured and oxygen given. If not present, i.v. access is obtained and if not yet taken, bloods for full blood count, renal function, liver function, glucose and coagulation screen. Magnesium sulphate 4 gram prepared by another team member will be given as slow i.v. bolus over 15-20 minutes. Mag-pie trial showed better seizure control with better maternal & fetal outcome. Subsequently magnesium sulphate will be continued at 1 gram/hour i.v. to be continued till 24 hours after delivery. Reflexes, blood pressure, pulse rate, respiration rate & saturation will initially be assessed 1/4 –hourly and urine-output is measured hourly with a urimeter, all to early on identify magnesium toxicity. Toxicity can be treated with calcium gluconate.
Blood pressure needs to be controlled if necessary, striving for MAP <150 mm Hg (above this there is loss of cerebral auto-regulation) with oral or intravenous labetolol. I.v. hydrazaline is an alternative if inadequate response to labetolol. CTG is done to assess fetal condition.
Once patient is stabilized, plans must be made for delivery. This depends on bloods (coagulation) and capacity on neonatal unit, but should take place within 24 hours. If for whatever reason immediate delivery is not possible, giving i.m. beta-methasone to mother is useful as it will promote fetal lung-maturation. In that case all blood assessments above must be repeated in 6 hours. Mode of delivery is by means of caesarean, as induction will be too time-consuming and is unlikely to be successful at 30 weeks. Neonatologist must be present at delivery and caesarean is done by senior staff as bleeding problems are more likely.
Post-delivery patient is monitored in high dependency unit. Use of fragmin is not contra-indicated. Bloods are repeated 6-hourly, or 12-hourly once improving. Patient and partner need to be debriefed properly, as it is a traumatic experience.
Posted by S M.
SM

(b) Two hours later, she is found fitting. Discuss the principles underlying your subsequent management [11 marks].

A) This is severe preeclampsia a leading cause of maternal mortality and this woman requires immediate care. The blood pressure should be repeated immediately. Labetalol 200mg stat dose should be given if the blood pressure is still elevated in order to reduce it and prevent eclampsia and complications. A history should be taken for symptoms of imminent eclampsia such as headaches, altered vision or epigastric pain. I would find out about her obstetric history including outcomes of past pregnancies and medical disorders such as preeclampsia. Since, for example this may be the onset of reoccurence of severe preeclampsia leading to growth restriction and prematurity. I would find out whether this is the first episode of high blood pressure in the current pregnancy and whether she was on treatment for hypertension or preeclampsia. This would influence the drug treatment since the blood pressure may be uncontrolled on medication for preeclampsia.

The next step in the assessment is examination. The blood pressure should be repeated every 15 minutes with the appropriate size cuff until stable. The fundal height should be measured and plotted on a customised growth chart. If this shows that the baby is small for dates, then the baby may be growth restricted or there may be oligo gydramnios, both risksof severe preeclampsia. The abdomen should be palpate for uterine tenderness or rigidity to rule out placental abruption which can be caused by severe preeclampsia. The presenting part should be determined, if cephalic this would allow for an induction of labour and vaginal delivery if delivery is needed. The extremities should be examined for clonus since this is a sign of worsening preeclamsia. A cardiotocograph should be done to assess current fetal wellbeing.
The next step in the assessment is investigation. A full blood count should be done to check for anamia and low platelet count which are seen in the HELLP syndrome, a complication of preeclampisa. Urea, creatinine, electrolytes and urates should be done to assess renal function which may deteriorate in preeclampsia. A raised urate level may indiacte worsening preeclampsia. Liver function should be checked since raised liver enzymes indicate worsening preclampsia and are also part of the HELLP syndrome. An ultrasound scan should be done for fetal growth, liquor volume and dopplers. Growth restriction and ligohydramnios are complications of preeclampsia and abnormal dopplers indicate that the fetus is compromised and should be delivered.

b) The first principle of management is to call for help. I need midwives, obstetric team including the consultant and the anaesthetic team including the consultant.
The next principle is to check the airway, breathing and circulation quickly. The airway should be checked for patency since the tongue can block the airway and oxygen 10 litres by face mask given. Breathing should be checked. Intravenous access should be made.
Magnesium sulphate 4g intravenously should be given over 10 minutes to stop the seizure. An intravenous infusion of Magnesium sulphate must be then given at 1g/hour to prevent recurrent seizures. If a further seizure occurs then 2g bolus of Magnesium sulphate can be given.
Positioning of the patient is important and the left lateral position is ideal.
The blood pressure should be checked and antihypertensive such as labetalol 50mg IV over 5 minutes should be given if the blood pressure is greater than 160/100. A labetalol infusion should be started at 5mg/ml and titrated against the blood pressure. This is needed to control the blood pressure and prevent cerebral haemorrhage or further seizures.
Blood pressure, pulse and respiration should be checked every 15 minutes until stable, to determine whether further treatment should be given. Tendon reflexes should also be checked since magnesium toxicity can cause reduced tendon reflexes and reduced repiratory rate.
Monitoring of fluid input and output is essential. A foley\'s bladder cather should be inserted and a hourly urometer utilised. The fluids should be restricted to 80 mls/hr to prevent overloading and pulmonary oedema.
Full blood count, renal and liver function should be checked since these are likely to be deranged in eclampsia.
Thromboprophylaxis should be done by TEDS stocking and heparin since this woman is at increased risk of thrombosis.
Fetal wellbeing should be checked with the use of cardiotocograph, since eclampsia increases the risk of poor fetal outcome.
Promotion of fetal lung maturity should be done by giving steroids in the form of bethametasone 12mg intramuscularly ( 2 doses, the second dose 24 hours later). Neonatal unit should be informed since
the baby may need to be delivered.
This woman should be cared for in a high dependency unit.
When stable it is essential to debrief this woman and her partner.
Posted by M E.

ME
A healthy 35 year old woman is referred to the maternity assessment unit at 30 weeks gestation because she had a blood pressure of 155/110 mmHg and 4+ proteinuria.
(a) Justify your initial assessment of this patient [9 marks].
This patient has severe pre eclampsia, which is associated with an increased incidence of maternal and fetal perinatal mortality. In her inital assessment, taking a history for clinical features of pre eclampsia such as headaches, visual disturbances, epigastric pain and vomiting. The presence of associated severe abdominal pain or per vaginal bleeding, since there is a higher incidence of abruption with preeclampsia. Enquire about frequency of fetal movements and when last a fetal movement was felt, to aid in assessing fetal viability. I will ask about the presence of urinary symptoms such as frequency and dysuria, to rule out other causes of proteinuria.
I will ask about her past obstetric history, whether she had pre eclampsia or eclampsia in her previous pregnancies, since there is a higher incidence of recurrence. I will enquire about a family history of pre eclampsia, chronic hypertension or renal disease.
On examination, I will repeat her blood pressure usuing a manual sppygomomanometer, with an appropriately sized BP cuff, at the level of the heart with patient seated and at 45 degrees. Alos i would calculate her BMI, since obesity is a risk factor for preeclampsia. On palpation of the abdomen I will check for abdominal tenderness and stiffness which may indicate a concealed abruption. Liver tenderness is also present in severe PE. Check fundal height, since there is a liklihood of IUGR. Ausculate for the fetal heart, to confirm viability. I would check for presence of oedema in limbs and face, deep tendon reflexes and clonus. Presence of clonus may predict the risk of convulsions and whether MgSO4 is required. Fundoscopy can be performed to check for papilloedema.
I would check her antenatal clinic notes for her booking blood pressure and if there were any previous episodes of elevated blood pressure or proteinuria. Also I would check her dating scan since this would determine number of pregnancies and to confirm the dating of her pregnancy.
Intravenous access should be inserted and blood taken for CBC, liver function test and renal function test. If platlets are less than 100*10 6 a clotting profile will be done. Elevated uric acid is assocaited with poor maternal and fetal outcome. Renal failure is associated with haemorrhage and HELLP syndrome. Raised liver transaminases are seen in pre eclampsia.
24 hour urine collection will be commenced. SpO2 will be checked, since early signs of pulmonary edema can be detected.
Non stress test will be performed to check fetal well being. An ultrasound can also be performed to check fetal growth especially the abdominal circumference, because of IUGR, Liquor volume may be reduced. Doppler ultrasound of umbilical artery can aid in determining timing of delivery.
Senior obstetrician and anaesthetist should be informed of case and input used to direct the management of the case. Corticosteroids should be administered to improve lung maturity. If diastolic blood pressure remains greater than 110mmHg, Labetalol or nifedipine should be given. Blood pressure should be checked every 30 minutes. Once stable patient should be admitted to the Antenatal ward.

b.Two hours later, she is found fitting. Discuss the principles underlying your subsequent management [11 marks].
Call for help, contact anaesthetist, since recurrent seizures may require intubation, senior obstetrician and neonatologist since she will require delivery once stable.
Place patient in the left lateral position to reduce the risk of aspiration and airway occlusion. Remove any objects from around patient that may cause harm to her while she is fitting. Suction secretions from mouth and administer 5L O2 via facemask, to reduce the risk of hypoxia.
Assess airway, breathing, pulse since absence of any of these would require resuscitation. Administer 4g MgSO4 IV via infusion over 5 - 10 minutes. MgSO4 is the first line agent of choice for eclamptic seizures. A MgSO4 infusion should then be commenced at 1g per hr and continued until 24 hrs after the last seizure. If she has further seizures 2g MgSO4 bolus can be adminstered. The patient should be catheterised and hourly assessment of urine output charted, since oliguia may occur with eclampsia and Mg is excreted in the urine. Careful input /output should be documented. Total fluid intake should be limited to 80mls/ hour. This patient is at high risk for pulmonary edema, which can result in maternal death.
Vitals including blood pressure, SpO2 should be checked every 15 minutes. Labetolol IV should be adminstered to control BP.CTG should be performed to assess fetal well being.

There should be hourly assessment for Mg toxicity, absence of deep tendon reflexes, urinary output less than 20ml per hour, respiratory compromise. If present MgSO4 should be discontinued. If there is respiratory compromise 1g calcium gluconate should be administered over 10 mins.
Delivery of the fetus and placenta is required for definitive treatment of eclampsia. Corticosteroids should be adminstered even if delivery is required in less than 24hours, to reduce repiratory mortality.
Delivery should be via caesarean section, since she is only 30 weeks and induction of labour is less likely to be successful. Delivery should be performed once patient is stable, facitities are available in the neonatal ICU for the preterm infant and senior personell are present. Prior to delivery the mother and relatives should be counselled about the risk of prematurity versus maternal well being and the need for urgent delivery. They should also be counselled that she is high risk of further seizures post natally and the need for close monitoring.
Following delivery, TED stockings and thromboprophylaxis should be administered. Early ambulation should be encouraged. Eclampsia, Caesarean section are risk factors for venothromboembolism. Antihypertensive medication should be continued based on BP readings.
Posted by Asa A.

a)The patient has severe PET which is a cause of serious morbidity and mortality . I will ask about symptoms of severe PET as headache, blurring of vision and epigastric pain and vomiting . I will ask about her LMP to calculate gestational age . I will ask about previous pregnancies and their outcome and whether she had high blood pressure during any previous pregnancy . Iwill ask her if she was prescibed any medicine for high blood pressure. I will ask her about fetal movement if decreased or normal .
I will measure her BP while she is simisitting at 45 * . I will examine her abdomen for epigastric or right hypochondrial tenderness (HELLP syndrome ). I will measure the fundal symphyseal height (IUGR) .
The uterus will be palpated for tenderness as severe PET may cause placental abruption . I will examine for lower limb oedema . I will examine for clonus . Fundal examination for papiloedema will be done.
Iwill revise her notes and midtrimester scan for accurate dating .
I will ask for FBC , LFT , Urea & electrolytes , uric acid , creatinine , 24 hour protein in urine as a base line and to exclude HELLP syndrome . If platelets are less than 100,000 /L Iwill ask for clotting screen. I will order charting of her fluid input and output .

To assess the condition of the fetus I will order CTG as it can show signs of placental insufficiency . U/S with umbilical a doppler will be done to assess fetal growth and amount of liqour and placental blood flow.

b)The principles of management will include controlling fits, lowering BP , stabilizing her and delivering the baby .This will be done by involving multisisciplinary team of senior midwife ,consultant obstetrician ,aneasthesiologist and neonalologist .She will be cared for in ICU or HDU .
I will secure airway ,breathing , circulation.Start Mg sulphate 4 gm iv by iv pump over 10-15 min to control fits and maintained at 1 gm/hour after the last fit. Antihypertensives as labetolol or hydralazine will be given according to local protocol .BP will be measured /15 min till she is stable . Foleys catheter will be fixed . Fluid restriction to 80 ml/hour will be done for fear of pulmonary oedema. LFT ,RFT,FBC will be repeated to detect any deterioration of the condition .
Corticosteroids will be given to enhance lung maturity in the form of betamethasone 12 mg im for 2 doses 24 hrs apart . Once the patient is stable ,the decision for delivery willbe taken by consultant obstetrician . The mode of delivery will be determined with respect to fetal condition and cx ripening . The third stage will be managed by giving oxytocin 5iu iv slowly as she is at risk of PPH. She will continue using antihypertensives till bp is fully controlled . Before discharge she will be debriefed about the events that occured and given advice about contraception . At 6 ws post partum she will be examined by GP for BP and the presence of protienuria .
Posted by Asa A.

a)The patient has severe PET which is a cause of serious morbidity and mortality . I will ask about symptoms of severe PET as headache, blurring of vision and epigastric pain and vomiting . I will ask about her LMP to calculate gestational age . I will ask about previous pregnancies and their outcome and whether she had high blood pressure during any previous pregnancy . Iwill ask her if she was prescibed any medicine for high blood pressure. I will ask her about fetal movement if decreased or normal .
I will measure her BP while she is simisitting at 45 * . I will examine her abdomen for epigastric or right hypochondrial tenderness (HELLP syndrome ). I will measure the fundal symphyseal height (IUGR) .
The uterus will be palpated for tenderness as severe PET may cause placental abruption . I will examine for lower limb oedema . I will examine for clonus . Fundal examination for papiloedema will be done.
Iwill revise her notes and midtrimester scan for accurate dating .
I will ask for FBC , LFT , Urea & electrolytes , uric acid , creatinine , 24 hour protein in urine as a base line and to exclude HELLP syndrome . If platelets are less than 100,000 /L Iwill ask for clotting screen. I will order charting of her fluid input and output .

To assess the condition of the fetus I will order CTG as it can show signs of placental insufficiency . U/S with umbilical a doppler will be done to assess fetal growth and amount of liqour and placental blood flow.

b)The principles of management will include controlling fits, lowering BP , stabilizing her and delivering the baby .This will be done by involving multisisciplinary team of senior midwife ,consultant obstetrician ,aneasthesiologist and neonalologist .She will be cared for in ICU or HDU .
I will secure airway ,breathing , circulation.Start Mg sulphate 4 gm iv by iv pump over 10-15 min to control fits and maintained at 1 gm/hour after the last fit. Antihypertensives as labetolol or hydralazine will be given according to local protocol .BP will be measured /15 min till she is stable . Foleys catheter will be fixed . Fluid restriction to 80 ml/hour will be done for fear of pulmonary oedema. LFT ,RFT,FBC will be repeated to detect any deterioration of the condition .
Corticosteroids will be given to enhance lung maturity in the form of betamethasone 12 mg im for 2 doses 24 hrs apart . Once the patient is stable ,the decision for delivery willbe taken by consultant obstetrician . The mode of delivery will be determined with respect to fetal condition and cx ripening . The third stage will be managed by giving oxytocin 5iu iv slowly as she is at risk of PPH. She will continue using antihypertensives till bp is fully controlled . Before discharge she will be debriefed about the events that occured and given advice about contraception . At 6 ws post partum she will be examined by GP for BP and the presence of protienuria .
Posted by A H.
AH
a)This patient has severe pre-eclampsia, which is associated with significant maternal and fetal morbidity and possible mortality. She will be admitted to labour ward for assessment and monitoring.
Her parity will be noted. If parous I will check if she had previous caesarean as this will influence mode of delivery
Symptoms of impending eclampsia will be asked. This includes headches ( frontal), and visual disturbance which indicates cerebral irritation.
Nausea, vomiting or epigastric pain will be asked as severe pre-eclampsia can present as HELLP syndrome.
Shortness of breath or pleuritic chest pain will be sought as there is the risk of pulmonary oedema.
I will ask about constant lower abdominal pain, contractions and associated vaginal bleeding as there is a risk of placental abruption.
I will repeat the blood pressure using a mercury sphygmomanometer if available, and an appropriate-sized cuff. An automated blood pressure machine will be used if it was previously calibrated.They can give inaccurate readings unless they were calibrated. Her pulse rate will be noted.
The chest will be examined for crepitations or other signs of fluid overload.
The abdomen will be assessed for tenderness in the epigastrium and right upper quadrant. The liver will be palpated uterine tenderness will be sought ; this will indicate a possible abruption. Fetal viability and wellbeing will be confirmed by cardiotocograph. A vaginal examination will be done to assess the Bishop\'s score to plan for delivery.
I will check for clonus as its presence is a sign of cerebral irritation.
Bloods will be drawn for Full blood count, Renal function tests, liver function tests and uric acid. A low haemoglobin and low platelets will be found in HELLP syndrome. Platelet less than 80/femtolitre is a contraindication to inserting an epidural. The values will also be a baseline for continued monitoring.
A 24 hour urine collection will be commenced to quantify the volume of urine passed as well as proteinuria.

b) The patient suffered an eclamptic fit. I will call for help. The midwife in charge as well as a senior midwife will be summoned. The consultant obstetrician and anaesthetist will be called.
The patient will be turned on her side.Airway and breathing will be secured using a Guedel airway and administering oxygen via face mask.
Intravenous access will be secured and magnesium sulphate will be given to stop the seizure. A loading dose of 4 grams diluted in 40 ml will be given as a slow intravenous injection,followed by an intravenous infusion at a rate of 1 gram per hour as maintenance. Further fitting will be prevented by either increasing the infusion rate to 1.5 to 2 grams per hour or by giving 2 gram boluses.
A urethral catheter will be inserted for monitoring urine output.
Continuous assessment of pulse, blood pessure, and oxygen saturation will be done. Bloods will be repeated for FBC, RFTs, LFTs and coagulation profile.
Hypertension will be treated according to the department\'s protocol.
Fetal wellbeing will be assessed and if confirmed maternal antenatal steroids will be given to enhance lung maturity and reduce the incidence of intaventricular haemorrhage and respiratory distress syndrome.
The neonatologist will be informed and a cot arranged. In-utero transsfer will be done if no cots are available and the mother has been stabilised.
She will be counselled for delivery by caesarean section. Induction of labour at this gestation is likely to fail.
She will be monitored for magnesium toxicity by respiratory rate, and deep tendon reflexes.This is more likely if she is oliguric (,20ml/hr) or if there is impaired renal function in which case serum magnesium levels will be done.
Fluid will be restricted even if there is oliguria, in order to reduce the risk of ARDS.
She will be managed in intensive care unit or high depency unit until stable. Blood pressure will be closely monitored for at least 5 days after delivery.
The patient and her relatives will be counselled. She will be discharged with antihypertensives if necessary and she will be advised to have blood pressure and urinalysis checked by her GP at 6 weeks postpartum.
She will be given a follow-up appointment to discuss what occurred, her risk of recurrence and possible prevention in the preconceptual and antenatal periods. Contraception advice will be given.
Her GP and midwife will be informed.
Posted by Maayka ..
maayka

a) The patient has severe pre- eclampsia (PET) and because it can lead to development of Eclampsia, it is necessary to prevent this from occurring, as it is associated with an increased incidence of maternal mortality. A history would determine if there was a previous pregnancy with PET or a family history of PET. Any symptoms she may presently be experiencing of visual disturbances, epigastric pain/ tenderness, nausea and vomiting and headaches will increase the likelihood of impending eclampsia. Also asking about fetal movements may assess its well being and ruling out vaginal bleeding to exclude the possibility of an abruption.
Examination of her blood pressure (BP) should be done every 15 mins then every 30 mins if stable. Antihypertensive will need to be considered dependent upon the readings and other symptoms. Also her pulse and oxygen saturation, the latter because of the risk of development of pulmonary oedema. Generalized oedema, especially of the hands and face, do not necessarily indicate the need for treatment but worsening oedema may suggest increased likelihood of Eclampsia. If ankle clonus is present and more than 2 beats then consideration should be given to use of Magnesium sulphate (MgSO4) to prevent seizures. The abdomen will be checked to ensure that fundal height compatible with gestation age as intrauterine growth restriction (IUGR) is a common problem. Fetal heart rate (FHR) by Doppler should be assessed to rule out bradycardia and any decelerations. If possible, an ultrasound can be done to assess Biophysical profile, umbilical artery Doppler waveforms.
Initial investigations should include a full blood count (FBC) – to check baseline Hb and platelet count; urea and electrolytes and uric acid – to check baseline renal function and LFTs. A PT/PTT will be done if platelet count is less than 100 x 106.


b) The patient should be approached quickly while summoning for help from the senior obstetrician, anaesthetist and midwife. Her airway, breathing and circulation will be assessed while she is placed in the left lateral position and oxygen is administered by a face mask. Most times the fit will stop spontaneously if Eclampsia but if necessary Diazepam 10mg intravenously (IV) can be given.
The lab should be alerted as blood samples are taken for FBC, urea and electrolytes, PT/PTT, LFTs – to assess her baseline status and ensure there is no development of HELLP syndrome. Xmatch sample for 2 units blood will be requested in anticipation of delivery by Caesarean section (CS). To prevent further seizures MgSO4 should be administered by an infusion pump, a loading dose of 4 g IV over 10- 15mins followed by 1 g per hour till 24hrs after delivery or the last fit. Monitoring is required to ensure Mg toxicity does not occur by checking reflexes, respiratory rate, pulse and urine output.
Catheterization would have been done earlier to monitor urine output.
As the gestational age is 30 weeks, Bethamethasone should be administered to improve fetal lung maturity. Although it is unlikely to be given over 24 hours, there is still some benefit within less than 24 hours. The patient and her family should be briefed about the incident and the need for delivery to prevent further seizures as this would increase the possibility of maternal mortality.
The FHR will be assessed and if stable then delivery can be done as soon as the mother is stabilized on the delivery suite, otherwise it needs to be done urgently. CS would be the optimal mode as the induction delivery time likely to be prolonged at 30 weeks. Following delivery she will be transferred to high dependency unit and vitals monitored closely. Antihypertensives if started may need to be continued as well as the Mg SO4. Restriction of fluid input to approximately 80mls/ hour is to prevent the occurrence of pulmonary oedema.
An incident report would be filled following the fit and subsequent management includes in hospital monitoring for at least 5 days, as the risk of seizure recurrence is highest in this period. She will be followed up by her GP and 6 weeks postpartum by the consultant led team.


Posted by Lilantha W.
(a) Diastolic BP of 110 at 30 weeks with 4+ proteinurea warrants working diagnosis of severe pre-eclampsia (PET). PET should be treated promptly to prevent complications which could be serious for example, antihypertensive therapy, magnesium sulphate prophylaxis and timing of delivery would minimise complications such as stroke, eclampsia and prenatal mortality. Quick assessment to establish working diagnosis is required to commence immediate treatment, whereas, a through assessment is necessary to look for complications, establish the aetiology and to manage well.

Some of the classical symptoms of PET such as headache, visual haloes, double vision, epigastric pain, shortness of breath, swelling, nausea, vomiting and feeling unwell may be found. Most of these symptoms are due to increased capillary permeability. The objective assessment of above evidence can be done by eliciting physical signs such as reduced level of consciousness, fundoscopy to look for pappiloedema, visual field testing, epigastric tenderness, auscultating for basal crackles in lungs, eliciting hyper-reflexia and clonus. Amongst those, clonus, pappiloedema and epigastric tenderness are more specific. It is important to exclude differential diagnosis of renal disease, hypertension, liver disease at the same time, relevant systematic inquiry should be made.

History of foetal moments, vaginal bleeding are important to reveal the possibilities of oligohydramnios, IUD or abruption. Normal foetal movements, on the other hand, suggests a good foetal wellbeing; a CTG monitoring would confirm it.

Serial ambulatory blood pressure monitoring is required every 10mn until it is stabilised. Pulse rate, oxygen saturations and temperature to monitor general condition of the patient. Reduction of O2 saturations may indicate pulmonary oedema. Fluid balance should be carefully done to avoid fluid overload, therefore, catheterisation and monitoring hourly urine output would be required. Urine dipstix may be repeated to exclude previous false positives.

To establish the aetiology, the booking BP should be noted in the antenatal case notes. Risk factors such as diabetes, IUGR, multiple pregnancy, primigravidity, positive inherited thrombophilia screening in current pregnancy as well as previous PET, family history may be found.

A FBC would reveal Hb (to consider crosshatching), platelet count (thrombocytopenia in HELLP). A coagulation screening is done if thrombocytopenia is likely/found. Liver functions can be abnormal, hence, LFTs should be checked. Renal functions may be impaired and they can be affected during fluid balance, hence U&E is needed. High serum rate may indicate severe disease.

Uterine palpation may reveal tender, hard uterus in abruption. IUGR and oligohydramnios can be suspected during utrine palpation. Palpation for presenting part and assessment of cervical favourability has delivery implications. Drug history, any drug sensitivities and other allergies should be found. Time of last meal is important to time safe anaesthesia.

(b)The most probable clinical diagnosis is eclampsia which is a major obstetric emergency with serious maternal and foetal adverse outcomes, therefore, prompt execution of emergency management protocol is required. Emergency care team should communicate effectively to ensure the seizure control, blood pressure control and monitoring happens simultaneously. Initial stabilization of the mother followed by delivery (treating the cause) should be done along with careful monitoring to prevent complications.

After ensuring the airway is clear and open oxygen is given 10L/min via face mask. Patient should ideally be lying in left lateral position to maintain uterine perfusion and to minimise aspiration. Pulse oxymetry would monitor oxygenation. Seizure control is the next important step which is achieved by giving a 4g magnesium sulphate (MgSO4) bolus over 10min followed by infusion, usually 1-2g/h. High serum levels should be achieved to increase the seizure threshold, therefore, a second bolus may be required if seizure is not controlled over the first. However, magnesium depresses respiration and the myocardium and also MgSO4 has a narrow therapeutic window, hence cardiorespiratory monitoring (respiratory rate, continuous ECG monitoring) and serum Mg levels should be monitored. Prevention of seizure recurrence is achieved by continuing the MgSO4 infusion for 24h since the last fit or delivery.

Controlling blood pressure should be done promptly to prevent stroke which is the most lethal complication. Intravenous antihypertensives must be used for better efficacy; also enteral administration is not possible. If the hypotensive effect is not achieved with one agent, a second agent can be administered. Caution should be taken not to drop the BP drastically to prevent hypoperfusion of the uterus and other vital organs. Usually IV labetalol 50mg bolus followed by infusion is given as the first line. IV hydralazine is used as the second agent or if patient is asthmatic as the first choice. Nifedipine SR is an alternative. Doses should be titrated to maintain BP <160/100.

Increased capillary permeability results in increased fluid in interstitial space than intravascular space resulting in organ oedema. Careful fluid balance is need ed to prevent further worsening of cerebral, pulmonary or hepatic oedema. Fluid overload should be avoided (1ml/kg/h is sufficient) and CVP monitoring should be done once the patient is stable until full recovery. Fluid balance including hourly urine output should be charted.

As complication of eclmpsia, HELLP syndrome can be developed. Haemolysis, thrombocytopenia and abnormal liver enzymes can be found out with serial FBC, LFTs. A coagulation screening along with fibrinogen level is indicated if the platelet count is low in which case the risk of DIC is high. Renal function should be monitored with U&E, urate to prevent renal failure and to aid fluid balance.

Patient should be delivered once her condition is stable to do so, it should be a multi-disciplinary decision to optimise its accuracy. Caesarean delivery is indicated if the cervix/vaginal route is unfavourable. Caution should be taken for haemorrhage and DIC in patients with HELLP or placental abruption. Crosshatching 4 units of red cells is needed; FFP and cryoprecipitate may be required. Timing of the delivery is also depends on foetal wellbeing, which should be monitored with CTG and clinical examination as appropriate.

Patient should be monitored in a HDU/ITU even after delivery, as the risk of eclampsia is high postpartum. Prompt monitoring and treatment can be provided in these settings with good outcomes.

Eclmpsia is a main risk factor for venous thromboembolism, prophylactic dialtheparin along with TEDs, mobilisation is essential. Antihypertensives should be continued until the BP becomes normal.

Patient and the family should be debriefed early. Follow up at 6 weeks would encourage the patent to ask any questions, if any. Secondary prophylaxis can also be discussed eg. Low dose aspirin, calcium; other predisposing factors can be modified eg. Diabetes, hypertension.

Critical incident reporting should be done according to the unit protocol to aid local clinical risk management activities that will minimise the incidence of the adverse events in the future.
Posted by Ron C.
I noted that the vast majority of people have gone astray by discussing the B-part as management rather than principles. I think this is probably one of the most difficult parts of part 2 [:confused:]; we all know very well how to manage most situations, but to properly answer the essay question can be hard.

Dear Dr. Paul, could you kindly give us a bit of an outline on how best to approach a question asking for \"principles\" in addition to the answer to this question, as I think we will all very much benefit.... thank\'s
Posted by Ron C.
I noted that the vast majority of people have gone astray by discussing the B-part as management rather than principles. I think this is probably one of the most difficult parts of part 2 [:confused:]; we all know very well how to manage most situations, but to properly answer the essay question can be hard.

Dear Dr. Paul, could you kindly give us a bit of an outline on how best to approach a question asking for \"principles\" in addition to the answer to this question, as I think we will all very much benefit.... thank\'s