The smart way to learn. The smart way to teach.

MRCOG PART 2 SBAs and EMQs

Course PAID
notes336
EMQ1502
SBA2115
Do you realy want to delete this discussion?
Forum >>

ESSAY 213 - ECLAMPSIA

Posted by Sarwat F.
Eclampsia is an obstetric emergency. Principles underlying initial assessment of the woman include care of airway, breathing and circulation and then anticonvulsant and antihypertensive treatment.
Senior obstetrician, senior midwife, anaesthetist should be called for help. Woman is nursed in left lateral position. Intravenous line is maintained and blood obtained for full blood count, liver function tests, urea and electrolytes and coagulation studies. Her blood pressure, pulse, respiratory rate is checked. Intravenous bolus of magnesium sulphate is given as 4 grams diluted in 12 mls of normal saline. Input and output is checked by retaining foleys catheter. Maintainence dose of magnesium sulphate is started at a rate of 1 gram per hour. Her chart is quickly reviewed to check for any preexisting medical condition like epilepsy or any renal disease in which case dose of magnesium sulphate may need alteration. Her blood pressure is monitored and antihypertensive is given if mean arterial pressure is greater than 135 mm Hg or systolic more than 160 and diastolic more than 110 mm Hg. Antihypertensives include nifedipine, hydralazine or labetolol. Labetolol is given as infusion whereas nifedipine is usually given as adjunct to other antihypertensives to optimize control.
In patients on magnesium sulphate monitoring is very important because of low therapeutic index. Signs of toxicity include respiratory depression, depressed tendon reflexes and excessive sleep. As magnesium sulphate is excreted through kidneys, adequate urinary output of greater than 30 mls per hour should be maintained. For recurrent fits magnesium sulphate can be repeated in the dose of 2 gms stat dose. If still fits are not controlled muscle paralysis and mechanical ventilation is done in extreme cases only by consultant anaesthetist. In the absence of signs of magnesium toxicityserum magnesium is not routinely checked.
Patient will be reviewed by consultant obstetrician, anaesthetist. She will be shifted to high dependency unit for continuous monitoring and care. Her bloods will be repeated frequently depending on initial results. Various complications of preeclampsia and eclampsia like pulmonary edema, cerebral hemorrhage and HELLP syndrome are carefully watched for and prevented by adequate fluid balance.
Patient will be explained about all the events and will be given 6 weeks appointment to discuss issues regarding contraception and recurrence in future pregnancies.
Posted by Srivas  P.
General principles in managing this case involves management of airway, immediate control of convulsion and her B.P, Senior anesthetic and consultant involvement, watching out for other likely complications of ecclampsia, controlling and treating any complications like pulmonary edema, ARDS, cerebral edema, cerebral haemorrhage, DIC and giving supportive care in HDU till she stabilises.

First and foremost she should be prevented from falling and hurting herself. She should be put in left lateral position to prevent aspiration and airway should be kept open using a mouth gag to prevent tongue obstructing the airway and put on I/Nasal oxygen by facial mask.

Ecclampsia in pregnancy carries 2% mortality and 35% incidence of major complications. The consultant obstetrician, anesthetist who should be immediately informed while hematologist should be alerted and senior experienced midwife should be called over.

Her immediate care involves assessing B.P, Pulse and then taking blood samples for BUN, Creatinine, LFT, Clotting profile, Platelet counts and setting up an intravenous line. Her convulsion should be controlled by giving Mgso4, 4gm intravenously slowly. If she is hypertensive and DBP more than 110 and SBP more than 170, intravenous Labetalol or hydralazine should be given as both are effective and immediate control of B.P prevents intra cranial/retinal hemorrhages, a major cause of maternal mortality and morbidity.

After her immediate convulsion is controlled she needs maintenance therapy of MgSo4 5gm I/M 4hrly or as I/V dose of 1gm per hour through infusion pump. Incase of repeated convulsion, 2gm I/V bolus can be given. She should have continuous catheterization and her intake output should be monitored and intake adjusted to output so as not to cause pulmonary edema and fluids should be restricted depending on output.

Once she stabilizes she needs to be shifted to HDU for 24-48 hrs for 1:1 nursing and constant surveillance and should also have consultant and anesthetist care. She may need invasive monitoring if she has anuria or has pulmonary edema and volume status is not known especially if she has associated hemorrhage. Her reports should be reviewed and her observations of B.P should be done every 15 mins in the initial period and then can be observed 1-2 hrly and later 4hrly. Her RFT, LFT should be done 4hrly initially and then daily and she may need to be observed in HDU for 2 days. She needs SO2, urine out-put & renal function, FBC, clotting, LFT, tendon reflexes, respiratory rate also to be monitored.

Watch for any signs of bleeding from vagina, whether the uterus is contracted, bleeding from any other sites which may signify DIC. Need for blood or blood products will depend on amount of hemorrhage, her clotting profile and it should be given if necessary in consultation with hematologist. She should be assessed for thrombo prophylaxis and put on LMW if assessed as high risk.

Other complications of ecclampsia include DIC, renal failure, liver rupture, pulmonary aspiration and ARDS. Pulmonary complications can be prevented gy preventing aspiration, maintaining proper volume and avoiding pulmonary edema by over hydration till acute renal shut down reverses.

Her relatives should be debriefed by consultant to explain chain of events, the present care given and risks involved to her. The occurance of Eccampsia postnatally in the hospital should involve incident reporting.

She can then be shifted to ward but will need daily monitoring of B.P. MgSo4 should be given for 24 hrs after last fit. She can be put on oral antihypertensives till discharge and then should continue her medication at home. She should be reviewed in PNC after 15 days. At this visit contraceptive advice should be given. She should be told about recurrence risk in next pregnancy.
Posted by Ebeinheizer S.
Eclamptic fit is potentially fatal and can cause aspiration pneumonitis, cortical blindness, cerebro-vascular accident and permanent neurological deficit.

First principle in obstetric emergency as this is to call for help. I will call for the Consultant Obstetrician, Anaesthetist and subsequently involve the Intensivist in managing this patient. Assistance of the midwife, SHO and paramedical staff are also important.

Preventing cerebral hypoxia is utmost importance for initial resuscitation. I will assess her airway patency and breathing. I will ensure it is not blocked by her tongue, saliva or vomitus. Suction and inserting oropharyngeal airway helps maintain patency. It also prevents her unconsciously biting her tongue if fit recurs. I will give oxygen 5-10L/min via face mask and put her in recovery position. If she is not breathing spontaneously, intubation and ventilation would be necessary.

Stopping current fit and prevent recurrence is the next principle. I will give her slow intra-venous bolus of loading dose Magnesium Sulphate (if no iv cannula, it can also be given intra-muscularly). This is followed by a maintenance infusion of Magnesium Sulphate 1 gr/hour for 24 hours as it is proven to prevent recurrent fit. Additional 1-2 gram bolus Magnesium Sulphate can be given if she has further fits. At the same time, other causes of recurrent fit should be investigated such as electrolyte imbalance. If her blood pressure is high, as it usually would be, intravenous hydralazine infusion would also be commenced to maintain mean arterial pressure below 125 mm Hg.

Intensive monitoring in the High Dependency Unit is the next principle. This is because of her eclampsia and potential toxicity of Magnesium Sulphate. Close monitoring of her blood pressure, pulse rate, respiratory rate, fluid balance, urine output and reflexes would be done to detect any deterioration early and intervene immediately. Blood investigation for full blood count, liver function test, coagulation profile, urea, electrolytes, Magnesium and Calcium levels will be sent. If Magnesium toxicity is suspected, IV Calcium Gluconate 10% is given as slow bolus as antidotum.

Risk management is an integral component of her management. Careful documentation including incident reporting and internal audit of the entire management is important. When she is alert, I will see her preferably with her partner, to explain the events in detail. I will give her leaflets about pre-eclampsia/eclampsia (which are available in my hospital) and explain that there is an increased risk of this recurring in her future pregnancy. There are no proven methods to prevent this from recurring but research have shown that using low dose Aspirin 75mg daily from early pregnancy helps to reduce the morbidity associated with severe pre-eclampsia / eclampsia. I will also explain that she is also at increased risk of developing chronic hypertension and organize for the GP to reassess her blood pressure in 6 weeks. I will summarise about her eclampsia on her discharge notes with copies to her GP and midwife.


Posted by Ismatara B.
This is an obstetric emergency. The first and most important principle of management is to resuscitate the patient immediately: check airway, breathing, circulation and position the patients appropriately to prevent maternal injury during convulsion. Place the woman in left lateral position and administer oxygen by facial mask. Check BP and pulse oxymetry is introduced
Urgent senior obstetric, experience midwife and senior anaesthetic help should be requested. Haematologist should be informed.
The labour ward should have an agreed protocol which should be followed.
An intravenous line with a wide bore cannula (size 14-16 gauge) must be inserted immediately if not done earlier. After basic life support, the underlying prinsples of management include assssment of the patient with control of fit and BP, close monitoring to be careful weather any complications (CVA, DIC, hepatic or renal failure, ARDS, pulmonary oedema) arise and management accordingly. The patient should be managed in HDU or ICU. Her initial assessment includes, check pulse, blood pressure. Blood should be sent for FBC, group and safe, liver and renal function test and coagulation profile.
Further fits must be prevented. Magnesium sulphate is the drug of choice to control seizures. A loading dose of 4g should be given by infusion pump over 5 minutes, followed by a further infusion of 1 g/hr maintained for 24 hrs after the last seizures. Recurrent seiuzers should be treated with a further bolus of 2g MgSo4 or an increase in infusion rate of rate 1.5 or 2.0 g/hr.
The blood pressure must be controlled to prevent CVA and hypertensive cardiac failure. Rapidly acting drugs should be used. Labetolol is given intravenously, and hydralazine is given iv.
The patient should be managed in HDU or ICU under a single lead clinician with close monitoring which include:
Close fluid balance with input output chart is essential. Oliguria may complicate renal damage and fluid overload may precipitate pulmonary oedema. A CVP line and catheter with hrly urometer is a better option, especially in her postpartum period. Total fluid should be limited to 80ml/hr or 1ml/kg/hr. The volume of crystalloid should be tightly controlled.
As the patient is on magnesium therapy, MgSo4 toxicity should be assessed clinically (deep tendon reflexes, respiratory rate, SO2 and urine output hrly or half hrly as per protocol). If the woman is oliguric, losses deep tendon reflexes, develops respiratory depression, hepatic or renal impairment or recurrent seizures, MgSo4 level should be checked.
Blood pressure should be monitored depending on antihypertensive therapy.
FBC, U&E, LFT and Clotting should be checked every 4-6 hrs. If there is any suspected neurological problem, CT or MRI is to be done.
Thromboprophylaxis should be given according to risk factor as per hospital protocol.
The woman,s family should be kept informed about the condition of the patient and the woman should be informed about the situation, when she recovers.
A clear documentation should be done about the timing of seizures, assistance requested and medicine/fluid given. Incident form should be filled up. There is a risk of late seizurs and she should be reviewed carefully before discharge from hospital. BP and urinary protein should be checked by the GP at 6wks postnatally. If hypertension or proteinuria persists then further investigation is recommended. Antihypertensive should be continued and reduction in a stepwise fashion. It may up to 3 months to return to normal. Breastfeeding is encouraged. Labetolol, atenolol, nifedipine and enapril are safe in breast feeding used either singly or in combination. She should be discussed about contraception and also about next pregnancy with preconceptual counselling, any risk factors and preventive therapy, as there is chance of recurrence.

Posted by Aroosha B.
A woman who has having an eclamptic fit needs immediate care which involves maintaining airway, left lateral position and oxygen inhalation. Abort convulsions with diazepam 10 mg i.v. or clonazepam 1 mg i.v.. Call for senior help (consultant obstetrician and duty anaesthetist). Evaluation of level of consciousness if deeply unconscious may need artificial ventilation but it will be done by the anaesthetist. Assessment of vital signs and control of blood pressure to maintain diastolic BP of 95 ? 105 mmHg. Seizure prophylaxis with iv magnisium sulphate bolus of 4 g and if further fit then a further bolus of 2 g followed by 1 g per hour in infusion. Assessment of organ damage by coagulation screen, renal function, LFT, Platelet count is done on an urgent basis. Admission to high dependency unit is done and she is started on continuous monitoring with ECG, Pulse oxymetry and vital signs. Catheterisation is done to assess renal output. CVP monitoring is preferred for intake output assessment as these patients are high risks for fluid overload.

When she is relatively stable her management is done according to her level consciousness with mild or no impairment of consciousness her BP is stablised with rapidly acting drugs like Dihydralazine or a Labetalol infusion. Meticulous surveillance specially the cardiovascular system is continued. Maintenance of intake output of fluids is done on a strict basis. Ringer?s lactate is recommended as an IV fluid @ directed by hourly urine output in the previous hour + 30 ml for insensible losses. Her respiratory rate, patellar reflexes and urine output is specially monitored to diagnose magnesium toxicity. Serum magnesium should be measured 4 hourly to detect toxicity. BP should not be lowered to rapidly as cerebral perfusion will be lowered with a risk of cerebral ischemia. Her investigations will be repeated at six hourly intervals and hemotoligist or physician, or cardiologist will be involved if any abnormality.

With patient having marked impairment of consciousness airway management may necessitate intubation. If she is extremely restless or has poor arterial blood gases then also she will need intubation. In such patient CT Scan or MRI will be recommended after review by neurologist for detection of focal neurological signs. She will be continuously monitored in HDU till she is stabled for atleast 48 hours after which time she can be shifted to ward. Her family will be kept informed at all times and before discharge she will be offered appropriate contraception and risk of recurrence is explained. A followup visit will be arranged for her with a senior obstetrician. It is important to counsel the patient on booking early in future pregnancy and possible administration of low dose aspirine in the future pregnancies to detect pre eclampsia as early as possible.
Posted by Kishor S.
The principles that underlie the initial assessment are as follows. Firstly, it should be done by senior obstetric team (obstetrician and midwife) and anaesthetist. Therefore, they should be alerted immediately. Secondly, she should be assessed whether or not there was preexisting pre-eclampsia that will include review of ante/intranatal history. If there is positive history, then use of antehypertensive, and control of BP, any complications eg abruption placentae, growth restriction; LFT and RFT should be looked for.

Next principle is assessment of general condition and functions of the organs likely to be involved in eclampsia and its complications. These include self inflicted injury eg tongue bite and level of consciousness, BP and pulse rate. Organ functions will be evaluated by LFT, KFT, coagulogram, serum electrolytes. Hyperpyrexia and constricted pupil would suggest cerebrovascular accident.

General principles of subsequent management are: She should be managed in HDU by multidiscipline team involving anaethetist, haematologist, nephrologist, cardiologist and neurologist (depending on the complications) in addition to obstetric team. Family member/spouse should be informed of all the events.

Next principles will be on two aspects. Firstly, during a fit, the principles should be prevention of self inflicted injury, aspiration and maintenance of airway and proper oxygenation with O2. Second principle is prevention of further fits, control of hypertension and prevention/management of complications (renal, HELLP, pulmonary oedema, retinal detachment and CVA).

All these will involve use of magnesium sulphate as per local protocol and intravenous diazepam for immediate control of fits and in the event of sporadic occurrence of fit during the management. Control of acute hypertension, if any will be done by hydralazine or labetolol as per local protocol but if she requires subsequent prolonged antihypertensive, methyl dopa should not be used as it is associated with higher depression. During postpartum period there is no contraindication of the use of ACE inhibitors or amlodepine. Fluid management should be strictly monitored. Though in general 80 ml/hour is recommended, it has to be individualized on the basis of body weight, urine output and electolytes.

Thirdly, as a part of risk management an incident form needs to be filled up because eclampsia is one of the causes of maternal mortality.

Lastly, the principle of management will be on the assessment of the any residual disease particularly renal disease or chronic hypertension at 6 weeks and 3 months. This will also include counseling of future pregnancy and contraception.


Dear Dr Paul, Could you please let me know whether bullets can be used as you have used in model answers. THANKS.

Posted by Freha Z.
Initial management should be based on placing the women in left lateral position and securing the airway. Giving oxygen if needed. Then call for help, involving consultant obstetrician, senior midwife and anaesthetist. Local protocal for management of eclampsia should be followed.
Eclampsia is rare therefore such cases are managed preferably in High dependency Unit. Magnesium sulphate is drug of choice for seizures because women treated with it have fewer further seizures compared with women treated with diazepam or phenytoin. It is given by intravenous route 4g loading dose over 5-10 minutes followed by maintenance infusion of 1g/hr continued for at least 24 hours after last seizure.
Initial assessment of patient include her BP, Pulse, Respiratory rate and after starting magnesium sulphate signs of its toxicity such as patellar reflex 1hourly. Close monitering of fluid intake and urine output is mandatory. Investigations like Hb, LFTs, Renal function tests, platelets and O2 saturation should be done and monitered regularly. Early referral to regional centre for advice should be considered if complications develop.
High blood pressure should be controlled to reduce risk of further attacks and cerebrovascular accident.
When the women is stable. Her condition should be discussed with her and she should be informed that she has a higher risk of developing pre-eclampsia in her future pregnancies and hypertension in later life. A 6 week follow up appointment should be arranged. Discharge should be made informing G.P and community midwife.
For high standareds of care audit and adherence to guidelines can minimize clinical and medicolegal risks. Training courses and drills for junior doctors and midwives can further improve care.
Posted by Kishor S.
Dear Dr Paul,
The first part of the question says ?principles underlie INITIAL ASSESSMENT not initial management?. That is how I started with assessment.

Another query: Does this type of question mean only the enumeration of the principles? If it is so, it will be very short and may not look like an essay.
Posted by neera  B.
This is a life threatening emergency , so prompt treatment is needed. Aim of management is to establish airway, control convulsions, stabilize, blood pressure and maintain fluid balance.
Aspiration should be prevented by positioning head in lateral and establishing airway.
Urgent help from multidisciplinary team involving sr obstetrician, intensivist, senior physician with interest in eclampsia and anaesthetist be sought. Clear communication between member of MDT is essential.
Unit protocol should be followed.Convulsions should be controlled, magnesium sulfate intravenously is the first choice (Magpie Trial) . If recurrent seizures occur, its dose can increased or thiopentone or phenytoin considered.
Antihypertensives should be started since systolic BP over 160 mm Hg can cause cerebral hemorrhage which increases risk of mortality. Labetolol( I/V, oral ) nifedipine oral or intravenous hydralazine are quick acting .
Baseline hematological and biochemical investigations are sent and monitored serially .Clinical monitoring of blood pressure with mercury manometer and appropriate sized cuff, deep tendon reflexes , respiratory rate and fluid balance is important. Indwelling urinary catheter and CVP line aid the same.
Thromboprophylaxis risk assessment is done and appropriate measures taken. Clear documentation is essential .Incident reporting should be done..
Subsequent management is in a High Dependency Unit or in ICU, multidisciplinary team with a lead consultant should continue her care.
Monitoring of clinical, hematological, biochemical parameters and fluid balance is continued. It is very unusual for fits to occur after 72 hrs. of delivery. Anticonvulsants should be stopped 24 hrs after last fit. Anticonvulsants are gradually tapered and switched to oral. Explanation is given to the patient about all the events once she is stable. Breast feeding is permissible. Discharge is delayed till 3 days after the last fit. Follow up visit 2 wks later and clear communication with GP for BP following is essential. Contraception should be advised and risk of recurrence in next pregnancy discussed.
Posted by Kishor S.

Dear Paul,

Sorry to bother you. Need last minute clarification!!. You have suggested to see the good answer above.

Do we have to write exactly what happens in a clinical situation, not according to the sequence as the question dictates? (Because you have appreciated when it is presented as it happens in a clinical situation.)

When the question is PRINCIPLES OF INITIAL ASSESSMENT, the good answer says ?call for help?. Is it a principle or an action to be done or an assessment?

Since the duration of a convulsion is a few minutes only, whenever we called to see a patient who is fitting, almost invariably it is not possible to site an IV line/injection to control the fit. Therefore, we take immediate measures to prevent aspiration, injury and oxygenation and in the meanwhile that particular fit subsides (unless it is status eclampticus). Call for help comes later or maybe simultaneous, if we have to press a button to alert people.

Consequently, stopping a current fit is almost impossible with medication (IV Diazepam) unless the fit were anticipated in an imminent eclampsia. Prevention of further fits and control of sporadic fits during the course of definitive medication are the principles.

You said principles of initial assessment are checking the airway, resuscitation? I am confused whether it is principles.

Next query: Who is supposed to make the initial assessment? Am I qualified enough to assess an eclamptic patient or am I supposed wait for senior staff whom I have called for the assessment. What is my status in this MRCOG Exam? Am I a SHO, registrar or consultant? What level of answer is expected in MRCOG Exam?
THANKS