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MRCOG PART 2 SBAs and EMQs

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Essay 272 - Pre-eclampsia

Posted by g.b. D.
a)
I will maintain the airway by head tilt and chin lift and put a airway. This will prevent tongue biting and maintain airway and prevent the tongue to fall back.
I will ask help from senior obstetrician and anesthetist and senior staff nurses on antenatal ward.
I will ask the nurse to load 8 ml of 50% solution (4gm) of magsulf , dilute it with 12 ml of normal saline and give it iv over 8 to 10 mins.
This is effective in controlling the fit in 95% of cases of eclampsia. if the fit is yet uncontrolled then i will repeat 2 gm bolus of magsulf. once the fit is controlled, i will shift the patient to delivery suite. maintainence infusion of magsulf of 1 gm per hour will be started.this will continue for 24 hrs after last fit or 24 hrs after delivery whichever later.

In cases of recurrent seizures, drugs like phenetoin and diazepam should be used in single dose to control the fit. if the patient is in status then she may need assisted ventilation and transfer to ICU to prevent mortality.

i will moniter her continously for pulse BP, RR, oxygen saturation every 15 mins till she settles and later 1 hrly.a foley\'s catheter is inserted to maintain hourly i/o chart. This is to detect pulmonary odema or magsulf toxicity at earliest.
Decreasing RR,decreasing Urine output and absence of deep tendon reflexes indicate magsulf toxicity. In such situation i will send the serum Mg levels.
if RR becomes less than 8/min,i will give 10 ml 0f 10% calcium gluconate solution.this will reverse magsulf toxicity.


b)
I will send blood investigations like cbc with platelets,peripheral smear for schistocytes, RFT ,uric acid, and LFTs including LDH . this will indicate if HELLP syndrome has set in.if the platelets are below 100,000/ml then I will send a complete coagulation profile
I will continue maternal monitering with pulse, BP, RR , SaO2, i/o chart 1 hrly.
Control of bp can be achieved by iv labetelol (if she is not an asthmatic), or iv hydrallazine in the acute phase and later with oral labetelol or nifedipine. This is to prevent cerebrovascular accidents though it doesnt treat the disease etiology.Fetal heart have to be monitered with continous ctg monitering. Magsulf may cause poor variability.
Steroids should be given im for fetal lung maturation because even a single dose has shown to be of benefit to prevent respiratory distress in neonate.
I will give iv hartman’s solution at fixed rate not exceeding 75 ml per hour .this is to prevent fluid overload.
I will do a p/a examination to check symphsiofundal height, fhs, lie and presentation of fetus.It is quite likely that fetus is growth retarded due to severe placental insufficiency. A portable ultrasound on labour ward will determine the weight of fetus which will be communicated to the neonatal team. I will do a pv examination to asses the bishops score. At 30 wks in a primi is is expected to be very unfavourable and delivery by ceserrean section would be necessary.
When the mother is conscious she has to be informed regarding her and fetal status and the need for delivery.support from staff and family is essential. If she is drowsy or in is on ventillatory support the administrators have to be involved and decision taken by consultant in the patients best interest.
The investigations have to be reviewed and repeated 12 hrly. A decision of time and mode of delivery has to be taken by consultant .it has to be communicated to the consultant anesthetist to decide regarding the type of anesthesia.Induction of GA causes hypertension and is likely to precipitate cerebral bleeds. A controlled induction will have to be done.
If platelet counts are above 80,000/ml then epidural would be a preffered choice. Neonatologist has to be present at the time of delivery. Syntometrin has to be avoided for pph control. Oxytocin can be used in infusion.
Posted by Farina A.

A) Initially I would call for help and meanwhile try to keep the patient in lateral position and put her in a state where she does not hurt herself and does not aspirate. Her tongue should be protected from tongue bite and airway should be maintained. Next step is IV access with the help of a person with known experience and injection diazepam 10mg IV direct or MgSO4 loading dose, according to the unit protocol. Patient should be catheterized to maintain intake and output during MgSO4 maintenance dose. High flow O2 mask should be provided and the pt should be transferred to high dependency ICU for continues close monitoring and IV anti-hypertensive to control BP.

B) Pt should be kept on MgSO4 maintenance dose that is 1gm/hr in order to prevent from further fits. Liver and kidney function tests are checked immediately to decide for the continuation of the drugs and assess the severity of the disease. Meanwhile patient pulse, BP, temperature, SPO2, input, output and patellar tendon reflexes are monitored half hourly. Antihypertensive treatment with IV lebetalol Hydralazine or methyl dopa, according to the unit protocol is continued. Coagulation profile and fetal surveillance by non stress test, biophysical profile and Doppler US should be done .As the definite treatment of eclampsia is termination of pregnancy, corticosteroids should be given for fetal lung maturity. However risks of neonatal morbidity should be balanced against maternal condition. Patient partner and other family members should be involved in the decision making process. Informed consent for induction of labour is of crucial importance. Mode of delivery should be decided according to Bishops scoring however at a preterm gestational age induction of labour is more likely to fail so, CS can be an option. General anesthesia is more favorable for the eclamptic pts .Neonalolgists presence is a must at the time of delivery which should be ensured before delivery. If decided for vaginal delivery continues CTG monitoring along with continued antihypertensive and anti convulsive therapy is given. In order to prevent from MgSO4 toxicity appropriate monitoring with rapid measurement of serum Mgso4 levels and availability of Ca gluconate is ensured. In case pt is developing HELLP syndrome platelet transfusion can be considered at levels below 50,000.Consultant involvement at an earlier stage is required along with an opinion from a physician, nephrologist and hepatologist. An incident form should be filled.
Posted by Shachi M.

(a) Logically outline your interventions culminating in termination of the seizure [6 marks].

This patient is having an eclamptic fit. I will call for help (anaesthetist, obstetrics senior house officer, obstetrics consultant, labour ward co-ordinator midwife, porters) immediately, by putting out a crash call. During the seizure I will make sure that the patient’s airway is patent and that she is in a safe environment. I will secure intravenous access and give magnesium sulphate (effective in eclamptic fits) 4g iv bolus over 15-20 minutes . While securing intravenous access I will take bloods (full blood count, liver function tests, renal function tests, clotting screen, urate and group & save) and send them off urgently. If the patient continues to have fits despite having first bolus of magnesium sulphate, a second bolus of 2g magnesium sulphate iv can be given.

(b) Justify your subsequent ante-partum care [14 marks].

Once the patient stops fitting she should be placed in left lateral position. This helps to take the pressure of aorta and also helps in maintaining patency of airway in case she starts fitting again. Her blood pressure should be stabilised first, and then she should be transferred to high dependency unit on labour ward.
Various antihypertensives can be used, depending on local protocols. Intravenous labetalol is fast acting and can be given as iv bolus followed by infusion. It should not be used in a patient with severe steroid dependant asthma as it can cause severe bronchospasm. Intravenous hydralazine is another effective option. Oral nifedipine is an effective option for control of blood pressure, but its use in a fiiting patient is limited because of its route of administration. Once the patient is stable and transferred to high dependency unit, magnesium sulphate infusion (iv) should be started, patient catheterised and continuous electronic fetal monitoring performed. Her pulse, blood pressure, oxygen saturation and respiratory rate should be checked every 15 minutes and urine output and reflexes should be checked every hour. This is because magnesium is a toxic drug (though not toxic in the dose used for eclampsia) and can cause central nervous system and respiratory depression. Magnesium sulphate is excreted only by kidneys and can reach toxic levels if the patient’s urine output is low. Hence magnesium sulphate infusion should be decreased or stopped if the patient has low respiratory rate, decreased urine output or absent reflexes. Calcium gluconate can be used to reverse the effect of magnesium sulphate.
Intravenous fluids should be restricted to 85 mls per hour as there is risk of pulmonary edema due to fluid overload. (due to leaky capillaries).
The patient should receive steroids (betamethasone intramuscular 12mg) to help prevent respiratory problems in the neonate, as it is expected to be born prematurely.
A plan for delivery should be made once the patient is stable (as delivery is the only cure for pre-eclampsia) and the neonatal unit should be informed.
The mode of delivery in this patient should be by caesarean section. The patient should be warned that she might need to have classical caesarean section if the lower section of uterus is not well formed. The procedure should be explained to the patient , with its risks and complications and informed consent obtained.
After delivery, the patient should stay on high dependency unit and the magnesium sulphate infusion continued for at least 24 hours. The patient and her partner should be debriefed, all the events clearly documented in notes and an incident form filled to facilitate risk review.
Postnatally the patient should continue to have close observation as 44% eclamptic fits occur in postnatal period. One must consider clexane thromboprophylaxis (if clotting screen is normal), early mobilisation and TEDS stockings, as she is at high risk of developing thromboembolism.
Posted by Manoj M.

a) This is acute obstetric emergency requring immediate help from trained multidisciplinary team including midwives and anaesthetist.
Start with basic life support with left lateral tilt to minimise aortocaval compression of gravid uterus. Airway maintainence and high flow oxygen at 10litres per minute to prevent hypoxia, maintain breathing and circulation (if not spontaneous cardiopulmonary resusitation with chest compression and insufflation in the ratio 30:2) with large intravenous acesses for administring medication.
Aim is to abort fit with any agent easily available, ideally magnesium sulphate is the drug of choice to abort fit with a dose of 4grams (8mls) given intravenous/intramuscular over 8-10mins. Other drugs to be considered to abort fits are diazepam/ lorazepam intravenous / per rectal(diazemuls).
If fits is not controlled with initial medication anesthetic input to paralyse and ventilate will be the alternative to abort the fits.

b) Her subsequent care should be transferred to high dependency unit with one to one care and continous monitoring with input from multidisciplinary team involving senior obstetritian, anaesthetist, midwives. She should be maintained on magnesium suplhate to prevent further fits and close monitoring of magnesium toxicity signs (reduced respiratory rate, oliguria, absent reflexes). Magnesium toxicity should be corrected with calcium gluconate (20% 20mg).
Blood pressure should be controlled with anti hypertensive agents like hydralazine /labetolol as increased risk of cerebral events like stroke/bleed with hypertension.
Strict intake output balance maintained with a indwelling foleys catheter and with a central venous line with intake restricted to 1mls/kg/hour as increased risk of pulmonary oedema and heart failure.
Laboratory values of recent bloods immediate after seizure may sugget low platelets and raised transaminase suggesting of HELLP syndrome.
She should also be grouped and saved as she may need blood transfusion.
Senior obstetric review for immediate delivery as soon as she is stabilised as risk of mortality and morbidity with prolongation of pregnancy.
In this situation caesarean section is the best mode of delivery and can consider steroids if time permits but may not be possible to complete the course.
Paediatric team involved with discussion of care with mum of newborn as most likely will need immediate neonatal care/need transfer to higher level neonatal unit after delivery.
Watch for post partum haemorrhage at delivery and avoid ergometrine for uterotonics as it may cause rebound hypertension.
Proper documentation of care with timing to minimse litigation and risk management.

Posted by HSPHM A.
You have been asked to review a 30 year old primigravida who is an in-patient on the antenatal ward because of pre-eclampsia at 30 weeks gestation. Her blood pressure is 180/115 mmHg and she complains of nausea and epigastric pain. During your assessment, she starts fitting.


(a) Logically outline your interventions culminating in termination of the seizure [6 marks].


The CEMACH reports continue to highlight deaths from eclampsia and note substandard care provided to many such women. As she is an inpatient with pre-eclampsia and having a seizure, its likely to be eclampsia which is an Obstetric emergency. Without leaving the patient, I would press the emergency the buzzer and call for help – midwives, SHO, anaesthetist and let someone inform the consultant. The aim would be to control the seizure and minimize maternal trauma secondary to the seizure. Placing the woman in left lateral position, I would assess her airway patency, her breathing and circulation. I would start high flow oxygen and if not already cannulated get two large bore iv cannulae in, sending baseline PET bloods (FBC, U&E, LFT, Coagulation, Urate) at the same time.

Magnesium Sulphate is the drug of choice and usually present on the crash trolley. I would preload the woman with 500 mls of iv fluids (ideally colloids) and give 4 gm of MgSO4 (8ml) over 5 to 10 minutes. If MgSO4 is not present lorazepam or Diazepam iv or PR can be given. I would then commence her on continuous infusion of 1gm/hr of MgSO4 and make arrangements for her to be transferred to the high dependency unit on the labour ward, where her would have half hourly observations of pulse, blood pressure, urine output (after catheterizing), respiratory rate and deep tendon reflexes and would be put on continuous fetal monitoring. With recurrent fits a further 2g bolus of MgSO4 can be given and if still persisting, the anaesthetist might need to intubate the patient and transfer to intensive care unit. With a blood pressure of 180/115, I would go through her history and check on her anti-hypertensives; giving her a 10mg dose of oral Nifedipine or starting her on Hydralazine iv with an aim to keep the BP below 160/100. I would also fluid restrict her to about 85 ml/hr.
(b) Justify your subsequent ante-partum care [14 marks].

Subsequent antenatal care would be a balance between the maternal condition and fetal well being. If there is not acute fetal indication like bradycardia, delivery can be delayed till the mother is stable.

MgSO4 infusion should continue for atleast 24 hours after the last fit; titrating the rate of infusion with her observations. Compliance with her existing antihypertensive therpary(if any) should be addressed, and doses might need increasing. Additional antihypertensive to Methyldopa (usually first line) like Labetolol or Nifedipine might be needed. She and her family should be debriefed about the events and warned about a prolong stay in hospital and possible early delivery. Any associated comorbidities, like diabetes, pre-exisiting hypertension should be assessed.

At 30 weeks, if she has already not had steroids, I would administer them. A careful assessment and notes review would ascertain presence of any growth restriction of the baby. If not I would arrange an urgent growth scan with dopplers assessment. Delivery should be aimed ideally after 34 weeks. Early delivery might be contemplated if maternal blood pressure is difficult to control, or her biochemistry is worsening (AST > 70, Platelets <100), or the mother is symptomatic of pre-eclampsia – headache, visual disturbances, epigastric discomfort, or there are signs of fetal compromise – abnormal biophysical profile (usually twice daily CTG) / abnormal ultrasound findings.

Vaginal delivery would be preferred but at 30 weeks, a vaginal examination to assess favorability of cervix for induction and fetal lie/presentation would guide a choice between induction of labour or caeserian section. This should be discussed with the couple and clearly documented in the notes. A visit to neonatal unit should be arranged as the baby would be likely to need special care.

After delivery, she should be counseled about continuing medication for atleast 6 weeks (maybe more) and a visit to the GP around then to recheck blood pressure and proteinurai, to rule out essential hypertensiuon or renal disease. She should be made aware that her medications would be changed (to atenolol or enalapril or nifedipine)after delivery which are safe with breast feeding.

However, if her blood pressure is well maintained, and she is asymptomatic with normal biochemistry, she can be managed as an outpatient with twice weekly day assessment unit visit to check blood pressure and protein (repeat 24 hour urine if any increased proteinuria). She should be seen by a consultant in the antenatal clinic and timing and mode of delivery should then be discussed with her.

Posted by J P.
a.This is a case of Ante partum Eclampsia which causes high maternal and fetal mortality.Initial priority will be to maintain airway by shifting patient to left lateral positon and head tilt..Tngue bite will be prevented by moth gag..Nasal oxygen will be administered and maintenance of circulation and iv access will be the next priority.Two 14 gauge needles will be used for this and blood will be sent for full blood count to look for thrombocytopenia in case of HELLP syndrome.The other investigations that will be done are group and save serum,liver and renal function tests and clotting profile.I will call for help from senior obstetrician,anaesthetist and midwife.I will assess the cardiovascular status by looking for pulse and blood pressure.Magnesium sulphate is the drug of choice for eclampsia.Initial intravenous loading dose of 4 gm of 50 %solution is given over a period of 10 minutes.If the fit reccurs within 10 minutes additional dose of 2 gm iv given.If the fit is uncontrolled intravenous diazepam will be considered. If patient remains unconscious and fit recur assisted ventilation may have to be considered with the help of anaesthetist.

b.Patient [if conscious] and her attenders will be briefed of the events.Patient will be shifted to ITU.Blood pressure,pulse will be monitored hourly,blood investigations repeated 4-6 hourly.Catheterisation of bldder will be done to montor urine output to watch for magnesium toxicity.Urine out put, respiratory rate ,spo2 ,tendon reflexes will be monitored to look for magnesium toxicity. Magnesium sulphate regimen continued as per hospital protocol.Urine output monitored hourly or 4th hourly according to hospital protocol.Per abdominal examination will be done to assess the uterine size fetal presentation and the heart. Per vaginal examination will also be performed to assess the nature of the cervix and the pelvis. Antihypertensive management will depend on the blood pressure. I n case blood pressure is persistent as 180/115 mm/Hg IV Hydralizine or Labetlol will be administered as MAP > 125 MM/hg is associated with increased risk of CVA.Maintenance therapy will be by methyl dopa depending on blood pressure but no drug is considered to the other.Careful fluid administration is is important because of the risk of pulmonary edema.Initial fluid will be hartmanns solution and the amount will be calculated as intake be equl to previous hour urine output plus 30 ml.No routine role of frusemide in eclampsia.Definitive treatment is delivery which should be explained and documented and balanced against risk of prematurity and maternal risk in continuing pregnancy.Corticosteroids will be administered because of risk if prematurity.I will also explain them that there is no advantage in prolonging pregnancy compared to immediate stabilsation and delivery.If delivery is planned mostly will be be by caesarean section because of unripe cevix at 30 weeks.If cevix is favourable induction of labour by prostaglandins can be done.
Accurate documentation of events and filling of incident form is important.
Posted by Sam M.
She has a obstsric emergency ,I will call for help for SHO and midwife ,oncall obstericain and anaesthetist .I will check her air way breathing and circularion .if breathing is absent ,I will secure airway and start ventilation . I check her circulation ,if no circulation then I will start CPR mean while I will ask sho to call arrest team, inform anaesthetist on call and on call obstetrician .I will ask midwife to put patient in left lateral position and start oxygen .When circulation is established ,I will pass 2 i/v lines .Take blood to send for blood group rh factor and cross match ,blood complete examination ,platelet count ,LFTs ,urea and electrolyte ,creatinine clearance and coagulation profile,.After catheterization ,urine sample will be sent for proteins and microscopy. I will attach ,pulse oxymeter ,bp apparatus and ecg to patient for monitoring.To control fits ,I will give her loading dose of magnesium sulphate 4 gm over10 to 15 minutes minutes followed by infusion at a rate of 1g/hr.I will maintain an input and out put record.Checking of breathing rate ,deep tendon reflexes and pulse oximetry regularly every 10 minutes for 2 hours and then evry 30 minutes.urine out put hourly is necessary to early suspect magnesium toxicity and do intervention .Breathing rate less than 16 /minute , output lessthan 100ml / 4hr ,pulse oxymetry lessthan 95%,lost deep tendon reflexes ,either individually or in combinations suggest magnesium toxicity .Treat with 10 ml of 10% calcium gluconate given over 10 minutes.continue infusion for until 24 hrs after the last fit. IF another episode of fit occurs ,give another dose of 2 gm magnesium sulphate. SERUM magnesium level are done if magnesium infusion would last for more than 24 hrs.If recurrent fits does not stop then consider single dose of either diazepam or thiopentone .intubation and ventilation to maintain breathing is necessary with uncontrolled fits.Monitor patient in high dependency unit

Part b. It is important to stabilize patient first .Furthur management depends on patients condition and diagnosis after avialibilty of investigations. To control blood pressure give her lobetalol/hydrallazine and monitor that ½ hourly. Continuous fetal monitoring started.
Eclampsia in presence of protein uric hypertension necessitate an urgent delivery. After examination assessing fundal height ,lie .presentaion ,estimated size ,liquor volume,FHR by continuous monitoring. I will Do a vaginal examination to asses bishop score .Arrange for ultra sound scane for estimated fetal weight ,liqour volume, placental localization . After discussion with oncall consultant obstetricians mod of delivery and steroid for fetal lung maturation will be decided .At this early gestation ,bishop score most likely will not be favourable .A caesarean section will be justified. Type of anaesthesia will be discussed with anaesthetist,regional anaesthesia in absence of coaggulapathy is not a contraindication in eclampsia .paediatricain will be informed to attend the baby for prematurity. Most senior obstetrian and anaesthetist do this caesarean section.at section .Lower uterine segment will not be formed and a classical may be required to deliver a premature especially if malpresented baby.All the incident clearly be documented and informed consent from mother taken..Monitoring for blood pressure and fits continued post natally as well.
Posted by Priti T.
A} I would like to call for the immediate help for the senior Obstetrician,Anasthetist,midwives,porters and SHO to manage this obstetric emergency of antepartum eclampsia.Each unit has a local protochol for the management of airway,breathing and circulation for the emergency resuscitation of the patient with seizure;which is to be followed in this case.The women should be positioned in the left lateral position to prevent aspiration.Further oropharyngeal airway should be inserted for the suction of the secretion/vomitus and to prevent the tongue bite in the seizure patient.Oxygen 5-10L/min is given via face mask and if she is not breathing spontaneously then the endotracheal intubation and the ventilation may be required with the help of the anasthetist.
Intravenous line is to be maintained by putting two large bore cannula.I/V Diazepam is given to terminate the seizure if not spontaneously terminated already.Loading dose of MgSO4[magnesium sulphate] I/V or even I/M is given to prevent further seizures.Maintainence dose of 1-2gm/hour is given for 24 hours after the seizure.At the same time other recurrent causes of fits like electrolyte imbalance should be ruled out.
Her high B.P. of 180/115 is to be controlled with intravenous labetalol infusion or I/V Hydrallazine bolus to maintain the[MAP] mean arterial pressure below 125;this is important so as to prevent CVA[cerebrovascular accidents] associated with high MAP.
She should be monitored for the magsulf toxicity.Close monitoring of patient\'s B.P,Pulse,Respiratory rate,patellar reflax,urine output [Foley\'s cathetar] is done to detect any deterioation in the condition.

B] Patient has severe pre eclampsia with a superimposed seizure.She should be shifted to HDU[High Dependency Unit] with 1:1 midwife care.Multidisciplinary care is to be sought and the neonatalogist and SCBU are to be informed.The decision for the termination of the pregnancy is to be taken by the consultant Obstetrician in view of the prematurity of 30weeks.
Various investigations of the patient should be sent.FBC with clotting screen,U&E LFT,RFT ,Serum Magnesium,Serum Calcium are done.Blood should be grouped and saved.24 hours urine is collected and sent for proteins.Strict intake and output chart should be maintained.Her intravenous fluids should be less than 80ml/hour and foley\'s cathetarisation is done.Further intake should be guided by the urinary output plus the insensible losses.Fluid overload should be avoided to prevent pulmonary oedema.
After the stabilisation of her condition the decision of delivery is taken verses the prematurity of the foetus;The maternal health takes precedence over the foetus in view of the serious condition of the mother.Foetus is assessed by the CTG,Scan to monitor Biophysical Profile and the various complications like IUGR and placental abruption are ruled out.Antenatal Betamethasone may be given but it may not have the time to show the effect.For the nulliparous patient ,with 30 weeks pregnancy Caesarian section is the preferred mode of delivery as the bisop\'s score may not be favourable at the preterm gestation.Regional anasthesia like epidural is preferable to the general anasthesia if the platelet count is over 80,000/ml.General anasthesia can aggravate the hypertension.Ergometrine is to be avoided for the prevention of the PPH and oxytocin infusion is given.Neonate is to be monitored in the neonatal ICU in view of the prematurity.
Thromboprophylaxis and TED stockings are given if required.
Proper documentation and the incident report form should be filled for the eclamptic seizure.

Posted by N K.
(a) Logically outline your interventions culminating in termination of the seizure [6 marks].
It is a life threatening condition. The immediate action would be to secure air way and breathing. Will position the patient in left lateral position, remove excessive secretions and give oxygen via mask. I will also ensure her safety (trauma).
I will summon immediate help from senior obstetrician, anaesthetist and other staff. My next step in management would be to control her seizures. For this local protocol would be initiated where magnesium sulphate 4mg would be given over 5-10 mins followed by infusion- 1mg/hour. If further fits, a repeat dose of MgSO4 2mg will be given or increase the MgSO4 infusion to 2mg/hour. Other drugs which may be considered are diazepam, Phnetonin or thiapentone. These are 2nd 3rd line drugs given in single doses.
If still not controlled, she needs to be intubated by anaesthetist for positive pressure ventilation at ITU for monitoring.

(b) Justify your subsequent ante-partum care [14 marks].
Her subsequent ante partum care would be aimed at controlling the blood pressure and stabilising her. With the blood pressure of 180/115 she it at high risk for CVA or hypertensive heart failure. She will be managed as per local protocol, where usually IV labetalol followed by infusion and where it is contra indicated or failing to control BP or as dictated by the protocol hydralazine will be given bolus first followed by infusion. Oral labetalol or oral nifedipin could also be used for maintenance. ACE inhibitors, angitensin receptor bloking drugs and diuretics should be avoided.
All her vital parameters should be continuously monitored – BP, PR, and oxygen saturation. Fluid balance is essential as hypovolaemia can precipitate renal failure and hypervolaemia may cause pulmonary oedema. Fluid restriction to 80ml/hr and hourly urine output (minimum 20ml/hr) should be maintained. If it is less than the desired, colloid infusion and anaesthetic input should be considered as she may require invasive monitoring. It is important to check for signs of Magnesium toxicity. Regular monitoring of Respiratory rate, tendon reflexes, Input/out put and level of conciousness is essential. If toxicity is suspected, will do magnesium levels and consider calcium gluconate 1g (10ml) in 10 mins.
Blood would be sent for FBC (Hb, platelets), LFT, U+E, urates and clotting profile to look for complications. Group and save is also essential.
State of the fetus needs to be monitored by continuous CTG. If conservative management is considered and when the patient is stabilised an ultrasound assessment for fetal growth, liquor and Doppler is necessary to decide on optimum time of delivery. Corticosteroids can be given for fetal lung maturity. However, maternal condition takes priority over the fetus when the patient is unstable.
Decision to deliver should not be made until the patient is stabilised and when a senior obstetrician is present. As she is only 30 weeks gestation, decision to deliver could be differed and a conservative approached followed as this may improve fetal outcome however, it should be balanced against maternal condition. Mode of delivery will depend again on maternal and fetal condition, fetal presentation and cervical assessment.
Patient and partner will be debriefed throughout and after the management. Appropriate documentation and an incident report will be filled in.
Posted by Drxyz A.
DRXYZ


a) As this is an obstetrics emergency, I will call for help. I will make the position of the patient as left lateral, maintain airway for breathing and IV line. I will request MgSO4 bolus dose 4 gram IV over 5 to 10 minutes to abort the fits. Meanwhile I will ask to check the blood pressure, pulse, oxygen saturation. I will ask for antihypertensive such as IV labetalol / Hydralazine according the the availability in the setup. I will ask to pass folley\'s catheter to check the urine output. I will request blood group and cross match, renal function test, liver function test, coagulation profile and urea electrolytes. I will ask senior obstetrician, anaesthetist, haematologist and senior midwife to intervene. After bolus dose of MgSO4 I will start maintenance dose of 1 gram / Hr which will continued for 24 hours after the last fit. Monitoring of the MgSO4 will by respiratory rate, oxygen saturation, urine output and by deep tendon reflexes. If patient gets another fit the loading dose 2 gram of the MgSO4 can be repeated. Fluid restriction will be done to avoid pulmonary oedema. If there is oligurea, the maintenance dose of MgSO4 will be decreased to .5 gram / Hr. Serum Mg level need to be checked intermittently.

b) I will the explain to the patient and her partner about her and her baby\'s condition. The risk of prematurity of the baby will be explained. Patient will be told about mode of delivery.

As patient is 30 weeks pregnant with eclampsia, I will the assess the maternal condition clinically as well as by lab investigations. Dexamethasone will be given. I will do abdominal examination, fundal height, lie and fetal heart rate. I will do the CTG and ask for USG for fetal weight, biometery, Doppler USG and biophysical profile. I have to weigh between the maternal condition and delivery of the premature baby. In this condition role of conservative management is there. If maternal condition is stable and no fetal distress we can prolong the pregnancy for 7 to 14 days. Patient will multidisciplinary care. Paediatrician will be informed about the condition of the baby. I will ask for strict maternal monitoring for blood pressure, urine output, continuation of the anti-hypertensives, lab investigations sould be done daily or twice weekly according the condition of the patient. For the fetus I will do the daily CTG, doppler USG and USG for liqour weekly. Management will be changed from conservative to active management whenever there is uncontrolled hypertension, HELP syndrome or fetal distress.

At this gestation poor Bishop scoring leads to failed induction so I will opt for caesarean section. Senior obstetrician, Senior anaesthetist and paediatrician should attend the delivery.
Posted by San S.
(a) Logically outline your interventions culminating in termination of the seizure [6 marks]
I would call for help of senior midwives, senior obstetrician and senior anaesthetist. It is important to protect her airways with chin lift or jaw thrust and Oxygen administered. Any secretions or aspiration that may cause airway obstruction should be removed with suction. She should be positioned on her left lateral through out the resuscitation. IV access should be gained to administered magnesium sulphate 4g(loading dose) over 10 to 15 minutes followed by infusion rate of 1g/hour.
If seizures persist, a further dose of magnesium sulphate of 2g or increased rate of infusion of 1.5g to 2g/hour can be given. Intubation should be considered with help of anaesthetist in persistent seizures despite initial treatment and iv diazepam can be administered to stop seizures. Once stabilise, patient should be transferred to high depency unit on delivery suite.

(b) Justify your subsequent ante-partum care [14 marks].
Maternal BP should be monitored 5-10 minutely and administration of parenteral antihypertensive with labetalol or hydralazine to stabilise her BP to decrease morbidity and mortality. Administration of antihypertensive ahould adhere with agreed local policies. BP control should be aim for a MAP<125mmHg.
Bloods should be send for FBC, U&Es, LFTs, uric acid and clottings to assess biochemistry deterioration and to assess safety of regional anaesthetic use.
Neurological examination is important to assess any neurological deficits especially after eclamptic seizures. She should be fluids restricted on 80ml/hour and fluids input and output measured. She should be catheterised and hourly urinary output measured. Her chest should be examined for signs of pulmonary oedema especially if she has coexisting renal failure secondary to the disease.
Magnesium sulphate infusion should be continued for 24 to 48 hours and oxygen saturation and reflexes monitored to signs of magnesium toxicity especially if there is coexisting renal failure (magnesium sulphate excreted by kidneys). Toxicity should be reversed with calcium gluconate. Thromboprophylaxis and TED stocking should be use to prevent thromboembolism.
As she is at increased risk of fetal hypoxia from seizures and placental abruption fetal wellbeing should be monitored with CTG.
If maternal and fetal condition is satisfactory, steroids can be considered prior to delivery in view of prematurity. However, administration of steroids should not delay delivery if there is maternal or fetal deteioration of condition. Delivery likely caesarean section in view of gestation (unless in labour)should be carried out only when maternal condition is stabilised.
Her family members shouldbe kept informed of incident and management plan and this clinical incident should be reported.
Posted by Asma kamal K.
Eclampsia is an obstetric emergency and leading cause of maternal morbidity and mortality and perinatal mortality. The patient will be managed according to the unit protocol for the management of eclampsia. I will call for help (SHO, nurses,midwife, senior obstetrician,anesthetist,porter) and inform hematologist, laboratory, ITU/HDU, operation theater staff and NICU about the emergency. I will nurse the woman in lateral position to prevent aspiration and maintain airway and give her high flow oxygen with face mask. If I am unable to maintain airway then with help of anesthetist I will maintain airway with tracheal entubation . I will ask the nurse to maintain intravenous line with two large gauge cannula (14-16G) and send blood for FBC,LFTs,U & E, clotting profile, grouping and save. Most of the fits are self limiting . To terminate and to prevent further episode I will give her magnesium sulphate (MgSo4) i.v bolus 4 grams over 5-10 min and two doses of 5gram i.m in each bouttock. If fit reoccur I will give her MgSo4 2gram(4 G if weight > 70Kg).If she does not stop fitting then I will ask the anesthetist to give diazepam or thiopentone , intubate and ventilate with positive pressure ventilation. The patient will not be left alone and will be transferred to ITU or HDU for further management.

(b)The patient will be managed in HDU with single lead clinician and 1:1 nursing care. Multidisciplinary(ITU physician, senior obstetrician, anesthetist, renal physician, hematologist and neonatologist) input is paramount in this case. To prevent cerebral vascular damage blood pressure will be brought slowly down with i.v bolus of hydralazine or labetelol and then maintenance infusion continued. Intravenous antihypertensive agents usually causes sudden profound hypotension and fetal distress so they should be given with i.v fluid bolus preferably with central venous monitoring(If no coagulopathy). Monitoring with B.P,pulse,respiratory rate, oxygen staturation,ECG every 15 min and FBC,LFTs,Clotting profile 6-12 hourly will be done. Strict input output record will be maintained to prevent pulmonary edema and renal damage. Fetal condition will be assessed with CTG. After stabilization the patient will need delivery (with or without fetal distress) and at this early gestational age the safest option for her is caesarean section. An informed consent will be obtained from the patient (if conscious and well oriented) or the Family(partner or next of kin) with special emphasis on the uterine incision and prematurity. As at 30weeks of gestation lower segment is not formed properly a classical upper uterine incision will be given. Upper uterine incision is associated with morbidity and mortality (hemorrhage, scar rupture in labour). The patient risk for thrombo-embolism will be assessed and if required thrombo-prophylaxis started. Caesarean section will be done by the senior obstetrician and under general anesthesia.MgSO4 will be continued for 24 hours after the last fit or delivery whichever first.Other complications of eclampsi like coagulopathy, renal failure pulmonary edema will be looked for and managed. Patient will remain in ITU/HDU for 24-48 hours post delivery. Good communication between NICU and patient family will be maintained all the time . Proper documentation, incident reporting and risk management will be done.
Posted by S W.
a. Seizure is terminated by giving loading dose of Magnesium sulfate 4 mg by intravenous infusion over 5-10 minutes, meanwhile checking airway and breathing and keep the patient on left lateral position to prevent maternal injury, oxygen is given also. We should call for help of senior obstetrician, senior anesthetist and experienced midwife without leaving the patient alone. We check pulse rate and blood pressure. Pulse oxymetry is helpful in measuring oxygen saturation. Antihypertensive is prescribed like labetalol, nifedipine or hydralazine. If the fit is terminated we keep her on maintenance dose of MgSo4, but if seizure reoccur, we give another bolus dose, 2g by slow IV infusion. Alternatively thiopentone and diazepam can be used, but in only single dose as Diazepam is associated with increase maternal death. If fit is persistent, intubation may be needed with the use of positive pressure ventilation in intensive care unit.

b. Subsequent antenatal care includes careful assessment, stabilization of blood pressure, prevention of further convulsion and continuous monitoring with making a delivery plan in an optimal time for both the mother and her fetus.
Antihypertensive drugs used in the acute stage include labetalol, oral or IV, nifedipine, orally or Hydralazine intravenous infusion. Blood pressure is measured every 15 minutes, then every 30 minutes and if the patient is stable, measuring is done 4- hourly. Prevention of recurrence of convulsion is done by keeping the patient on MgSO4 maintenance dose 1g/hr for about24 hour after the last fit and if the fit is reoccur, further 2 g bolus dose is given and the maintenance dose can be increased to 1.5-2g/l with monitoring of patient respiratory rate and deep tendon reflex for early diagnosis of MgSO4 toxicity particularly in oligouric patient, if urine output is less than 20 ml/hr, the MgSO4 infusion should be halted.
The patient is sent for FBC including platelet count, liver function test and renal function test at least daily to assess severity and progress of the condition. Elevated liver enzyme more than 75 iu/l is significant. Serum uric acid is also of prognostic value. If platelet count is less than 100 X 10 6/l, a clotting profile will be needed. If HELLP syndrome is suspected, a blood film is done to diagnose haemolysis by finding fragmented red cells. Protein in urine is measured by visual dipsticks, 1 g /l is significant, also we can use spot protein creatinine ratio but more ideally is 24 hours urine collection proteins.
Strict fluid balance should be maintained to avoid fluid overload. Diuretics is given if complications occur like heart failure or pulmonary edema.ٍ
Fetal cardiotocography is the mainstay of fetal monitoring, it can reflect fetal condition at that time and it is easy and can be repeat and it does need expensive instruments or highly skilled personnel but it is of low predictive value. If conservative management is selected to prolong pregnancy as far as the patient is stable and asymptomatic, ultrasonography is done to measure fetal size and amount of liquor, also Doppler study of umbilical blood vessels.
Delivery is the definitive treatment. Corticosteroids is prescribed to enhance fetal lung maturity and if the patient remain stable and asymptomatic we try to defer delivery to enhance perinatal outcome, we should balance maternal well being against fetal prematurity or fetal demise due to placental insufficiency. Mode of delivery will depend on fetal position, fetal condition and likelihood of success of induction of labour. Written and verbal information is given to the patient and her family.
Posted by Vaishali Sriniv J.
a) I will call for help and inform consultant obstetrician, consultant anaesthetist and senior midwife. Airway should be assessed and protected. Nasal oxygen should be given and breathing is to be maintained. Circulation should be assessed and maintained by putting I/V cannula. Blood should be sent for CBC, liver function tests, renal function tests. If platelet count is less than 100 x 10( then coagulation profile is to be assessed. Bladder should be catheterized and input output chart is to be maintained. I will do urine dipstix test for proteiion of corticosteroidsns Intravenous magnesium sulphate 4 g should be given slowly over 5 – 10 minutes to control convulsions. It is to be followed by I/V magnesium sulphate maintainence drip. Labetolol or hydralazine can be given for the control of BP. Patient should be given one to one midwife care. Vital parameters and BP should be monitored every 15 minutes. Respiratory rate, reflexes, urine output is to be monitored to look for toxicity of magnesium.
b) Patient should be managed in HDU by multidisciplinary team of consultant obstetrician , consultant anaesthetist, neonatologist and experienced midwife. CBC, liver function tests, 24 hour urinary proteins need to be repeated every dayBlood should be sent for grouping and crosmatching . Antihypertensive treatment should be continued to control BP. Pelvic ultrasound is to be arranged to assess wellbeing of the foetus. Once patient is settled decision to deliver or to continue pregnancy should be taken by the consultant. If baby is alive then role of corticosteroids for lung maturity should be considered. The role of conservative management for the action of corticosteroids should be weighed against the decision of immediate delivery. The risk to mother should be given priority. Vaginal delivery should be aimed but the Patient may need to be delivered by caesarean.section due to early gestation.. Neonatologist and SCBU need to be informed. Role of thromboprophylaxis to prevent VTE need to be considered. Magnesium sulphate should be continued 24 hours postpartum to prevent seizure.
Posted by H P.
I will maintain airway by lateral head tilt and chin life to prevent aspiration and tongue fall. I will insert an oropharyngeal airway to prevent tongue bite and administer oxygen via face mask. I will try to prevent her from fall or injuring herself. I will call for help and inform senior obstetrician, anaesthetist, midwife, obstetric SHO and porters. Two wide-bore canula inserted and blood collected. I will send blood for complete blood count, liver and renal function test, coagulation profile, and group and save. Local unit protocol for eclampsia will be followed. I will give her intravenous loading dose of 4gm (50% w/v) magnesium sulfate infusion diluted in normal saline over 10 minutes. If the seizures are not spontaneously controlled, a further 2 gm magnesium sulfate or intravenous diazepam may be given. Her pulse, blood pressure, respiratory rate and oxygen saturation are monitored continuously. In case of refractory seizures or unconsciousness she will have to be intubated and assisted ventilation started. If the blood pressure is above 160-110mmhg of mean arterial blood pressure above 125mmhg, intravenous labetolol or hydrallazine is given according to unit protocol. Foley’s catheter is inserted and spot test for proteinuria is done. Continuous CTG monitoring is started for fetal surveillance. The relatives are informed about her condition and she should be shifted to high dependency unit for further management. Proper documentation of events is done. Incident form is filled.

(b) Definitive management involves termination of pregnancy under optimum conditions to ensure favorable outcome for both mother and fetus. Patient is managed in HDU under 1:1 care with a single lead consultant. Maternal pulse, blood pressure, respiration and oxygen saturation are monitored every 15 min till condition stabilizes. Urine output is monitored hourly. Baby is monitored by continuous CTG.
Results of blood investigation checked and repeated on daily basis or more frequently if abnormal. In case of low platelets or raised liver enzymes, possibility of HELLP syndrome is ruled out. There may be altered coagulation profile, and raised serum LDH and peripheral blood smear may show schistoctyes.
In case of platelet count <40,000/cumm, she will need platelet transfusion and/or fresh frozen plasma in case of bleeding diathesis.
Magnesium sulfate infusion is continued at the rate of 1gm/ hour for 24 hours after last seizure or delivery whichever is later. Signs of magnesium toxicity like decreased respiratory rate, absent deep tendon reflexes, altered sensorium, and oliguria are monitored and if present, urgent serum magnesium levels checked. Toxicity is reversed by 10 ml of intravenous 10% calcium gluconate.
Antihypertensive treatment should be continued to prevent cerebrovascular accidents. Oral labetolol or nifedepine is given to maintain mean arterial BP below 125 mmHg.
Strict fluid balance is maintained to prevent pulmonary edema. Input should be equal to output + insensible losses not exceeding 80ml/ hour.
Her risk for VTE is assessed and thromboprophylaxis started.
Antenatal corticosteroids for fetal lung maturity are administered if not already given. Portable ultrasound arranged for fetal lie, growth, weight, liquor volume and Doppler studies. Senior neonatologist and NICU should be informed. In the absence of facilities for preterm baby, the mother should be transferred to tertiary care unit if she is haemodynamically stable.
Complications of delivering a preterm baby should be balanced against the risk of continuing pregnancy with eclampsia. The patient if stable, her relatives, consultant obstetrician and senior neonatologist should be involved in decision making and prognosis explained. Details of all events, decisions and all communication to the patient and the relatives should be documented.
Cervical assessment for Bishop’s score is done. At 30 weeks in a primigravida the cervix is unlikely to be favorable and caesarean section may have to be planned. It should be done in the best possible time with senior obstetrician, anaesthetist, OT staff and neonatologist present. General anaesthesia is avoided but in case of low platelets (<40,000/cumm), regional anaesthesia may have a higher risk of haemorrhage. Platelet transfusion may be given before surgery.
If the maternal condition permits, pregnancy may be continued till 32 weeks gestation. Maternal monitoring of blood pressure, respiration, urine output, reflexes and blood test is continued throughout. Antihypertensives are also continued. Increased fetal surveillance with daily CTG and biweekly Doppler studies is done.
Rarely, vaginal delivery may be contemplated in case of a favorable cervix and if the maternal condition is stable. Ergometrine is avoided after delivery
Posted by Iffat ara M.
A):As this a life threatening condition. I will call for help especially consultant, senior midwife and anaesthetist.I would like to assess and maintain airway, place her left lateral position & will give her oxygen. Avoid the maternal trauma. Keep I/V line patent to give emergency drugs. Magnesium sulphate is the therapy of choice to control seizures. A loading dose of 4 gm should be given by infusion pump over 5-10 minutes followed by further infusion of 1 gm maintained for 24 hour after last seizure. Recurrent seizures should be treated with either a further bolus of 2 gm magnesium sulphate or increased in infusion rate to 1.5gm or 2.0gm/hour. I would like to check her blood pressure, pulse every 15 mistunes. Pulse oximetry is helpful. As MgSo4 is..mostly excreted mostly in urine so urine output should be closely observed. If it become reduced below 20ml/hour the MgSo4 infusion should be halted. MgSo4 toxicity can be assessed by clinical assessment as it causes a loss of deep tendon reflexes and respiratory depression. If there are sign/symptoms of toxicity of magnesium I will stop the infusion. Calcium gluconate(10ml) over 10 minutes can be given. If there are repeated seizures then alternative agents such as diazepam or thiopentone may be used but only as single doses, since prolonged use of diazepam is associated with increase in maternal death. If convulsion persist intubations is likely to be necessary to protect airway and maintain oxygenation. Transfer to intensive care fascilities with inter mittent positive pressure ventilation is appropriate in these circumstance. Nursing care one to one should be provided.
Antihypertensive treatment should be started. Labetalol IV/Nifcdi pine/hydrallazine can be given(according to unit protocol).monitoring of maternal condition include blood pressure & pulse (checking every 15 min), oxygen saturation monitoring ,strike fluid balance to (prevent the pulmonary adima) maintain input & output chart. I will send blood for FBC, LFTs, RFTs, urea & electrolytes & coagulation profile. Urine analysis especially for proteinuria. Foetal monitoring will be done by CTG. The decision to deliver should be made once women is stable & with appropriate senior personnel present. Keeping in view that she is a primi gravida & 30 weeks pregnant so caesarean section would be mode of delivery. So corticosteroides would be given. I will communicate senior neonatoloist for SCBU and also communicate anaesthetist for type of anesthesia. I will keep on informing the family about all the events. And I will document each & every event on the file & also fill the incident report.
Posted by Farkhanda A.
Eclemtic fits in ante natal periods Occur in 38% of pregnancies which are complicated by pre eclamaptic toxaemia. In this scenario first of all , I will stop fit episode by giving intra-venous (IV) diazepam which is effective immediately. I will put the patient in recovery position that is left lateral to prevent her risk of inhalation of secretions and falling back of her tongue to obstruct her breathing passage.
We can also give Magnesium Sulphate (Mg So4) 4 mg slow IV injection to stop her seizure, but in a fitting patient it will be difficult. Once her fit subsided even then there is a risk of recurrence of further fits. To prevent that, I will start Mg So4 infusion according to unit protocol. I will check her air ways for any secretions collection and give her oxygen- O2- by mask. I will ask midwife to pass folly’s’ catheter . I will make sure that patient should be in quite comfortable atmosphere; otherwise any noisy situation can act as aggravating factors. I transfer the patient in high dependent unit – HDU- in delivery suite once her condition will be stable.
B
I will inform consultant obstetrician and ask anaesthetist on call for labour ward to maintain IV access in both arms with wide bore cannula. I will ask midwife to check blood pressure, if it is higher than 160 (systolic) and diastolic 110, I will start antihypertensive regime IV in order to keep her mean arterial pressure (MAP) below 125 as if it is higher than this , then cerebral auto regulation will be lost and there is a risk of further fits.
Her further ante natal care will be multidisciplinary team including obstetrics consultant, Paediatrician, anaesthetist and probably haematologist. Her HDU monitoring chart will be used in order to monitor her . BP, pulse, Respiratory rate, O2 saturation, input output chart and her reflexes. She should be on restricted fluid that is 85 ml of IV fluid per hour, otherwise, there is a risk of pulmonary oedema.
Ultimate treatment is termination of pregnancy by delivering her. She should be given steroids either betamethasone 12 mg intramuscular, 2 doses 24 hours apart or 12 hours apart if situation is not under control or dexamethasone 6 mg 6 hourly in 4 doses.
Send her blood for full blood count to check her platelets and haemoglobin to see the development of HELLP syndrome ( haemolysis, elevated liver enzymes and low platelets) which can occur in 10 to 15 % of pregnancies which are already complicated.
There is high risk of venous thrombo embolism, so give her deterrent stockings and prophylactic dose of low molecular weight Heparin-LMWH-
Her condition can be improved, but full recovery will be only after delivery. The Senior obstetrician and neonatal doctor should discuss with her about her condition, mode of delivery and prognosis of preterm neonate.
Posted by A P.
The history is consistent with eclampsia accounting for 5/10000 maternities and a mortality of 1.8% , a further 35 % suffering a major complication. Hence swift action is required. Initial intervention would be to call for senior help: consultant obstetrician, anaesthetist and midwife. One should be aware of and follow the unit’s protocol. Once it is safe to approach the patient, ensure any potentially harmful objects are away from her. Main aim of intervention is to stabilise her, treat and prevent further seizures. Assessment and maintenance of the airway is paramount. The patient is positioned to prevent aspiration (left lateral); the airway is protected and oxygen administered by a facial oxygen mask. Oxygen saturation is monitored. Intravenous access is secured and bloods to assess platelets, renal and liver function are obtained as a full blood count, urea and electrolytes and liver function tests. The patient is catheterised to look for signs of oliguria using an hourly urometer. The most effective way to control the fit is by magnesium sulphate given as a 4 gram bolus intravenously over 5-10 minutes. Prevention of further seizures is by a maintenance infusion at 1g/ml/hour for 24 hrs after the last seizure. Respiratory depression and depressed reflexes are signs of magnesium toxicity and 10ml of 10% calcium gluconate given to treat it..Intravenous diazepam or thiopentone may be used only once as second line treatment as there has been an increase in maternal mortality. Failure to control fits will require intubation and admission to intensive care. Ensure good communication between obstetric/anaesthetic team and patient’s partner.
b. Once the patient is stabilised, blood pressure is monitored every 15 minutes using an appropriate sized cuff, the patient at 45 degrees, using korotkoff phase 5 with repeat measurements to ensure accuracy. Automated measurements tend to underestimate values. Mean atrial pressure is key indicator for acute antihypertensive treatment as >125mmHg results in loss of cerebral autoregulation and increased risk of cerebral vascular accidents.Oral/intravenous(IV) labetolol, oral nifedpine or IV hydralazine is recommended. Drugs to avoid include sublingual nifedipine (profound hypotension); ace inhibitors, angiotensin-receptor blockers and atenolol due to adverse fetal effects. Bloods are taken daily or more often if deterioration occurs. Fluid restriction is 1ml/kg/hour to minimise pulmonary oedema and urine output maintained above 20ml/hr necessitating use of an an input /output chart. Clotting is taken if platelet count falls below 100 x10 (6)/ l. the pateint should be assessed for thromboprophylaxis.Fetal assessment in the acute situation is via cardiotocograph (CTG), and subsequently by growth, liquor volume and umbilical doppler to look for growth restriction,presentation, oligohydramnios and abnormal dopplers. Corticosteroids are administered to enhance fetal lung surfactant production and minimise respiratory distress syndrome. All of the above determine need and mode of delivery and discussion between consultant obstetrican, neonatologist and patient is required. At a gestation of 30 weeks a caesarean section is more likely as success of induction is reduced. Scbu should be informed.
Posted by Atashi S.
(a) Eclamsea is an obstetric emergency .It needs prompt and effective treatment .I will call for urgent help including consultant obstetricians ,anesthetists ,midwife ,nurses and paramedical stuff. patient should be kept in left lateral position.Airway should be kept patent. oxygen is tobe given by face mask.To stop current fit I will start loading dose of MgSo4 immediately either intravenously or intramuscularly which one is available .To prevent recurrent fit maintainence dose of MgSo4 is to be started for 24hrs after the last convulsion .Gentle catheterization is to be done to evacuate the bladder as full bladder may provoke further fit .Control of BP should be done by using intravenous labetalol or hydralazine .
(b)
Once the patient is stabilize she should be treated in HDU under a single lead clinician .Monitoring includes half hrly pulse , BP,respiratory rate and hrly urine output is to be done.To detect sign of MgSo4 toxicity respiratory rate must be above 12 per miniute ,pattelar reflex must be present and hrly urine output must be more than 30ml .Detection of 2ndary organ involvement including CVA and renal failure is important .Strict fluid balance should be maintained to prevent fluid overload. Blood should be send for full blood count ,urea and electrolyte , LFT ,coagulation profile ,magnesium and calcium level . To prevent thromboembolism thromboprophylaxis is to be given by using low molecular wt heparin. FHR is to be checked by auscultation and foetal well being is to be monitored
by doing CTG.P/V examination is to be done to detect whether patient is in labour or not .If she is in labour then ARM isto be done for augmentation of labour . IV oxytocin drip is to be added if uterine contraction seems to be inadequate .If pt is not in labour then caesarean section is to be done .It should be done by consultant obstetrician under GA and anesthesea should be given by consultant anesthetist.Paediatrician must be present at the time of delivery.All the events should be explained to the husband or to the relatives . Proper documentation , risk management and incident reporting is an integral part .
Posted by SHAGUFTA T.
A) As Eclamptic fit is an obstetric emergency, I will follow hospital agreed protocol for management of Eclampsia. I will call for help from senior obstetrician, anaesthetist, midwife & ask to bring Eclampsia bag. I will keep the patient in Left lateral position with head tilt to prevent airway obstruction by backward fall of tongue and to avoid aspiration, also to avoid Aortocaval compression. High flow oxygen will be started and I/V cannula inserted. Same time blood for PET investigations (FBC, U&E, LFTs, Urine for protein after catheterization ) taken. To terminate/ stop fit Magnesium sulphate is the drug of choice. Magsulf 4g loading dose diluted in Normal saline will be given over 5-10 mins. Followed by maintenance dose of 1g/hr. to prevent further fit. In case of recurrent fit 2g repeat bolus can be given, or rate of I/V infusion increased to 1.5-2g/hr. I/V diazepam will be given (with senior’s advice), if seizure continues. Antihypertensives like I/V hydralazine or Labetolol to be given to bring down blood pressure. Pt should be catheterized, and restricted fluids given to keep Input-Output maintenance chart, in order to avoid pulmonary edema. Once fitting stopped Pt should be shifted to HDU to keep 1:1 midwifery care and vigilant monitoring of her condition.
After stabilization of her condition & transfer to HDU, Antihypertensives I/V or oral Aldomet if conscious will be continued to maintain her BP. Frequent monitoring of her Vitals (every 15 mins in beginning, then half hourly after stabilized, 4 hrly when asymptomatic)—P, BP, Respiratory rate, deep tendon reflexes input/output should be continued. Once mother is stabilized, assessment of fetal wellbeing is done, I will arrange CTG, USS, biophysical profile. If fetus is alive & not compromised, Steroids to mother is given to enhance fetal lung maturity & reduce the risk of RDS. Mode, time & place of delivery will be decided by Consultant Obstetrician in conjunction with multidisciplinary team of anaesthetist, neonatologist, SCBU staff. Debriefing of her condition to Pt if she is conscious & to her attendants should be arranged. Informed consent taken for time & mode of delivery according to maternal & fetal condition, but mother is given priority. Delivery can be delayed only if maternal & fetal condition allows in order to give time for steroids to act. As she is Primi & less than 32 wks, Ideal mode of delivery will be by LSCS as cervix might not be favourable for IOL. Review of lab results by senior obstetrician, if Low platelet, Coagulation profile should be done and correction of coagulopathy if any, to prevent HELLP syndrome. Continous maternal & fetal monitoring (if alive) throuout labour, cutting short 2nd stage of labour is done. Active management of 3rd stage of labour by syntocinon, Methergin to be avoided due to risk of further rise in BP. Risk of VTE should be assessed & thromboprophyllaxis considered. Incident form should be filled for risk management, debriefing done, information leaflet provided. Pt informed that there is risk of recurrence in post partum period so she should be kept under observation for 5 days & advised to come back for followup.
Posted by hoping ..
You have been asked to review a 30 year old primigravida who is an in-patient on the antenatal ward because of pre-eclampsia at 30 weeks gestation. Her blood pressure is 180/115 mmHg and she complains of nausea and epigastric pain. During your assessment, she starts fitting.
(a) Logically outline your interventions culminating in termination of the seizure [6 marks].
This patient has very likely suffered eclamptic seizure. Urgent help should be summoned from senior midwives, anaesthetist, Obstetric residents and Obstetric consultant. Patient should be positioned in left lateral. Her airway and breathing should be assesed and if compromised oro/nasopharyngeal airway inserted. Rarely intubation is required for status eclampticus. Two large bore venous access should be obtained and bloods sent for urgent fullblood count to check platellet count.Coagulation profile should be sent and checked if plateleets below 100.Liver and renal function tests should be requested to look for any derangement. Blood group and save should be requested as risk of abruption or coagulation abnormality requiring transfusion is high. Patient should be transferred to high dependancy unit and eclampsia protocol followed. Magnesium sulphate 4g should be given intravenous over 10 minutes folowed by infusion. Antihypertensive infusion should be commenced and her blood pressure monitored every 15 minutes. Oxygen saturations should be monitored because of risk of pulmonary oedema.

Patient should be closely monitored in High dependancy unit because of need of close surveillance. With blood presuure higher than 160/110 mmHg there is increased risk of cerebrovascular accident thus it should be checked every 15 minutes initially and then half hourly until stable. Hydaralazine or labetalol could be used as iv antihypertensives as are safe in pregnancy.Labetalol should be avoided if she is asthmatic. Indwelling catheter inserted with hourly urometer and fluid Input should be restricted to 1ml/kg body weight/ hour because of risk of pulmonary oedema.Central venous pressure monitoring should be considered. Magnesium infusion should be continued as it reduces risk of recurrent seizure and maternal mortality. Hourly reflexes and respiratory rates checked to detect Magenesium toxicity early. Blood results should be chased and if HELPP suspected blood film should be requested. Bloods should be repeated in 6 hours to detect ant worsening picture.Fetal wellbeing should be assesd withcardiotocography.Corticosteroids should be given if not already received to reduce neonatal morbidity. Compression stockings should be worn and heparin considered depending upon urgency of delivery and haematological picture. Timing of delivery depends upon mothers stability and fetal wellbeing. It involves balancing maternal risk versus gaining fetal maturity.If stable conservative treatment could be continued for 24 hours to get steroids on board and reasses situation at 24 hours. Growth, liquor and umblical artery doppler should be checked because 30% have fetal growth restriciton. If conservative is planned beyond 24 hours biochemistry should be checked every day.However as this patient is symptomatic and had eclampsia there is incresed risk of deterioration necesitating early delivery.This is likely to be by caesarean section as she is nulliparous at 30 weeks gestation. Cervical assesment should be done to asses favorablity for induction.Regional anaesthesia is not contraindicated if no coagulation abnormality. Oxytocin 5 iu should be given for third stage and ergometrine avoided because of risk of severe hypertension. Once stable iv antihypertensives should be changed to oral. Patient should be obsereved in hospital for atleast 4 days postpartum because of increased risk of eclampsia. Patient should be informed of events and management plans.Incident reporting should be done in view of eclampsia. She may need to continue antihypertensives upto 3 months postnatal.
Posted by Ephia Y.
You have been asked to review a 30 year old primigravida who is an in-patient on the antenatal ward because of pre-eclampsia at 30 weeks gestation. Her blood pressure is 180/115 mmHg and she complains of nausea and epigastric pain. During your assessment, she starts fitting. (a) Logically outline your interventions culminating in termination of the seizure [6 marks]. (b) Justify your subsequent ante-partum care [14 marks].

The diagnosis is that of an eclamptic fit. I will place the patient in semi prone position and call for help from anaesthetist, senior midwife and consultant. I will assess the airway by lsitening for abnormal breathing sounds and feeling for air movement.

Breathing is checked.The airway will be cleared by chin tilt and an oxygen mask applied for oxygenation. If the airway is blocked, the aiway is aspirated.

Circulation is checked by pulse, blood pressure and oxygen saturation measurement and if arrested, CPR initiated.

IV access is obtained with a wide bore cannula to adminiter magnesium sulfate and antihypertensives.

Magnesium sulafte 4gm in 20% solution is adminsitered IV over 10 mins. If seizures continue a further 2-4 gm depending on the patient\'s weight is administered IV.

If MgSO4 is not available, diazepam 10ml is administered IV. It can also be used if the second loading dose of MgSO4 fails to control fits.

Subsequent management includes preventing further fits by maintaining the dose of MgSO4 (1gm/hr). The patient is transferred to the high dependency unit. The aim is to stabilise the patient and plan delivery.

If blood pressure is high IV Labetalol or hydralazine is given with the aim of maintaining BP at systolic of 130-140mmHg and diastolic of 90-100mmHg. I will be cautious about severe drop in blood pressure.

The bladder is catheterised to monitor urine output. The patient is monitorred for pulse, BP, respiratory rate, oxygen saturation, patellar reflexes and urine output. Warning signs of MgSO4 toxicity are diminution of patellar reflexes and reduction in respiratory rate. Monitorring is carried out every 10 mins for first 2 hours and if stable, then every 30 mins.

Fluid balance charts are maintained and fluids are restricted to 80 mls an hour to minimise risk of pulmonary oedema.

Blood is sent for urea and electrolytes for renal function, liver function tests including liver enzymes, albumin, full blood count for haemoglobin and platelets, coagulation profile, urates, group and save. 24 hour urine collection is started for total proteins. If magnesium toxicity is suspected, magnesium levels can be checked.

Continuous fetal monitorring is carried out by CTG. As the gestation is 30 weeks and delivery is indicated as soon as the patient is stable, risks of prematurity and increased likelihood of delivery by Caesarean section are discussed with the patient. Consultant obstetricians, paediatricians and anesthetists are involved in decision making along with the patient.
Posted by S G.
(a)Logically outline your interventions culminating in termination of the seizure [6 marks].
Fits in pregnancy is most likely due to eclampsia unless proven otherwise. Eclampsia is associated with maternal and perinatal morbidity and mortality. While stabilizing her, call for immediate help from senior anesthetist, obstetrician and midwives. Patient should be in left lateral position to relieve aortocaval compression and prevent aspiration. Airway should be secured by guedels airways. High flow oxygen should be given by face mask to prevent hypoxia. Two large bore intravenous cannulas should be inserted. Full blood count, liver function tests, renal function tests, clotting profile should be sent as eclamsia may be associated with haemolysis, thrombocytopenia, elevated liver enzymes and altered renal functions. She should be given fast acting intravenous antihypertensive to lower the blood pressure and 4 grams loading dose of intravenous Magnesium sulphate over3-5 minutes. It should be followed by maintenance dose of magnesium sulphate of 1grams per hour for 24 hours if there are no signs of magnesium toxicity. She should have indwelling catheter for hourly urine output chart. She should be transferred to high dependency unit on labour ward. She should have pulse, blood pressure, oxygen saturation monitored every 5-10 minutes initially. She should have ECG. Family member should be debriefed.
(b)Justify your subsequent ante-partum care [14 marks].
Patient should be explained about the diagnosis if she is stable. As eclampsia is associated with significant maternal and perinatal morbidity, the main aim is delivery. She should have a cardiotocography(CTG) for fetal assessment. She should be given a dose of steroid for fetal lung maturity. If the CTG is reassuring then eclampsia at 30 weeks gestation is an indication for delivery by Caesarean section. Induction of labour at this gestation is unlikely to be successful. Risks of operative delivery and prematurity should be discussed with the patient. Senior pediatrician, anesthetist and obstetrician should be present at delivery. Majority of fits occur during postpartum period so maintenance dose of magnesium sulphate infusion should be continued 24 hours post delivery. Fluid should be restricted to prevent pulmonary oedema . BP should be controlled by antihypertensive to prevent cerebrovascular accidents. She should be monitored for signs for magnesium toxicity like respiratory depression, decreased urinary output, loss of deep tendon reflexes. Calcium gluconate is the antidote for magnesium toxicity. TED stockings and low molecular weight heparin should be given for thromboprophylaxis. Early mobilization should be encouraged. Couple should be debriefed . Incident form should be filled. She should be discharged from hospital when stable and follow up should be arranged with community midwife or GP for blood pressure check. Recurrence risk is high in future pregnancy. She should be advised about contraception if she wishes.
Posted by R M.
a) Eclampsia is an obstetric emergency associated with serious maternal and perinatal morbidity and mortality. I’ll call for help from senior obstetrician, anesthetist, senior midwife and porters. Consultant obstetrician and anesthetist will be informed. Patient should not be left alone. I’ll protect the patient from trauma by placing her in a safe environment and left lateral position. Preventing cerebral hypoxia is of utmost importance- I’ll assess whether her airway is patent and she is breathing spontaneously; I’ll assess circulation by rechecking pulse and BP. I’ll give her oxygen by mask and secure intravenous access using two big bore cannulas (as safely as possible). I’ll draw blood for FBC, urea and electrolytes, LFT, clotting screen, serum uric acid and grouping and cross matching and send them off urgently. I’ll assess foetal heart rate. The vast majority of seizures are self limiting. If it is not resolving by itself, I’ll give her magnesium sulphate (which is the anticonvulsant of choice in this case) 4g, as 20% solution intravenously over 10 – 15 minutes. This will stop seizures in most cases. I’ll shift her to HDU and will start an HDU chart with 5 minutely BP, pulse rate, oxygen saturation and respiratory rate.

b)Severe Pre-Eclampsia and eclampsia are associated with serious maternal risks (like trauma, aspiration, HELLP Syndrome, pulmonary edema, CVA, abruption, anesthetic and surgical complications of delivery) and foetal risks (IUGR, risk of iatrogenic prematurity, hypoxia and abruption). Patient will be shifted to HDU for further management under a lead Consultant .Local protocols will be followed. Management should be by a multidisciplinary team including consultant obstetrician, anesthetist, ITU/HDU physician, neonatologist and senior midwife.

Eclampsia is an absolute indication for delivery. But maternal condition has to be stabilized prior to delivery. BP should be controlled by IV Hydrallazine/Labetolol to prevent cerebrovascular accidents. Maintenance dose of magnesium sulphate 1g per hour should be given slow intravenously to prevent recurrent seizures. If seizure recurs, further boluses of 2g IV or increase maintenance to 1.5 – 2g per hour(with close monitoring of serum magnisium levels). If there are repeated seizures, alternative medications like IV Diazapam/Thiopentone should be considered in bolus doses. I’ll be vigilant as polypharmacy is associated with respiratory depression and increased maternal mortality. Patient should be closely monitored with respiratory rate, urine output and patellar reflexes to detect magnesium toxicity. If there is any clinical evidence of magnesium toxicity serum magnesium level should be measured. If it is above therapeutic level (2 – 4 millimoles / litre) infusion should be stopped and calcium gluconate given IV.

Strict fluid balance charts will be maintained as there is risk of pulmonary edema/renal failure.IV fluids should be restricted to less than 80ml/h.Catheter should be inserted and urine output measured.Thromboprophylaxis with TED stockings and LMWT heparin should be considered as pre-eclampsia is a risk factor for thromboembolism .Close surveillance should be in place for any evidence of cardiac/renal failure or CVA and appropriate specialists involved promptly.Patient will closely monitored by measuring PR,BP,RR,SO2,tendon reflexes,LFTs,RFTs,Uric acid,ECG ,auscultation of lung bases and fluid balance charts.

Foetal condition should be monitored using CTG. Corticosteroids should be given to enhance pulmonary maturity and reduce neonatal respiratory morbidity and mortality. SCBU should be informed regarding the need for bed. If neonatal bed and resuscitation facilities are not available in utero transfer to higher centre should be considered provided maternal and foetal conditions are satisfactory. Risk of iatrogenic prematurity will be discussed with the patient and her family and discussion with the neonatologists will be arranged.

Mode and timing of delivery will be decided by consultant obstetrician once maternal condition is stabilized and foetal conditions are satisfactory (preference always go to mother). Caesarian section is likely in this case as cervix is unlikely to be favorable at 30 weeks in a primigravida. Consultant anesthetist will be informed. An epidural or spinal anesthesia will be preferred unless there is evidence of thrombocytopenia/ coagulation disorder (HELLPS) which will necessitate a general anesthesia. Risks of operative delivery & anaesthesia will be discussed with the patient and consent obtained.

Risk management is very important. I’ll keep woman and her family informed at all stages. I’ll clearly document the timing of seizure, assistance requested and drugs/fluids administered. I’ll fill risk management forms.

Posted by Najah Ali A.
(a) Eclamptic fit is an obstetric emergency that need swift quick action to avoid associating morbidity and mortality. Each unit should have agreed protocol to manage such emergency. Putting the patient in recovery position left lateral for safety and to avoid aspiration, I will ask my staff to call the most senior obstetrician, anesthetist for help, quick assessment of the patient breathing, secure and maintain the airway , provide a high facial oxygen saturation, check pulse and the blood pressure. Collecting blood for fbc, urea and electrolyte, liver function test, coagulation and save serum. At the same time I will start the loading dose of mgso4 at 4 grams I/v over 5-10 min, following with the loading dose at rate of 1 gram/ hour. As the eclamptic fit is a self limiting, there is an evidence that the mgso4 is the agent of choice for preventing further fit, and associated with less maternal mortality [magpie trial].Intravenous anti hypertensive agent [labetalol, hydralazine] according to the unit protocol and to the availability consider to be the agents of choice, risk of profound hypotension and fetal distress is there with both agent. Further fit can be managed by second dose of mgso4 or by increase the infusion rate 1, 5-2 gram/hour. Further fit Diazepam, Phenitoin should be considering with intubations to protect airway and maintain oxygen supplementation.

(b) As the patient condition is stable transfer the patient to H.D.U under multidisciplinary team care involving consultant obstetrician, anaesthist, neonatologist, hematologist and alert the porter to be around. Continuous monitoring of blood pressure, pulse, oxymetry, respiratory rate, deep tendon reflexes, strict urine in put and out put, for early detection of mgso4 toxicity and to be managed accordingly by stop the infusion or by giving the antidote calcium
gluconate .strict fluid balance is associated with good pregnancy out come, one of recommended regimen is urine out come in the last one hour+30ml of infused fluid; this will reduce the risk of pulmonary edema and the risk of renal failure. Fluid load is best to be monitored by C.V.P. Close assessment and evaluation of the patient according to her symptoms, signs and blood work [hematology and chemistry] every 4-6 hours with consultant review and other related specialty if any complications arise. Assessing the fetal well being by regular CTG, U/S looking for fetal presentation, placental location, AFI, fetal growth and by doing umbilical artery Doppler. Delivery is the definitive treatment .Once he condition is stable the woman and her partner should be counseled by properly trained counselor in conjunction With Neonatologist regarding the need of imminent delivery to avoid such mishap which can be life threatening condition and once the lady is primigravida and remote from her due the delivery almost will be through caesarean section and any method of labor induction is unlikely to succeed. The baby will be premature so administration of corticosteroid as per unit protocol will reduce risk of RSD, IVH, and NND, reduce the NICU duration and it is coast effective with out any significant maternal risk, all the information will be baked with printed written leaflet. If the hospital is unequipped or unable to deal with such gestational age arrangement for inutero transfer where such care can be provided .clear careful documentation of all procedures intervention has been under taken taken, the names of all staff involved in the patient care should be clearly documented, keeping the lady and her family updating at all the time is of paramount importance. Writing an incidental report is a vital as apart of risk management.

Posted by SK K.
A)My first priority would be to secure airway, breathing & circulation and also ensure patient safety from any injuries caused by fall. I will call for help the midwives, SHO, porters .
I will make the patient supine with left lateral tilt, secure airway and check for breathing, if there is an arrest I would intiate CPR. I would secure two large IV bore cannule and collect & send the blood for investigation, FBS, Platelet count, U & E, Lfts, uric acid, group & save , clotting screening. To control the seizures I would give 4 gm MGso4 as a 20% solution diluted in dextrose saline slowly over 20 minutes and then continue at 1 gm/ hr.
Any subsequent seizures I will repeat 2gms iv MGSO4 and if still uncontrolled thereafter give her to 40 mg IV diazepam or 800 mg IV pheytoin (12-15 mg/ kg).
I will also ensure that oropharyngeal secretions are being sucked out and I would secure a metal/ plastic airway to prevent toungue bites or prevent toungue from falling back & occluding airway. If need arises endotracheal intubation would be considered with the help of anaesthetist

B) .pt will be admitted to HDU with single lead clinician and will be under multidisciplinary care . Subsequently I would asses her vitals pulse, bp, respiratory rate, reflexes. I would cathetrise her as hourly input/output chart is necessary in deciding fluid balance , in detecting ranl failure & need arises to decrease MGSO4 dose in cases of decreased urine output. Bp if high could be controlled by IV labetol 40 mg IV bolous repeted at 15-30 minutes interval or IV hydralazine 15 mg IV bolous. Per 15 minutes check of vitals, urine output, rflexes for first 1 hr therafter hourly for 4 hours therafter 2 hourly.
Lab investigation along with serum magnesium and calcium , will be checked every 4-6 hourly. After stabilizing the mother, I would note fetal condtion. Ceck for fetal heart rate, presentation, whether there is onset of contaraction and also assess Bishops score
I would then communicate to the consultant brief him of the episode and discuss further management.

At the earliest opportunity, I would also speak to her relatives and explain to them the necessity to delive urgently and also inform them of anticipated complications due to eclampsia.
A s patient has been inpatient, it is likely that she must already have received inj. Dexamathasone 2 doses of 12 mg each for fetal maturity. If not already administered, I would administer dexa and and prepare to deliver her . Aim for vaginal delivery, but the fact that she is primi with 30 weeks points to high probability of poor bishops and likely failure of IOL. Ceaserean section for poor bishops, malposition, fetal distress is favoured .
I would inform the paediatrician & scbu, Ot staff & theater coordinator, speak to the hematologist and arrange for blood & blood products and also inform the senior anesthetist also speak to ICU, ITU incharge of likely admission.
I would continue to monitor her vitals closely. Control her blood pressure. Watch & treat any complication eg: pulmonary edema, renal failure, DIC vigourusly.
MGSO4 drip will be continued till 24 hrs, past delivery a post last seizures whichever is last.
Accurate documentation and risk management is necessary .
Once a patient has convulsed due to preeclempsia there is no expectant or conservative mangment. Termination of pregnancy is the definitive treatment for improving maternal outlook. Though it may well mean iatrogenic prematurity with its risks.



Posted by g.b. D.
I will Do a vaginal examination to asses bishop score . Arrange for ultra sound scane for estimated fetal weight ,liqour volume, placental localization why is this necessary? You are going to deliver the baby whether the scan says it weighs 500g or 1500g . After ...........
what will we tell to the patient when she asks about the prognosis of baby?... dont we need to know the wt of baby even if we are going to deliver the baby?... and it definitely makes a diff to the neonatologist if the baby is 500 or 1500 gms....a lot of diff in neonatal managemant and prognosis of the baby....