Protocol for MANAGEMENT OF SEVERE PRE-ECLAMPSIA/ ECLAMPSIA Green top guideline 2010

1. Protocol for
MANAGEMENT OF
SEVERE
PRE-ECLAMPSIA/
ECLAMPSIA
Green top guideline
2010
Prof. Aboubakr Elnashar
Benha university Hospital, Egypt
ABOUBAKR ELNASHAR

2. BACKGROUND
Eclampsia (E)
convulsions superimposed on pre-eclampsia.
Preeclampsia (PE)
PIH in association with proteinuria (> 0.3 g/24 h) ±
oedema
Severe PE
Significant proteinuria (1 g/litre) PLUS
DBP ≥ 110 mmHg on 2 occasions OR
SBP ≥ 170 mmHg on 2 occasions OR
DBP ≥ 100 mmHg on 2 occasions & with at least 2 S or
S of imminent E.
HELLP syndrome:
Variant of severe PET (haemolysis, elevated liver
enzymes and low platelet count).ABOUBAKR ELNASHAR

3. Clinical features of severe PET
in addition to hypertension & proteinuria:
Severe headache
Visual disturbance
Papilloedema
Liver tenderness
Epigastric pain and/or vomiting
Signs of clonus
Platelet count <100 x 106/l
Abnormal liver enzymes
(ALT or AST rising to above 70 iu/l)
HELLP syndrome.
ABOUBAKR ELNASHAR

4. MANAGEMENT
I. Maternal monitoring
II. Foetal assessment
III.Control BP
IV.Prevention of seizures
V.Control of seizures
VI. Fluid balance
VII.Delivery
VIII. Postparum
ABOUBAKR ELNASHAR

5. I. Maternal monitoring
1.BP:
/15 m until the woman is stabilised and then /30 m in the
initial phase of assessment.
/4-h if a conservative management plan
2. Input and output chart.
3. Full blood count, liver function and renal function
tests.
Repeated at least daily when the results are normal but
more often if the clinical condition changes
•AST >75 iu/l or ALT >70 iu/l Significant
>150 iu/l: increased maternal morbidity
Uric acid should not be used for clinical decision-making.
Platelet count<100x106: consideration for delivery.
4. Clotting studies
not required if the platelet count >100 x 106/l.ABOUBAKR ELNASHAR

6. •Diagnosis of HELLP syndrome
1. Haemolysis:
LDH levels, or blood film (fragmented red cells).
2. Platelet count: <100 x 106
ABOUBAKR ELNASHAR

7. II. Foetal assessment
•In the acute setting:
CTG
•In labour:
continuous electronic fetal monitoring.
ABOUBAKR ELNASHAR

8. •In Conservative management:
1. US :
F wt
A FI
2. Umbilical artery Doppler
3. CTG
ABOUBAKR ELNASHAR

9. III. Control BP: Antihypertensive treatment
Indications:
1. SBP> 160 mmHg or
DBP>100 mmHg.
2. SBP <160 plus
severe disease :
heavy proteinuria or
disordered liver or haematological test
ABOUBAKR ELNASHAR

10. •Drugs:
•Acute , severe:
Nifedipine: oral not sublingually
IR cap:10 mg initial; repeat after 30 m if necessary
IR cap: 10-30 mg tid; not to exceed 120-180 mg/d
ABOUBAKR ELNASHAR

11. Hydralazine
IV: 5 mg over 5 min, repeat /20 min until
DBP 95 mmHg, No more than 4 doses.
If not give Labetalol or Nifidipine.
Maintenance: 10 mg/h
Add 2ml NS to reconstitute 20 mg
hydralazine.
Withdraw 0.5 ml hydralazine solution
and add 9.5 ml NS to give total 10 ml
solution.
ABOUBAKR ELNASHAR

12. Labetalol:
IV: 20 mg; subsequent doses of 40, 80,
80 mg IV at 20-min intervals.
Maintenance: 40 mg/h
Oral: 100 mg BID
ABOUBAKR ELNASHAR

13. Chronic, moderate
Nifedipine
SR tab: 30-60 mg qd; not to exceed 90-120 mg/d
Hydralazine.
Oral: 25 mg tds
•Methyldopa
was the most commonly used therapies in the UK.
safe in long term follow-up of the delivered babies
some studies have suggested some benefits of labetalol.
•Atenolol
increase in IUGR.
•ACE inhibitors and ARBs
contraindicated {unacceptable fetal adverse effects}.
•Diuretics
relatively contraindicated for hypertension
should be reserved for pulmonary oedema.
ABOUBAKR ELNASHAR

14. IV. Prevention of seizures
Indications:
1. Severe PET:
once a delivery decision has been made and in the
immediate postpartum period.
When conservative management of a woman with
severe hypertension and a premature fetus is made
it would be reasonable not to treat until the decision
to deliver has been made.
ABOUBAKR ELNASHAR

15. If Mg So is given:
1. It should be continued for 24 h following delivery
or 24 h after the last seizure
2. Regular assessment of:
a. Urine output: <20 ML/H: STOP
b. Deep tendon reflexes: Loss: Stop
c. Respiratory rate:
d. Oxygen saturation
Antidote: Ca gluconate 1 g (10 ml) over 10 m
ABOUBAKR ELNASHAR

16. V. Control of seizures
I. 1. Do not leave the patient alone. Prevent maternal
injury during the convulsion.
2. Call for help and place a code blue call- Medical
Emergency call.
4. Initiate resuscitation.
5. Turn the patient into left lateral position when able
to do so.
6. Inform the consultant obstetrician and anesthetist
on call.
II. AIRWAY
1. Assess and maintain patency, using oral suction if
necessary.
2. Insert a plastic oral airway if possible
3. administer oxygen therapy via face mask.
ABOUBAKR ELNASHAR

17. III. BREATHING
1. Assess respiratory rate and ambubag using
facial mask/laryngeal mask or endotracheal tube if
necessary.
IV. CIRCULATION
1. Evaluate Pulse and B P. If absent, initiate CPR.
2. Secure IV access as soon as possible with main
line infusion, with three-way tap attached, of
Hartmann's Solution, administered at a very slow
rate, as fluid intake will be restricted to 1 ml/kg/h
3. Pulse oximetry is helpful.
ABOUBAKR ELNASHAR

18. 2. Mg SO4 is the therapy of choice
Loading dose: 4 g given by infusion
pump over 5–10 min
Maintenance: infusion of 1 g/h for 24 h
after the last seizure.
Prepare loading dose:
Add 4g (8ml) of 50% MgS04 to 12ml of
NS. Administer slowly IV over 10 m.
 Prepare Maintenance dose:
Add 50g (100ml) of 50% MgS04 to
400ml of NS (withdraw 100mls from
500ml bag of NS, prior to adding
MgS04).
Administer IV via volumetric pump at
10ml/h =1g/h.
ABOUBAKR ELNASHAR

19. 3. Once stabilized
plans should be made to deliver the woman but
there is no particular hurry and a delay of several hrs
to make sure the correct care is in hand is
acceptable
The woman’s condition will always take priority
over the fetal condition.
ABOUBAKR ELNASHAR

20. Recurrent seizures.
1. Increase the rate of infusion of Mg So4 to 1.5 g
or 2.0 g/h
2. Diazepam or thiopentone may be used, but only
as single doses,
3. Intubation
4. Transfer to intensive care facilities with
intermittent positive pressure ventilation
ABOUBAKR ELNASHAR

21. VI. Fluid balance
1. Total fluids should be limited to 80 ml/h or 1
ml/kg/h
2. The regime of fluid restriction should be
maintained until there is a postpartum diuresis
3. If there is associated maternal hge, fluid balance
is more difficult and fluid restriction is inappropriate.
ABOUBAKR ELNASHAR

22. VII. Delivery
When:
•> 34W: Once the woman is stable
•<34 w and delivery can be deferred >24 h:
corticosteroids
•Conservative management at very early
gestations(26W) may improve the perinatal outcome
but must be carefully balanced with maternal
wellbeing, only be considered if the mother remains
stable
ABOUBAKR ELNASHAR

23. How?
Depend on
1.presentation
2.fetal condition
3.likelihood of success of IOL after assessment of
the cervix.
•>34 w with a cephalic presentation:
vaginal delivery should be considered.
Discuss the mode of delivery with the mother.
Vaginal prostaglandins will increase the chance of
success.
Anti-hypertensive tt should be continued throughout
assessment and labour.
•<32 w: CS is more likely as the success of induction
is reduced
ABOUBAKR ELNASHAR

24. The third stage:
5 u IM Syntocinon or 5 u IV Syntocinon given slowly.
Ergometrine or Syntometrine should not be given for
prevention of hge
ABOUBAKR ELNASHAR

25. VIII. Postpartum management
1. .
a. Women who develop hypertension or symptoms
of PE postnatally (headaches, visual
disturbances, nausea and vomiting or epigastric
pain): referred for a specialist opinion and
investigation to exclude PE.
b. Women who deliver with severe PET (or E): close
observation postnatally for 4 days or more
c. Careful review to ensure improving clinical signs
is needed before discharge.
ABOUBAKR ELNASHAR

26. 2. Anti-hypertensive
•Continued as dictated by BP.
•BP should not be allowed to exceed 160/110
mmHg
•A reduction in anti-hypertensive therapy should be
made in a stepwise fashion.
•Avoid alpha methyldopa
•In breastfeeding:
labetalol, atenolol, nifedipine and enalapril can be
given
ABOUBAKR ELNASHAR

27. 3. Follow-up and final diagnosis
1. An assessment of BP and proteinuria at the 6 w.
If hypertension or proteinuria persists then further
investigation is recommended.
2. Preconceptional counselling
ABOUBAKR ELNASHAR

28. ABOUBAKR ELNASHAR