Protocol for

MANAGEMENT OF

SEVERE

PRE-ECLAMPSIA/

ECLAMPSIA Green top guideline

2010

Prof. Aboubakr Elnashar Benha university Hospital, Egypt

ABOUBAKR ELNASHAR

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

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

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

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.

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•Diagnosis of HELLP syndrome

1. Haemolysis:

LDH levels, or blood film (fragmented red cells).

2. Platelet count: <100 x 106

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II. Foetal assessment

•In the acute setting:

CTG

•In labour:

continuous electronic fetal monitoring.

ABOUBAKR ELNASHAR

•In Conservative management:

1. US :

F wt

A FI

2. Umbilical artery Doppler

3. CTG

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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

•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

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

Labetalol:

IV: 20 mg; subsequent doses of 40, 80,

80 mg IV at 20-min intervals.

Maintenance: 40 mg/h

Oral: 100 mg BID

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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

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

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

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

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.

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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

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

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

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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

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

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

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

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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.

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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

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

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