SDMS ID: P2010/0509-001 2.

28-06WACS Title: Replaces: Description: Target Audience: Key Words: Policy Supported:

Management of Eclampsia
Management of eclampsia Midwifery and Medical Staff, Queen Victoria Maternity Unit Eclampsia

P2010/0491-001 Magnesium Sulphate (MgSO4) P2010/0510-001 Intravenous Hydralazine for Severe Hypertension in Pregnancy

Purpose: Eclampsia is an obstetric emergency that requires multidisciplinary management. Definition: The occurrence of seizures and/or coma in a woman with signs and symptoms of pre eclampsia. Eclampsia is thought to arise from cerebral vasospasm, cerebral oedema and disruption of the blood brain barrier. The incidence of eclampsia is 1 in 2000 pregnancies. Seizures can occur before, during and after labour in roughly equal proportions. Signs and symptoms of impending eclampsia: severe frontal headache cerebral oedema diminished urinary output impending renal failure visual disturbances retinal oedema epigastric pain haemorrhage of the subcapsular region of the liver vomiting and nausea related to cerebral oedema and liver damage hyper-reflexia can signal impending eclampsia

Management of eclampsia Call for help CODE OBSTETRIC Ensure airway by: turning the woman on her side suctioning the mouth to clear any saliva, mucous, blood and/or vomit Administer facial oxygen Protect the women from injury by raising bed side rails or if on a hard surface place padding under her head. Note the features and duration of the seizure: time of onset progress of the seizure body involvement presence of incontinence time of cessation
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Obtain IV access and consider bloods for uric acid, FBC, liver function, coagulation, group and hold. Control seizures administer IV Magnesium Sulphate (Attachment 1) Control hypertension administer IV Hydralazine (Attachment 2) Following the seizure, assess and record BP, pulse, and respiration fetal heart rate CTG if indicated level of consciousness presence of restlessness or twitching injuries sustained during the seizure uterine contractions vaginal loss Consider need for IV hydration being mindful of the risk of fluid overload total fluids should be limited to 80ml/hour or 1ml/kg/hour. Insert indwelling urinary catheter and commence hourly urine output measures. Following initial stabilisation the women should receive one on one care. Nurse in a quiet room with external stimuli kept to a minimum. Discussion with the consultant to develop an appropriate management plan.

Attachments
Attachment 1 Attachment 2 Attachment 3 IV Magnesium Sulphate Administration Protocol IV Hydralazine Administration Protocol References

Performance Indicators: Evaluation of compliance with guideline to be achieved through medical record audit annually by clinical Quality improvement Midwife WACS Review Date: Annually verified for currency or as changes occur, and reviewed every 3 years via Policy and Procedure working group coordinated by the Clinical and Quality improvement midwife. November 2009 Midwives and medical staff WACS Dr A Dennis Co-Director (Medical) Sue McBeath Co-Director (Nursing & Midwifery) Womens & Childrens Services

Stakeholders: Developed by:

Dr A Dennis Co-Director (Medical) Womens & Childrens Services

Sue McBeath Co-Director (Nursing & Midwifery) Womens & Childrens Services

Date: _________________________
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ATTACHMENT 1 IV Magnesium Sulphate Principles and Method of Administration Anticonvulsants may be used for short-term treatment pending delivery 50 ml syringe of 50% solution The intravenous line should not be used to inject any other drugs Administration should always be via a syringe or infusion pump. 8ml (4g) MgSO4 (50% solution) given over 15 minutes IMED pump settings: rate: 32ml volume to be infused: 8ml 2ml (1g) MgSO4 (50% solution) per hour 30 minutely initially then 1 hour when stable Maternal blood pressure, patellar reflexes, respiratory rate and hourly urine measures. Unable to elicit patellar reflexes Respiratory rate less than 10 per minute Urine output less than 30ml/hour Calcium gluconate (10ml of 10% solution) by slow intravenous injection over 5 minutes. Stop infusion Summon emergency assistance code blue Initiate respiratory support via bag and mask until woman is intubated and ventilated Give IV calcium gluconate 1g in 10ml over five minutes

AIM: Presentation: Administration:

Loading Dose:

Maintenance Infusion Observations

Discontinue infusion and notify medical officer if: Antidote for magnesium toxicity Management of respiratory arrest

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ATTACHMENT 2 IV Hydralazine Principles and Method of Administration AIM: to achieve a gradual reduction in blood pressure to safe levels (90mmHg diastolic), rather than a precipitate drop. NOTE: the risk of sudden hypotension can be greater in women with a contracted plasma volume. Trade name: Apresoline Presentation: 20mg ampoule Incompatibilities aminophylline, ampicillin, hydrocortisone, sulphadiazine, dextrose diluents Dose: Hydralazine 5 mg as an intravenous bolus Reconstitute 20mg of hydralazine in 20ml of normal saline to make a solution of 1mg per ml. Administer by slow IV push at a rate of 5mg (5ml) over 5 minutes. Repeat if necessary at 20 minute intervals up to a maximum of 3 doses. Concomitant Continue existing oral antihypertensive therapy and review Antihypertensive Therapy: dose regimen OR If conscious commence oral antihypertensive therapy (such as clonidine, labetalol or oxprenolol) in addition to the intravenous hydralazine Persistent hypertension despite 3 boluses of IV hydralazine 5mg may be due to a compensatory reflex tachycardia: If heart rate <125 bpm Commence hydralazine infusion of 10mg/hr Load 50 mg of IV hydralazine into 50 ml of normal saline (not a glucose containing solution) Run the infusion through an infusion pump at a rate of 10ml/hr Increase rate by 5ml/hr every 15 minutes until blood pressure is controlled. If heart rate >125 bpm Give oral clonidine, labetalol or oxprenolol in addition to hydralazine infusion Maternal and fetal Continuous CTG throughout administration of hydralazine observation and and until BP is stable (30 minutes after the last dose) monitoring Record BP (mercury sphygmomanometer) and pulse every 5 minutes are after each bolus Continue 5 minutely BP and pulse until stable, then measure hourly Record BP every 15 minutes for the first hour of a continuous infusion, then measure hourly if stable.

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ATTACHMENT 3 REFERENCES American Academy of Family Physicians 2000 Advanced life support in obstetrics (ALSO) course syllabus (4th edn). American Academy of Family Physicians, Kansas Enkin M, Keirse J, Neilsen J et al 2000 A guide to effective care in pregnancy and childbirth. Oxford University Press, London Pairman S, Pincombe J, Thorogood C, Tracy S, Midwifery preparation for practice 2006 Elsevier Australia Australasian Society for the Study of Hypertension in Pregnancy (ASSHP) 2000 The detection, investigation and management of hypertension in pregnancy: executive summary. Online: http://www.racp.edu.au/asshp/news.htm

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