eclampsia

see also seizures, Obstetrics, magnesium, pre-eclampsia and eclampsia

• Airways, Breathing
  • if GCS still low, have a low threshold for intubation as likely to require emergent LUSCS
• Circulation
  • iv access
  • left lateral position for optimised fetal circulation
  • iv fluids 500-1000ml NSaline stat
  • FBE, U&E, LFT's, coags, group and hold, VBG +/- ABG
• call obstetrics and anaesthetics ASAP
• commence iv 50% Mg SO4 infusion ASAP to Rx seizure and prevent further seizure:
  • 4g load over 5min, then 1g/hr (if further seizure, give a further 2-4g IV over 5min)
  • monitor for toxicity looking for:
    • check BP, HR RR every 5min during load dose
    • loss of deep tendon reflexes (usually at 8-10mEq/L)
    • slurred speech, muscle weakness, hypotension
    • decreased resp. rate & cardiac depression (resp. then cardiac arrest usually at 13mEq/L)
    • decreased urine output
• treat hypertension:
  • expand maternal intravascular volume with crystalloid 500-1000ml, then,
  • urgent IV hydralazine
    • 10mg slow IV boluses every 20min prn (max. 60mg)
    • NB. need to wait 10-20min for response
  • if BP still high, add IV labetalol 20mg stat then either:
    • 10-20mg slow IV doubling every 10-2min prn to max. 300mg, or,
    • infusion at 1-2mg/min titrated to response (decrease to 0.5mg/min or less once BP controlled)
  • NB. nitroprusside can be used for short periods but risks cyanide toxicity
  • NB. GTN can be used but requires arterial line to monitor & risks metHb
  • NB. ACEI's are C/I as may cause fetal anuria or renal failure
• continuous CTG monitoring
• IDC
• if ongoing seizures despite therepautic levels of Mg, consider:
  • ensure U&E's, glucose checked
  • CT scan to exclude intracranial pathology
  • seizure Rx as for non-pregnant adults:
    • see seizures
    • diazepam (risks fetal resp. depression)
    • phenytoin 20mg/kg IV over 60min
• consider art line but beware if BP > 250mmHg, can be issues with the art line pressure bag relief valve which has a max. pressure of 300mmHg
• consider CVC line
• arrange emergency LUSCS ASAP

• monitor serum levels (normal range in pregnancy 1.5-2mEq/L, Rx range 4-7mEq/L
  • if mild Mg toxicity, with-hold infusion
  • if severe Mg toxicity:
    • resp. support, O2, monitor ECG, SaO2
    • IV 10% calcium gluconate 10ml at rate`< 5ml/minute
    • consider giving loop diuretic to enhance excretion