eclampsia

Mx of eclampsia in the ED

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

ongoing care

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