eclampsia case ukandtz- june 2007 - case discussion with notes

Case 2 ALSO(UK) June 2007

Case Presentation BP19 year old G1 P0+039 weeks - antenatal care outside your area Contractions 3-4 in 10 minutesPregnancy uncomplicated - except 1st trimester UTI Excessive weight gain during pregnancyRecent generalized oedemaPMH etc nil of noteHistory

On ExaminationFacial & generalised oedema +++Admission BP = 164/102 (repeat 160/100)Urine = +++ protein

VE : Cervix = 4 cm dilated, 100% effaced, station 0, membranes intact

- contractions 3-4 in 10 mins, - baseline FHR = 140bpm - normal variability, no decelerationsCase Presentation BP

What concerns you about with this situation?

likely to have severe pre-eclampsia both fetal & maternal risks such asrisk of ECLAMPSIAintracranial haemorrhage risk of pulmonary oedema (iatrogenic fluid overload)hepatorenal failure

Case Presentation BP

How would you calculate the MAP?

Diastolic + [1/3 the difference between systolic and diastolic]

2. [Systolic + twice the diastolic] then divide by 3


What lab investigations would you order?Full Blood Count(Coagulation) Group & Save for X-matchUrea, Creatinine & ElectrolytesLiver Function TestsUrateMSU (inc Gram Stain)


What other data do you need at this point?

her handheld antenatal recordsCase Presentation BP

Would you give antihypertensive and/or magnesium sulphate at this point?

Antihypertensives probably not at this stage as MAP160mmHg should be treated

Magnesium Sulphate most units would start MgSO4 at this stage (ref MAGPIE study)Case Presentation BP. IN THIS CASE, NEITHER IS GIVEN..

30 minutes later

While awaiting laboratory results, you are called urgently to delivery suite

The patient has a grand mal seizure that lasts about 1 minute

CTG shows a fetal bradycardia of 80 bpm after the seizure


What would you do at this point?

CALL FOR HELP +++++INITIATE BASIC ABCs remember left lateral tilt!!A airway cant be inserted during a fit C includes x2 large bore cannulaeInitiate unit Eclampsia protocolDO NOT NURSE IN THE DARK!!Give loading dose MgSO4 (what dose?)Foley catheter/fluid balance ( rate IV fluid?)Keep NBM review need to treat BPCase Presentation BP

Would you use diazepam to shorten the fit?

NO most fits are self-limiting

avoids polypharmacy

diazepam kept for recurrent fits or when MgSO4 unavailable (e.g. pre-hospital care)


What is the significance of the fetal bradycardia?

occurs frequently during an eclamptic fit

proceeding to immediate LSCS because of the bradycardia MAY ENDANGER THE MOTHERS LIFE

stabilise the mother - Resuscitating the mother will resuscitate the fetus


How would you deliver when stable - LSCS versus induction with vaginal delivery?

Labour induction can usually be considered if:

gestation >32 weeks

cervix reasonably favourable (i.e. delivery likely within 12 hours) cervix is often favourable in pre-eclampsia

fetal condition stable (i.e. no severe IUGR)Case Presentation BP

After the seizure...Meticulous attention to fluid balance - intake / output assessed hourly

4g loading dose MgSO4 then infusion at 1-2 g/hr

Total IV fluids limited to 80-85ml/hr or 1 ml/kg/hr

Foley catheter


Case Presentation BPFetal bradycardia recovers with control of seizures, oxygen and left lateral positioning

Contracting 4-5 in 10; lasting 60-90 seconds

ARM - meconium-staining

FHR = 160bpm with decreased variability

Consultant Anaesthetist / Obstetrician and theatre aware of situation

BP = 180/110 (what is the MAP now ?) 133

What would you do next?

Control Blood Pressure

Analgesia as appropriate


Are you worried about her blood pressure?

YES in this case, BP>180/110 and/or MAP>125 puts maternal CNS at risk (intracranial haemorrhage)Case Presentation BP

How would you control the blood pressure?

can you name 2 drugs you could consider using?

SL NifedepineIV hydralazine (bolus +/- infusion)


Will the MgSO4 itself lower the BP?

NO it is primarily for seizure prophylaxis


What are the signs of magnesium toxicity?

IN ORDER

loss of reflexessomnolencerespiratory depressionparalysis finally cardiac arrest


What is the antidote for magnesium toxicity?

Calcium gluconate 1g IV over 3 minutes(10mls 10% calcium gluconate)Case Presentation BP

What action should be taken for absent reflexes?

Stop MgSO4 until reflexes return


What action should be taken for respiratory depression / somnolence?

Stop MgSO4

Give O2

Recovery position (as reduced level of consciousness)

Monitor closely



What action should be taken for respiratory arrest?

Initiate BLS

Intubate/ventilate immediately

Stop MgSO4

I.V. calcium gluconate

What action should be taken for cardiac arrest?

Initiate Basic Life SupportAirwayBreathing - ventilateCirculation CPR

Stop MgSO4

I.V. calcium gluconate

If antenatal immediate Caesarean Section


The blood results returnObservations BP 140/95 Pulse - 90bpm Resp rate - 12/min Temp - 37.8C Urine output 30ml over past hour Blood results Hb 12.0g/dl WBC 21x109 Platelets 185x109 Coagulation normal / LFTs NormalMagnesium level is therapeuticCase Presentation BP

The patient has another grand mal seizure What would you do next?

general supportive measures (ABCs)

second bolus MgSO4 (2g) should be given even if levels are therapeutic, as long as no signs of toxicity

consider another neuroleptic or GA if seizures continue despite second bolusCase Presentation BP

Would you deliver if so how?

once stable, delivery by urgent LSCS may be appropriate after this 2nd fit (assuming vaginal delivery is not imminent) Case Presentation BP

Is she septic ?(T = 37.8C WCC = 21 x 109)

NO - WCC and pyrexia are more likely related to the grand mal fit

Should antibiotics be started ?

NO - unless there are other overt signs of infection


Does she have HELLP syndrome?

NO HELLP typically presents with:

Haemolysis

Elevated Liver enzymes (ALT/AST)

Low PlateletsCase Presentation BP

The delivery and then?

VE confirms cervix 7cm dilatedOxytocin augmentationNormal delivery within 1 hour Healthy 3.8kg baby boyApgars = 6 (1 min) + 9 (5 min) Placenta delivered & appears intact No uterine atony or perineal traumaCase Presentation BP

Post-deliveryWhen would you discontinue MgSO4?

continue for minimum 24 hours post-delivery (possibly 48 hours if recovery is protracted)

More than 40% of all eclampsia occurs post-delivery


Post-deliveryIf uterine atony occurs, what drugs would you use?

oxytocin 5-10 units (slow IV bolus) + IV infusion

prostaglandins - misoprostol 600-800 mikrograms (PR)

ERGOMETRINE - usually avoided because of unpredictable BP spikes, BUT MAY BE NECESSARY IN INTRACTABLE, SEVERE ATONIC BLEEDINGCase Presentation BP

Final question.

Would you have changed treatment of initial fit given a history of grand mal epilepsy?

NO still give MgSO4 because of possibility of eclampsia

remember the old adage every fit in mid/late pregnancy is an eclamptic fit until proven otherwise


SLIDES FOR THIS PRESENTATION ARE SET UP SO THAT THE QUESTION APPEARS FIRST (encourage & allow answers from the audience).THE CORRECT ANSWER APPEARS ON THE NEXT CLICK. A FEW QUESTIONS ON THE SLIDES APPEAR IN RED ANSWERS TO THOSE QUESTIONS DONT APPEAR ON THE SLIDES BUT ARE CONTAINED (IN BOLD) ON THE INSTRUCTOR SHEETAn additional useful reference to read before leading this discussion group is:RCOG Green-top Guideline - The Management of Severe Pre-Eclampsia/Eclampsia (10A), March 2006 http://www.rcog.org.uk/index.asp?PageID=1542

TEACHING POINTS WITH THIS CASEProper evaluation of pre-eclampsiaProper use of MgSO4, indications, and its effects on patient and fetal heart tracingAppropriate response to post-seizure fetal bradycardia Indications and use of antihypertensivesOther complications that can occur with eclampsia

It is important to remember that you have only 35 minutes to complete this portion of the workshop. Plan your time wisely so that the majority is spent on these essential teaching points.There are 38 slidesA 19 year old G1P0 presents to delivery suite at 39 weeks gestation by LMP with contractions every three minutes. She is booked for delivery elsewhere and is visiting relatives in your area. She is blood group A Rhesus positive and rubella immune. In taking her history, she tells you that her pregnancy has been uncomplicated except for an urinary tract infection in the first trimester. She has gained 21kg with this pregnancy and has complained of generalized oedema to her GP. She has no allergies, and her only medication was prenatal folate until 12 weeks. She has no other medical problems. Her other lab test results are unremarkable. On examination she has generalized oedema (including facial). Her blood pressure on arrival is 164/102. Dipstick of her urine shows 3+ proteinuria. Repeat blood pressure hour later is 160/100. Her membranes are intact, she has had no vaginal bleeding and the cervix is 4 centimetres dilated, 100 percent effaced, with a vertex presentation at 0 station. The patient denies headache, epigastric pain, or visual changes. The external fetal monitor shows a reactive, reassuring trace. The baseline fetal heart rate is 140bpm, there is normal variability, and there are no decelerations. She is contracting every three minutes. Likely to have pre-eclampsia with all its attendant risk to mother and fetus. In particular will need to be aware of maternal risks of hypertension (and resulting end organ damage such as intracranial haemorrhage and hepatorenal failure), ECLAMPSIA and iatrogenic fluid overload during and after labour.TRY GOING OVER AN EXAMPLE e.g. BP 160/100

MAP = 100 + [160-100] / 3 = 100 + [60] / 3 = 120Consider full blood count (inc platelet count), biochemistry profile (urea & electrolytes, uric acid, LFTs), baseline clotting screen (??is this necessary at present if platelets >100??). Consider Group & Save.Antenatal records, any ultrasounds Antihypertensive probably not at this stage. MAP is below 125 (actually 120) and no symptomsMagnesium sulphate since the MAGPIE study many units would put this patient onto magnesium. The study itself suggested benefit even in cases with BP 140/90 and only protein 1+. In the UK we have tended to treat moderately severe (such as this case) or severe pre-eclampsia. IN THIS CASE NEITHER IS GIVENCALL FOR HELP +++++EMPHASISE IMPORTANCE OF BASIC ABCs (IN THAT ORDER!!)Turn patient on her sideCheck AIRWAY (you cannot insert an airway during the fit!!) Give oxygen and Protect airway (have suction available)SPONTANEOUS BREATHING should re-establish after the fit endsInitiate eclampsia protocol:DO NOT NURSE IN THE DARK!!!Establish appropriate IV access (ideally two large bore cannulae) Load with MgSO4, 4-6 gms intravenously over 20 min. and begin infusion at 1-2 gm/hr Place Foley catheter, monitor input and output (4 hourly assessment of output is adequatePatient to have nothing by mouthIV N Saline or Hartmans at 80 85 ml/hr or 1mg/kg/hrGroup & save (if not already done)

Does hypertension itself need treating? (In this case - not at present = 150/100)NO eclamptic fits like all grand mal fits are usually self-limiting lasting 2-3 minutes. You should give the loading dose of Magnesium immediately. This avoids polypharmacy. Diazepam can be used in the rare cases of recurrent fits when magnesium is unavailable or in pre-hospital care.

Fetal bradycardia is a frequent finding subsequent to an eclamptic seizure because of uterine hyperactivity that may result from the seizure and secondary to maternal hypoxia. One would expect a period of fetal tachycardia with decreased variability to occur following resolution of the bradycardia. It is best to avoid an urgent Caesarean delivery for the bradycardia until the mother herself is stable. YOU MIGHT BE PUTTING THE MOTHERS LIFE AT RISK BY RUSHING INTO A CAESAREAN SECTION WHEN SHE IS UNSTABLE.Resuscitating the mother will resuscitate the baby The baby will likely recover as the mother stabilizes. Keep in mind the possibility of a placental abruption.The treatment after an eclamptic seizure includes delivery. If the eclamptic patient is not in labour, induction can begin after magnesium sulphate has been loaded and the patient stabilized. Proceed with induction if at least 32 weeks estimated gestational age and if the cervix is reasonably favourable (i.e. reasonable chance of delivery within 12 hours). Many patients with pre-eclampsia/eclampsia are rather easily induced and labour rapidly Your patient is admitted to the HDU, given a 4 gm IV loading dose of MgSO4, and started on a MgSO4 infusion at 1-2 gm/hr. A Foley catheter is inserted, and her urine output is carefully monitored. IV fluid at 85ml/hr is commenced (N Saline or Hartmans). Amniotomy is done and a fetal scalp electrode applied. The amniotic fluid shows scant, thin meconium. The fetal bradycardia recovers with control of her seizure, oxygen, and position change. Her baseline rate is now 160bpm and there is decreased variability. The obstetric theatre team is alerted and is on standby. Consultant is informed and is on the way in to review. Her blood pressure now is 180/110 (MAP = 133). She is having contractions every two to three minutes lasting 60-90 seconds.

Control of blood pressure neededAppropriate analgesia is required (consider epidural )Yes. Blood pressures that equal or exceed 160/110 (MAP persistently above 125) should be treated with antihypertensive agents to avoid maternal central nervous system damage. The goal is to lower the blood pressure to a diastolic of about 90 to 100mmHg. IV Labetalol in an initial dose of 20 mg intravenously is one option.IV Hydralazine 5 to 10 mg intravenously every 20 minutes is the alternative choice. It's duration of action is several hours. Adequate blood pressure control is often achieved with one or two doses.Oral Nifedipine can be used to treat pregnancy induced hypertension but works unpredictably and can cause dramatic falls in blood pressure (esp. if taken sublingually). It is thus less useful in this acute situation

An epidural will also help to lower blood pressure (provided platelets are OK) . Anaesthestist may also consider insertion of a long-line for CVP monitoring.No. MgSO4 is for seizures prophylaxis, not primarily for treatment of blood pressure. After receiving medication, her blood pressure is now 140/95, pulse 90bpm, respirations 12/min, and temperature 37.8 degrees C. Her urine output over the past hour has been 30ml. You receive her blood results and find the following: haemoglobin = 120 gm/l, haematocrit = 36%, WBC = 21x109 and liver enzymes are normal. Her platelet count is 185 x109. Her magnesium level is 7 mg/dl (normal = 4 to 8mg/dl). Her clotting and fibrinogen levels are also normal. General supportive measures (ABCs)

Women already on magnesium sulphate prophylaxis who have seizures may still receive an additional bolus of two grams if they show no signs of magnesium toxicity.

A second neuroleptic agent should generally be used in the woman who continues to seize in spite of therapeutic magnesium levels and a second bolus. In this uncommon situation, diazepam, a short acting barbiturate or phenytoin may need to be used.

Involve senior anaesthetic help as GA, paralysis and ventilation would be required for prophylaxis or status epilepticus.Her elevated white blood cell count and mild pyrexia are likely related to the seizures (if there are no overt signs of infection).

Antibiotics are probably not requiredNo. H haemolysis EL elevated liver enzymes LP low platelets. One would look for haemolytic anaemia, elevated ALT and AST with low platelets to diagnose HELLP syndrome.

Commoner in multips and may respond to high-dose steroids Repeat vaginal examination shows her to be 7cm dilated. With oxytocin augmentation, she progresses rapidly to a normal vaginal delivery of a 3.8kg baby boy with Apgars of six (1) and nine (5). The placenta delivers spontaneously and appears intact. She has no uterine atony, no perineal trauma, and no postpartum haemorrhage Continue the MgSO4 for another 24 hours and then review. May be required 48 hours. More than 40% of all eclampsia occurs post-delivery. Uterine massage, oxytocin bolus 5-10 units slow IV (followed by an infusion) and Prostaglandins -Hemabate IM or misoprostol PR are appropriate. Compounds containing ergometrine should be avoided because of unpredictable rises in blood pressure. However, there is no such thing as never use ergometrine in pre-eclampsia if there was major & torrential atonic bleeding, ergometrine may be then RELATIVELY safe (& indeed may be required as a life-saving measure).

Cases of severe PPH in pre-eclampsia should definitely be managed using a CVP line (normal range is 4-10 cm H20)Check patients compliance with anticonvulsants. One would still give MgSO4 because of the presence of hypertension. The old adage every fit in mid/late pregnancy is an eclamptic fit until proven otherwise is a sensible course of action to follow.

eclampsia case ukandtz- june 2007 - case discussion with notes

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