Олег Блинников. Стандартизованные протоколы лечения эклампсии.

Подписаться на этот форум

Посмотреть другие темы

Severe pre-eclampsia / eclampsia protocol
(The protocol is adapted for conditions of the Provincial Hospital)

Definition.

Pre-eclampsia is a multisystem disorder that is usually associated with raised blood pressure and proteinuria in pregnancy. Eclampsia is defined as the occurrence of one or more convulsions in association with the syndrome of pre-eclampsia.

Criteria for inclusion

Any woman with severe proteinuric hypertension where the decision has been made to deliver and where one of the following criteria is met (Either 1,2, or 3)

1. Hypertension (>= 140/90 mm Hg) with proteinuria (>= 0.3g/day or
1. Hypertension (>>=2+ on analysis) and at least one of the following:
- Headache, visual disturbance, epigastric pain
- Clonus (>=3 beats)
- Platelet count <100 x 109, AST >50 IU/L

2. Severe hypertension (systolic >=170mm Hg or diastolic >=110 mm
Hg) with proteinuria (>=0.3 g/day or 2+ on urinalysis)

3. Eclampsia

If these criteria are met the patient is managed according to the
following protocol irrespective of mode of delivery or method of
analgesia

Whenever a patient is commenced on the protocol ensure;
1. Consultant in charge of the case is aware
2. Anesthetist on call for the labour ward is aware

Step 1. Initial Management

1. Transfer patient to High Care Unit
2. Place the patient in the recovery position (left lateral
position)
3. Secure and maintain the airways
4. Designate One to One nursing care
5. Give oxygen via a face mask
6. Put a pulse oxymeter
7. Establish monitoring of blood pressure and pulse
8. Set up a venous access, start Normal Saline 1L, (85ml/h)
9. Insert urinary catheter
10. Send bloods for Hb, Ht, Blood group, X match, Platelet count,
Transaminases, Urea and Creatinine, Glucose.

Step 2. Convulsions control (in case of Eclampsia)

1. Diazepam 10 mg, iv, over 2 minutes, then
2. MgSO4 10ml 15% , iv, slowly, over 5 minutes, then
3. MgSO4 10ml 15%, iv, slowly, over 10 minutes, then
4. MgSO4 50ml, 15% plus Normal Saline 1L, iv drip

A loading dose of 3g should be given over 15 minutes followed by a maintenance infusion of not more than 1g/h continued for at least 24 hours after the last seizure. Recurrent seizures should be treated by a further bolus of 1,5g (10ml 15%).

Magnesium toxicity causes loss of deep tendon reflexes, followed by respiratory depression and ultimately respiratory arrest. In most cases therapy can be monitored safely by hourly measurement of the patellar reflex and respiratory rate or oxygen saturation. Repeat doses of magnesium sulphate can be given only if:

- Urine output is at least 100ml per four hours
- Knee reflexes are present
- Respiratory rate is at least 16 per minute

Significant respiratory depression should be treated with 1g IV calcium gluconate given over 10 minutes.

Maximum dose of Magnesium Sulphate is 40 grams in 24 hours

Step 3. Treatment of hypertension

Reduction of severe hypertension (blood pressure > 160/110 mm Hg or mean arterial pressure > 125 mm Hg) is mandatory to reduce the risk of cerebrovascular accident. Treatment may also reduce the risk of further seizures

1. Hydralazine 5mg IV repeated every 20 minutes to a maximum cumulative dose of 20mg
or
2. Labetalol 20mg IV escalating to 40 or 80mg every 10 minutes to a maximum cumulative dose of 300mg
or
3. Nifidepine (Adalat) 10mg, orally or sublingually, twice daily

Fluid therapy

Close monitoring of fluid intake and urine output is mandatory. Record the urine output every 4 hours. Fluid therapy should be limited to maintenance normal saline or 5% dextrose (60-85ml/h). Suspect kidney failure if the urine output is less than 80ml per 4 hours. In such a case the total fluid intake should not exceed 500ml per 24 hours plus the amount equal to the amount of urine passed. Diuretics should be not used.

Delivery

The definitive treatment of eclampsia is delivery. However, it is inappropriate to deliver an unstable mother even if there is fetal distress. Once seizures are controlled, severe hypertension treated, and hypoxia corrected, delivery can be expedited. Vaginal delivery should be considered but caesarean section is likely to be required in primigravidae remote from term with an unfavourable cervix. Difficult deliveries must be avoided. If there is delay, caesarean section must be carried out immediately.

Labour should be induced by rupturing the membranes and giving oxytocin, only if:
o The cervix is very ripe (almost fully effaced, dilatation 2-3cm)
o The foetus is of normal or small size
o The pelvis appears of normal size on vaginal examination
o No other contra-indications for vaginal delivery is exist

Ergometrine should not be given in the third stage because it may cause a rise in blood pressure - instead, give Oxytocin 10 IU im.

Caesarean section should be performed if:
o There is a contra-indication to induction
o Active labour does not follow within four hours of induction

Vaginal delivery of an eclamptic woman in active phase of first stage labour should be allowed only if:
o Labour is progressing quickly
o There are no contra-indications to vaginal delivery.

5. After delivery

1. After delivery, high dependency care should be continued for a minimum of 24 hours. If the patient has fits after delivery, continue close observation and management for 48 hours after the last fit.
2. Monitor blood pressure hourly. Continue treatment of hypertension until diastolic blood pressure drops below 110 mmHg.
3. Continue to monitor urinary output. If the woman retains fluid it is because the kidneys are slow to excrete the fluid after delivery. This can cause a rise in blood pressure. Be careful not to give too much fluid intravenously during this period.
4. If after 48 hours there are no fits, the urinary output is adequate, and the diastolic blood pressure is below 100mgHg, continue 4-hourly blood pressure checks for several more days.