PE

1. MANAGEMENT OF SEVERE
PE/ECLAMPSIA IN DISTRICT
HOSPITAL

2. Definition
 Pre-eclampsia
 New hypertension presenting after 20 weeks with
significant proteinuria (>300mg protein in 24h)
 Severe pre-eclampsia
 Pre-eclampsia with severe hypertension and/or
with symptoms, and/or biochemical and/or
haematological impairment
 Eclampsia
 A convulsive condition that arises from PE

3. NICE GUIDELINES

4. Referral to critical care
 Indications for referral to critical care levels
 Level 3
 Severe PE and needing ventilation
 Level 2
 Severe PE with either of the following:
 eclampsia
 HELLP syndrome
 haemorrhage
 hyperkalaemia
 severe oliguria
 coagulation support
 IV antiHTN treatment
 Initial stabilisation of severe HTN
 Evidence of cardiac failure
 Abnormal neurology
 Level 1
 Mild or moderate PE
 Ongoing conservative antenatal Mx of severe pre-term HTN
 Step-down treatment after birth

5. Severe pre eclampsia :
Management Principle
 Control hypertension
 Aim diastolic BP between 80–100 mmHg
 Aim systolic BP less than 150 mmHg
 MgSO4 to prevent seizures
 Plan for delivery
 Where?
 When?
 How?

6. Control hypertension
 Labetalol(oral/IV)
 IV 25mg slow bolus
 repeat every 20 mins, max 2 doses
 If DBP>110 start infusion
 Nifedipine(oral)
 Hydralazine(IV)

7. Prevent Eclampsia
 MgSO4
 Loading dose
 Maintenance dose
 In district hospital – What is the best route while
waiting and during transfer?

8. Plan for delivery
 Manage pregnancy conservatively only in
mild PE
 Immediate delivery once BP controlled and
completed antenatal steroids if possible, if
-severe HPT develops refractory to
treatment
-maternal haematological, biochemical or
clinical indications
-fetal indications

9. Eclampsia: Principle of
management
 Resuscitation
 To stop the seizures
 Prevent recurrent seizure
 Control BP
 Plan for delivery

10. Eclampsia
 Resuscitation
 Call for help + refer to tertiary hospital
 ABC
 Secure 2 IV lines
 Abort seizure with IV/IM MgSO4 loading dose
then maintenance dose
 Start parenteral anti-hypertensive if DBP
>110 or MAP >125
 Plan for delivery: timing and mode

11. Case Illustration
 Hospital Betong on weekend @ 6 PM
 18 y.o. G1P0 @ 34 weeks
 Sudden onset of blurring of vision
 BP 180/120, urine albumin 3+
 Uterus 28 weeks, FH+
 Diagnosis ?

12. How to manage ?

13.  Control BP- what drug ?
How fast ?
 MgSO4 ?
 Loading
 Maintenance
 Plan delivery
 How are you going to arrange
 Referral
 Transportation

14. During transportation
 Prepare syringes of IV MgSo4 2g and IV/IM
Diazepam 10mg
 Give IV MgSO4 2g slow bolus over 5 minutes if
patient had an eclamptic episode during transit
 If repeated IV MgSO4 2g does not abort the
eclampsia, IV/IM diazepam 10mg can be given
by slow bolus over 5 minutes
 Ensure resus equipments available

15. The deteriorating patient
 Worst scenario for the ambulance team
 Look for reversible causes *
 Do things that you can do
 Ask for help *
 Don’t panic
 Don’t blame
 Don’t avoid issue

16. Things that commonly go wrong …
 Oxygen supply
 Airway obstruction
 Vital signs monitoring
 Problems with Fluid and Drug delivery
 Dislodged definitive airway
 Deterioration of condition of patient

17. Key take home messages
 Understand limitations of district hospital
 Know when to refer
 Management of PE in emergency situations