KENYATTA NATIONAL HOSPITAL

STANDARD OPERATING PROCEDURE

Dept: OBSTETRICS AND GYNAECOLOGYNO: SOP/KNH/OBS/46ISSUE: November 2008REVIEW: November 2010VERSION: 02Page 6 of 9

TITLE: MANAGEMENT OF PATIENTS WITH ECLAMPSIA OBJECTIVE To reduce maternal & perinatal morbidity and mortality.

1.0 Title MANAGEMENT OF ECLAMPSIA2.0 Scope: All women presenting with eclampsia at Kenyatta National Hospital. 3.0 Purpose

To reduce maternal & perinatal morbidity and mortality.4.0 Terms (definitions)

Eclampsia is the occurrence of convulsions that cannot be attributed to other causes in preeclamptic patient.5.0 Responsibilities

Primary nurse/midwife - Nursing care

SHO Primary doctor Senior Registrar

Consultant Anaesthetists 6.0 Method

MANAGEMENT PROTOCOLEclamptic convulsions are life threatening emergencies and require the proper treatment to decrease maternal morbidity and mortality. All patients presenting with history of convulsions or coma in pregnancy or early postpartum period should be managed as eclampsia till proved otherwise. 1. Call for help including appropriate personnel e.g. SHO, Senior Registrar, consultant and anaesthetist.2. Gather the ECLAMPSIA KIT3. Assess the airway, breathing and circulation and monitor vital signs (BP, Pulse rate, Respiratory rate, fetal heart) hourly.4. Clear the airway and administer oxygen by mask at 4-6L/min

5. Protect the patient against injury during the convulsion and do not actively restrain her.6. Put the patient in the left lateral position to help improve uterine blood flow if pregnant and prevent aspiration.

7. Two IV lines should be fixed of gauge 16-18. One line should be dedicated towards administration of MgSO4 and the other line for other medications.8. Insert a Foleys catheter size 16 0r 18 and balloon with 5ml of normal saline and connect to a urine bag.9. Administer MgSO4 Loading dose Give 4g of 20% MgSO4 solution IV over 5 minutes in the MgSO4 dedicated line.

Follow immediately with 10grams of 50% MgSO4 solution; give 5grams in each buttock as a deep IM injection with 1ml of 2% lignocaine in the same syringe. If convulsions recur within 15 minutes of the initial dosing give 2 grams of 20% MgSO4 solution IV over 5 minutes.Maintenance dosing

This can be done through the IM or IV route.

The IV route: give 1g of 20% MgSO4 solution every hour by continuous infusion. To prevent fluid overload reconstitute as follows: 4g of MgSO4 in 100mls, drain 200ml of saline from the litre normal saline bottle. Put 2100ml of MgSO4 solution (8g) in the now 300 ml normal saline bottle to make 500ml of 8g of MgSO4 this is given 8 hourly. This is given at 16drops/min. The IM route: give 5g of 50% MgSO4 solution with 1ml of 2% lignocaine in the same syringe by deep IM alternate buttock every 4 hours.

The maintenance dosing should be continued for 24 hours after delivery or the last convulsion whichever occurs last.Monitoring for magnesium sulphate toxicityBefore repeat administration ensure: Respiratory rate is at least 16/minute.

Patellar reflexes are present.

Urinary output is at least 30ml/hr over the last 4 hours. Withhold or delay MgSO4 administration if: Respiratory falls below 16/min. Absent patellar reflexes.

Urinary output below 30ml/hr over the last 4 hours. Keep antidote ready Incase of respiratory arrest Assist ventilation Give calcium gluconate 1gram slowly(10ml of 10% solution) If repeated convulsions give Diazepam 10mg IV slowly over 2 minutes.

If convulsions persist, intubate the patient to protect airway and maintain oxygenation and transfer to critical care unit.

10. Nursing care: These patients should be nursed by one nurse per patient or one nurse per acute room in the labour ward.11. Blood pressure control The drug of choice is IV hydrallazine.

If diastolic BP remains above 110mmHg give hydrallazine 5mg IV slowly every 15 minutes till the BP is controlled.

1 vial of 2ml has 20mg of hydrallazine. Add 18ml water for injection so as to have 20mg in 20ml of solution. Therefore, 5ml of this solution contains 5mg which is to be given every 15 minutes until the desired BP range is achieved.

The goal is to keep the diastolic BP between 90 and 100mmHg to prevent cerebral haemorrhage.

12. Fluid balance

The fluid of choice is normal saline. Maintain a strict fluid balance chart (monitor the amount of fluids given and the urine output) to prevent fluid overload with attendant pulmonary oedema.

Urine output should be maintained at 30ml/hour.13. Investigations Random blood sugar

Blood slide for malaria parasites

Bedside clotting time

Full blood count

Liver function test

Renal function test

Urine dipstick to assess proteinuria

Group and cross match blood.

14. Planning delivery Delivery should take place as soon as the womans condition has stabilized. Delivery should be effected within 12 hours of the onset of convulsions.

Assess the cervix. Vaginal delivery:a) If the cervix is favorable do artificial rupture of membranes and induce labour with oxytocin.

b) Dead fetus or too premature for survival: if the cervix is unfavourable ripen the cervix with prostaglandins or a Foleys catheter.

Caesarean delivery: Ensure coagulopathy has been ruled out (bedside clotting time less than 7 minutes).a) If the cervix is unfavorable and fetus is alive.b) If vaginal delivery is not anticipated within 12 hours.c) If there is evidence of non-reassuring fetal status.

15. Postpartum care Anticonvulsive therapy should be maintained for 24 hours after delivery or last convulsion whichever occurs last.

Continue antihypertensive therapy as long as the diastolic BP is 110mmHg or more.

Continue to monitor urine output. 16. Prophylactic therapyMgSO4 as per the protocol should be used in patients with severe pre-eclampsia to prevent convulsions.7.0 Reference

Royal college of Obstetrics and Gynaecology guidelines. Managing complications in pregnancy and childbirth: A guide for midwives and doctors. WHO 2007.8.0 Appendices Eclampsia kit Eclampsia monitoring chartPrepared by:

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Kenyatta National Hospital Obs & Gynae Department