ECLAMPSIA- ICU MANAGEMENT PROTOCOL

Definition One or more generalized tonic-clonic convulsions and/or coma in the setting of pre-eclampsia in the absence of other neurological conditions.

Clinical manifestations and diagnosis a) Maternal -imminent symptoms & signs persistant frontal/ occiptal headache visual disturbances right upper quadrant or epigastric pain altered mental status - generalized tonic-clonic convulsions lasting 3-4 minutes. b) Fetal -fetal bradycardia lasting 3-5 minutes during and immediately after a seizure.

Management * Definitive treatment is DELIVERY irrespective of gestational age. 1. Prevent maternal hypoxia and trauma - maintain airway patency. - prevent aspiration roll gravida to left side. - give O 8-10 litres/min via face mask. 2. Manage severe hypertension ( SBP160mmHg &/ DBP110mmHg) Hydralazine 5mg IV bolus Followed by 5-10mg IV boluses every 20 minutes. OR Labetalol

10mg IV bolus Followed by doubling dose at 10 minute intervals up to 80mg Maximum total cumulative doseof 230mg i.e 1020408080.

* Reasonable BP goals: SBP 140-155mmHg, DBP 90-105mmHg. * Maximal initial (within 10-20 minutes) fall in BP should not exceed 25% of presenting value. 3. Prevent recurrent seizures Magnesuim sulphate (MgSO) is the drug of choice. Safer and more effective than phenytoin or diazepam. Neuroprotective effect for fetus. Low cost, less sedative.

MgSO Loading dose 4g IV over 15-20 minutes PLUS 5g IM in each buttock. * Beware of hypotesion in a patient on Ca+ channel blockers. Maintenance dose 5g IM every 4 hrs in alternate buttocks OR 2g IV/hr continous infusion * Maintenance dose given only if: - patellar reflex present - respiratory rate> 12/min -urine output > 100mls in 4hrs * Loss of deep tendon reflexes is the first manifestation of symptomatic hypermagnesemia. * Serum Mg levels are not required if clinical status is closely monitored. * Calcium gluconate 1g IV is the antidote for Mg+ toxicity. 4. Management of persistant convulsions Additional bolus of MgSO, 2g IV over 15-20 minutes.

 Diazepam -

maximum of 2 boluses!

0.1-0.3mg/kg IV over 1 minute. Maximum cumulative dose is 20mg. OR

Lorazepam 0.02-0.03mg/kg IV.

* If no resolution of seizures: Load with phenytoin 15-20mg/kg over in 30 minutes in normal saline.

5. Delivery - is the definitive treatment. - achieved by the fastest mode possible. 6. Post Partum Care - monitor maternal vital signs closely. - input & output monitoring essential as a diuresis of> 4l/day is the most accurate indicator of clinical resolution. - continue MgSO prophylaxis for 24hrs after delivery or after last seizure whichever comes last.