and Management of Preeclampsia and Eclampsia 2 B y t he end o f t h i s s e ss i on t he l ea r n e r s w il l be ab l e t o D e ID: 1000620
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1. Prevention, Identification and Management of Pre-eclampsia and Eclampsia
2. 2By the end of this session, the learners will be able to:Define various terms in hypertensive disorders of pregnancyDescribe supportive care of woman with eclampsia during a fitDescribe the dose and route of administration of injection magnesium sulphate for the management of pre-eclampsia and eclampsiaLearning Objectives
3. Pre-eclampsia/Eclampsia is the Second Leading Cause of Maternal Mortality – Globally and in IndiaPre-eclampsia/Eclampsia can be prevented and managed by:Recording and monitoring of BP and urine protein examination of all labouring womenTimely identification of danger signsGiving inj MgSO₄ in all mothers having Severe pre-eclampsia and Eclampsia3
4. Definitions- Hypertensive disorders of pregnancyHypertension: BP >=140/90 TWO consecutive readings 4 hours apartChronic Hypertension: Hypertension before 20 weeks of pregnancyPregnancy Induced Hypertension (PIH): Hypertension after 20 weeksPre-eclampsia (PE): >=140/90 but <160/110 with proteinuria trace, 1+ or 2+Severe pre-eclampsia (Severe PE): >= 160/110 with proteinuria 3+ or 4+PE with presence of any symptoms like headache, blurring of vision, epigastric pain or oliguria and abnormal oedema over face, hands, abdomen and vulva Eclampsia (E): Convulsions with >=140/90 and proteinuria more than trace NOTE- Convulsions in pregnancy, labour and postpartum period should be considered ‘Eclampsia’ unless proved otherwise.
5. Need for MgSO4Management with Inj. MgSO4 should be given in following conditions:EclampsiaSevere PE: >= 160/110 with proteinuria 3+ or 4+PE with presence of any symptoms like headache, blurring of vision, epigastric pain or oliguria and abnormal edema over face, hands, abdomen and vulva 5
6. Management of Severe PE/E6
7. Anti - Hypertensive need to be given if Diastolic BP > 100 mm Hg (as per GoI protocol poster on Pre-Eclampsia)Tab Alpha-Methyl Dopa or tab Labetalol can be used for controlling BPTarget should be to maintain diastolic BP between 90-100 mm HgIn case of severe Pre eclampsia, use of tab Nifedipine or Inj. labetalol is recommended for initial control of BPRole of Anti-hypertensive7
8. Administration of MgSO4First dose (at Non-FRU level): Total 10 grams5 g (10mL) magnesium sulphate deep IM in each buttockPatient should reach FRU in 2 hours for further managementLoading dose (at FRU level): Total 14 grams4 g (8mL) magnesium sulphate diluted with 12 ml NS or distilled water in 20 ml syringe i.e. 20%, and given slow IV in 5-10 minutes5 g (10mL) magnesium sulphate with 1 ml 2% lignocaine deep IM in each buttock8
9. Administration of MgSO4- Maintenance Dose5 g (10mL) magnesium sulphate with 1 ml 2% lignocaine deep IM in alternate buttock every 4 hoursTo be given for 24 hours after last convulsion or delivery- whichever occurs later9
10. 10 Watch for toxicity signs before every maintenance doseUrine output: < 25-30 ml/hourDeep Tendon Reflex (knee jerk): Absent Respiratory rate: < 16/minuteAdministration of MgSO4- Toxicity SignsNOTE- With hold the next dose in case of presence of any toxicity signGive antidote Inj Calcium gluconate (10 ml 10 % in 10 minutes) slow IV for respiratory toxicity
11. We can administer 2 gm MgSO4 20% IV dose only onceThen we continue giving four hourly maintenance doses for 24 hrsGive diazepam, 5-10mg IV stat may be repeated every 10-15 minutes upto maximum of 30mg doseIf convulsions still not controlledIf convulsions controlledSend patient for C-section If convulsions still not controlled = status eclampticusAdministration of MgSO4- Recurrent Episode11Additional Dose: 2 g (4mL) magnesium sulfate diluted in 6mL of NS/distilled water in 10mL syringe i.e. 20%, given slow IV over 5-10 minutes.
12. 12GoI recommends use of magnesium sulphate by nurses in cases of severe pre eclampsia and eclampsia (first dose)Magnesium sulphate is a very safe drug and can be easily used with monitoring of toxicity signsEven in case where any sign of toxicity is seen, generally withholding the next dose is sufficient to address itAntidote may only be needed in case of respiratory toxicity which is very rare at the usual recommended doses with close monitoring Give antidote – Inj. Calcium gluconate 10 ml 10 % in 10 minutes slow IV for respiratory toxicity.Magnesium Sulphate is a Safe Drug to Use
13. DIAGNOSISPregnant Women Scenario (Irrespective of gestational age)Nursing Care requireDescriptionGESTATIONAL HYPERTENSIONPRE-ECLAMPSIASEVERE PRE-ECLAMPSIAECLAMPSIAPresenting in LabourPresenting Without LabourPresenting in LabourPresenting in LabourPresenting in LabourPresenting Without LabourPresenting Without LabourPresenting Without LabourAdmit and treat as per progress of labourFollow up in OPD once a weekAdmit and treat as per Progress of labourFollow up in OPD twice a weekAdmit and give MgSO4 & do needfulAdmit and give MgSO4 & do needfulStabilize convulsions, position in left lateral, Mouth gag, Do suctioning, clear secretion, Start oxygen, catheterize, give MgSO4 & terminate pregnancy within 12 hrsTo Identify What Nursing Care Needed
14. DIAGNOSISPregnancy of <23 WeeksPregnancy of 24-34 WeeksPregnancy of 35-36 WeeksPregnancy of >37 WeeksGESTATIONAL HYPERTENSIONPRE-ECLAMPSIASEVERE PRE-ECLAMPSIAECLAMPSIAIf unstable, give antenatal corticosteroids and terminate within 24hrsIf stableIf she is already in labour, let her progress in labourIf unstable, do not give antenatal corticosteroids and terminate within 24hrsIf stableIn all cases of eclampsia terminate pregnancy within 12 hrsTo Terminate the Pregnancy or Not14
15. 15WHO recommends calcium supplementation for prevention of PE/E in populations whose diets are deficient in calciumGoI recommendationsEvery woman would be given calcium supplementation for 6 months during ANC period after 1st trimester and for 6 months during lactation. Two calcium tablets would be given dailyEach tablet shall contain 500mg elemental Calcium and 250 IU Vitamin D3To be implemented at all levels of contact of the pregnant women with the health system.Calcium Supplementation for Prevention of Pre-Eclampsia/Eclampsia (PE/E)
16. Pre-eclampsia/Eclampsia is the major killer, deaths from which can be prevented through proper ANC and if this happens can be managed with timely administration of inj. MgSO4Proper nursing care and timely inj. MgSO4 administration is key in management of eclampsia case MgSO4 is a safe drug for mother and can be given without hesitation. Toxicity of MgSO4 is very rare.At sub Centre ANM can safely give first dose of 5-5 gms deep IM on each buttock and refer to higher facility for further management. Key Messages16