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SEVERE PRE-ECLAMPSIA AND ECLAMPSIA

PRE-ECLAMPSIA: onset of a new episode of hypertension during pregnancy (with persistent diastolic blood pressure >90 mm Hg) with the occurrence of substantial proteinuria (>0.3 g/24 h)²

Classifying Pre-Eclampsia and Signs of Imminent Eclampsia ²

	Mild Pre-Eclampsia	Severe Pre-Eclampsia
Diastolic blood pressure	< 110	110
Proteinuria	Up to 2+	3+ or more
		Indications of severe pre-eclampsia
Headache	Absent	May be present
Visual disturbances	Absent	May be present
Upper abdominal pain (epigastric region)	Absent	May be present
Oliguria (less than 400 mL in 24 hours)	No oliguria	Diminished urinary output to less than 400 mL in 24 hours
Hyper-reflexia	Absent	May be present
Pulmonary edema	Absent	May be present

Severe pre-eclampsia and eclampsia are managed similarly, with the exception that delivery must occur within 12 hours of the onset of convulsions in eclampsia.

All cases of severe pre-eclampsia should be managed actively. Symptoms and signs of “impending eclampsia” (blurred vision, hyperreflexia) are unreliable and expectant management is not recommended.

ECLAMPSIA MANAGEMENT

Immediate management of a pregnant woman or a recently delivered woman who complains of severe headache or blurred vision, or if a pregnant woman or a recently delivered woman is found unconscious or having convulsions:

SHOUT FOR HELP

Make a quick assessment of the general condition of the woman, including vital signs while simultaneously finding out the history of her present and past illnesses from her or her relatives.

Check airway and breathing
Position her on her side
Check for neck rigidity
Check her temperature

Not breathing? or Breathing is shallow?

->YES
Open airway and intubate, if required Assist ventilation using an Ambu bag and mask Give oxygen at 4–6 L/min

->No
Give oxygen at 4–6 L/min by mask or nasal cannulae

Convulsing?	->YES Protect her from injury, but do not actively restrain her. Position her on her side to reduce the risk of aspiration of secretions, vomit and blood After the convulsion, aspirate the mouth and throat as necessary. Look in the mouth for a bitten tongue: it may swell. Give magnesium sulfate. If a convulsion continues in spite of magnesium sulfate, consider diazepam 10 mg IV.
Diastolic blood pressure remains above 110 mmHg?	->YES Administer antihypertensive drugs. Reduce the diastolic pressure to less than 100 mmHg, but not below 90 mmHg.
Fluids	Start an IV infusion. Maintain a strict fluid balance chart and monitor the volume of fluids, administered and urine output to ensure that there is no fluid overload, Catheterize the bladder to monitor urine output and proteinuria.
Urine output less than 30 mL/h?	->YES Withhold magnesium sulfate until urine output improves; Infuse a maintenance dose of IV fluids (normal saline or Ringer’s lactate) at 1 liters in 8 hours; Monitor for the development of pulmonary edema. Never leave the woman alone. A convulsion followed by aspiration of vomit may cause death of the woman and fetus.
Observe vital signs, reflexes and fetal heart rate hourly
Auscultate the lung bases hourly for rales indicating pulmonary edema	If rales are heard, withhold fluids and give Furosemide 40 mg IV once
	Assess clotting status

Anticonvulsant drugs

Magnesium sulfate is recommended for the treatment of women with eclampsia in preference to other anticonvulsants. • (Moderate-quality evidence. Strong recommendation.)³

Magnesium sulfate schedules for severe pre-eclampsia & eclampsia^1,2

Loading dose

Magnesium sulfate 20% solution	4 gm IV over 5 minutes
Follow promptly with magnesium sulfate 50% + 1 mL of 2% lidocaine	8 gm IM; 4 gm in each buttock

Ensure that aseptic technique is practiced when giving magnesium sulfate deep IM injection; warn the woman that a feeling of warmth will be felt when magnesium sulfate is given
If convulsions recur after 15 minutes, give 2 gm magnesium sulfate (50% solution) IV over 5 minutes

Maintenance dose

Magnesium sulfate 50% solution + 1 mL of 2% lidocaine

4 gm IM every 4 hours, alternate buttocks

Continue treatment with magnesium sulfate for 24 hours after delivery or the last convulsion, whichever occurs last.
Before repeat administration, ensure that
- Respiratory rate is at least 16 per minute
- Patellar reflexes are present
- Urinary output is at least 30 ml per hour over the last 4 hours
Withhold or delay drug if:
-Respiratory rate falls below 16 per minute
-Patellar reflexes are absent
-Urinary output falls below 30 ml per hour over preceding 4 hours

In case of respiratory arrest:
-Assist ventilation (mask and bag; anesthesia apparatus; intubation)

Calcium gluconate (10 mL of 10% solution)

1 gm IV slowly until drug antagonizes effects of magnesium and respiration begins

The full intravenous or intramuscular magnesium sulfate regimens are recommended for the prevention and treatment of eclampsia.
• (Moderate-quality evidence. Strong recommendation.)²

For settings where it is not possible to administer the full magnesium sulfate regimen, the use of magnesium sulfate loading dose followed by immediate transfer to a higher level health-care facility is recommended for women with severe pre-eclampsia and eclampsia.
• (Very-low-quality evidence. Weak recommendation.)²

Magnesium sulfate is a lifesaving drug and should be available in all health-care facilities throughout the health system. The guideline development group believed that capacity for clinical surveillance of women and administration of calcium gluconate were essential components of the package of services for the delivery of magnesium sulfate.²

Use diazepam only if magnesium sulfate is not available¹

A Cochrane systematic review of seven RCTs involving 1396 women provided the evidence on the differential effects of magnesium sulfate when compared with diazepam for the care of women with eclampsia.4 Magnesium sulfate fared better than diazepam regarding critical maternal outcomes of death (seven trials; 1396 women; RR 0.59, 95% CI 0.38–0.92) and recurrence of convulsions (seven trials; 1390 women; RR 0.43, 95% CI 0.33–0.55).

Diazepam schedules for severe pre-eclampsia and eclampsia¹