A  35  year  old  female  is  39  weeks  pregnant.   Her  pregnancy   has  been complicated  by hypertension  and proteinuria.  Her blood pressure  is 160/120 mm Hg. You are called  to the labour  ward when  she suffers  a generalised (“grand mal”) convulsion.

Outline your overall plan of management.

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College Answer

Initial management
ABC – ensure patent airway, oxygen via reservoir mask or bag-valve-mask  assembly and
support ventilation as needed
Left lateral tilt
Terminate the seizure
Diazepam 5-10mg or Mg 4g IV up to 8 g
Monitors / investigations

Management of Hypertension
Hydrallazine
Labetalol
(Other agents are acceptable – late in pregnancy – increasing trend to use “mainstream”
agents)

Treatment of convulsions
MgSO4 bolus followed by maintenance MgSO4
(Shown to be more effective than phenytoin or diazepam in preventing recurrent seizures) Addition of Benzodiazepine / Barbiturate if recurrent seizures despite MgSO4

Planning for delivery
Brief period of resuscitation once seizures controlled.

Post partum management
Continue anti-convulsants until patient improves (diuresis, fall in BP).

Discussion

This patient was having what can be described as "severe preeclampsia". The seizure pushes her over into the eclampsia territory.

Consequently, the management should look like this:

  • Attention to the ABCS, with management of life-threatening problems simultanous with a rapid focused examination and a brief history.
  • Airway:
    • Assess the need for airway support in context of post-ictal unconscious state
    • Weigh benefits of intubation against risks in context of the known airway access problems associated with pregnancy
  • Breathing/ventilation
    • Assess oxygenation and briefly examine for aspiration
    • High flow oxygen via NRBM if patient is not in need of immediate intubation
  • Circulatory support
    • Assess cardiovascular stability
      • left lateral 30° tilt if hypotensive
    • Access with widebore cannula
  • Immediate investigations:
    • FBC - looking for thrombocytopenia
    • LFTs - looking for HELLP, hepatic encephalopathy
    • EUC - looking for hyponatremia
    • CMP
    • Coags
    • Antiepileptic drug levels, if relevant
    • CT brain, if the patient fails to awaken
  • Specific management
    • Antihypertensives:
      • labetalol, nifedipine or hydralazine are of equivalent benefit
      • methyldopa and sodium nitroprusside are second line agents
    • Antiepileptic therapy:
      • Loading dose of magnesium sulfate, followed by an infusion, aiming at a serum level of 2.0-3.5mmol/L
      • Diazepam and phenytoin can be considered if seziures are refractory
    • Arrange for a consultation with the obstetrician regarding the safety and practicality of immediate delivery.

References

References

Heres an article by Baha  Sibai, who came up with the Tennessee classification for the HELLP syndrome:

Sibai, Baha M. "Diagnosis, prevention, and management of eclampsia."Obstetrics & Gynecology 105.2 (2005): 402-410.