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.
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).
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:
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.