Eclampsia- Midwifery Emergencies

• Recognise time-critical emergency- Eclampsia
• Definition: One or more convulsions associated with pre-eclampsiaI (NICE,2010). Recognise that seizure may be the first presentation- In the postnatal period most common in the first 12 hours post birth.
• Call for help-emergency buzzer -SOAPS
• Senior midwife (Co-ordinate, keep theatre free, aware of workload on D/S)
• Obstetrician (Prescribe and administer drugs/ plan of care for birth/expedite birth)
• Anaesthetist (Manage airway, IV access, if transfer to theatre)
• Paed/Neonatologist (Infant risk morbidity/mortality/ compromised/hypoxia)
• Scribe (Document time of events/ seizure/ personnel, drugs etc)
• DRUGS/ECLAMPSIA BOX
• Record time and length of seizure (normally less than 90 seconds- self-limiting)
• DO NOT LEAVE WOMAN ALONE 
• Begin ABCDE approach

A=Airway

• Left lateral position- To open airway and reduce aorta-caval compression (if pregnant)

B=Breathing

• Give high-flow oxygen via mask with reservoir (12-15l/min)
• Due to seizures- hypoxic episode
• To improve oxygenation to vital organs i.e. brain

C=Circulation

• Site 2x large bore IV cannulas 
• Take bloods for:
  Full Blood Count- RBCs- haemolysing. Platelet count.
  U&E- To check renal function.
  Liver Function Test- Possible liver damage? Increased liver enzymes.
  Coagulation Screen-Damage to capillaries-thrombi produced.
  Group and Save- Crossmatch blood? Incase of theatre. Risk of DIC (Disseminated intravascular coagulation=formation of blood clots in the small blood vessels throughout body).
• Catheter- Strict input/output. Monitor uirne output-at least 100mls in 4 hours OR 0.5ml/kg/hr.

D=Disability

• During seizure protect from injury
• Do not attempt to restrain/put anything in mouth
• Use cot sides
• Following seizure remain in left lateral position to maintain open airway
• Maintain communication

• Control seizures- drug of choice- Magnesium Sulphate (MgSO4-)

• Loading dose- 4g Mag Sulph over 5 minutes. IV Bolus.
  8ml 50% MgSO4 (4g)
  in 12ml 0.9% NaCl (normal saline)
  into 20ml syringe
• Maintenance dose- 1g/hr
  20ml 50% MgSO4 (10g)
  in 30ml 0.9% NaCl (normal saline)
  into 50ml syringe
  Place into a syringe driver and set the pump to run IV at 5ml/hr- SAFE
• Continue for 24 hours following birth or last seizure (whichever was most recent)
• Side effects: Flushes, burning sensation up arm
• Toxicity suspected? Call for help. Stop Mag Sulph, administer O2, administer calcium glutonate IV 1g (100mls 10%), start BLS

• Blood Pressure (Need to treat hypertension to keep BP <150/100mmHg
• Pulse
• Respiratory Rate
• Patellar reflexes- Hourly- to monitor for magnesium toxicity
• Oxygen saturations
• Level of consciousness- AVPU
• Rationale for observations: Risk of respiratory depression, cardiac arrest

• Identify immediate aftercare will require level 2 critical care obstetric HDU
• Strict fluid balance- fluid restriction

If pregnant...

• Ensure left lateral, use wedge to avoid aorto-caval compression
• Monitor FHR immediately post-seizure- compare with mat pulse
• Commence continuous CTG
• Maternal condition must be stabilised prior to planning birth
• Involve paediatricians 

• One-to-one care
• Women, family and staff - psychological care
• MEWS, HDU chart, Drug Wardex, Fluid Balance chart
• Incident report form

Identify possible complications (Maternal and fetal) associated with this scenario

• Physical injuries: tongue biting, head injury
• Recurrent fits
• Maternal- Complications of PE, HELLP syndrome, coagulopathy, intracerebral bleeding, CVA, aspiration, perinatal morbidity and mortality
• Fetus- prematurity, hypoxia, compromised fetus

• Relationship to pre-eclampsia (ref)
• Incidence
• Research
• Magpie Trial
• Risk factors
• Other references

E=Exposure

• Respect dignity
• Minimise exposure and heat loss
• If pregnant, CTG (Risk of abruption/hypoxic episode/bradycardia common/mode of birth/birth plan) Obstetric review-timing of birth etc.
• Injuries (biting tongue/banged head etc).

B=Breathing

• Give high-flow oxygen via mask with reservoir (12-15l/min)
• Due to seizures- hypoxic episode
• To improve oxygenation to vital organs i.e. brain