Prevention, Identification and Management of Pre-eclampsia and Eclampsia

1. Prevention, Identification and Management of Pre-eclampsia and Eclampsia

2. Learning Objectives Bytheendof thissession, thelearnerswill beable to: • Definevarious terms inhypertensivedisordersof pregnancy • Describesupportivecareofwomanwitheclampsiaduringafit • Describethedoseand routeofadministrationof injectionmagnesium sulphatefor the managementof pre-eclampsiaandeclampsia

3. Pre-eclampsia/Eclampsia is the Second Leading Cause of Maternal Mortality – Globally and in India Pre-eclampsia/Eclampsia can be prevented and managed by: • Recording and monitoring of BP and urine protein examination of all labouring women • Timely identification of danger signs • Giving injMgSO₄ in all mothers having Severe pre-eclampsia and Eclampsia

4. Definitions- Hypertensive disorders of pregnancy • Hypertension: BP >=140/90 TWO consecutive readings 4 hours apart • Chronic Hypertension: Hypertension before 20 weeks of pregnancy • Pregnancy Induced Hypertension (PIH): Hypertension after 20 weeks • Pre-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 MgSO4 Management with Inj. MgSO4 should be given in following conditions: • 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 edema over face, hands, abdomen and vulva

6. Management of Severe PE/E

7. Role of Anti-hypertensive • Anti - Hypertensive need to be given if Diastolic BP > 100 mm Hg (as per GoI protocol poster on Pre-Eclampsia) • Tab Alpha-Methyl Dopaor tab Labetalol can be used for controlling BP • Target should be to maintain diastolic BP between 90-100 mm Hg • In case of severe Pre eclampsia, use of tab Nifedipine or Inj. labetalol is recommended for initial control of BP

8. Administration of MgSO4 • First dose (at Non-FRU level): Total 10 grams • 5 g (10mL) magnesium sulphate deep IM in each buttock • Patient should reach FRU in 2 hours for further management • Loading dose (at FRU level): Total 14 grams • 4 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 minutes • 5 g (10mL) magnesium sulphate with 1 ml 2% lignocaine deep IM in each buttock

9. Administration of MgSO4- Maintenance Dose • 5 g (10mL) magnesium sulphate with 1 ml 2% lignocaine deep IM in alternate buttock every 4 hours • To be given for 24 hours after last convulsion or delivery- whichever occurs later

10. Administration of MgSO4- Toxicity Signs • Watch for toxicity signs before every maintenance dose • Urine output: < 25-30 ml/hour • Deep Tendon Reflex (knee jerk): Absent • Respiratory rate: < 16/minute NOTE- With hold the next dose in case of presence of any toxicity sign Give antidote Inj Calcium gluconate (10 ml 10 % in 10 minutes) slow IV for respiratory toxicity

11. Magnesium Sulphate is a Safe Drug to Use • GoI 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 signs • Even in case where any sign of toxicity is seen, generally withholding the next dose is sufficient to address it • Antidote 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.

12. To Identify What Nursing Care Needed Presenting in Labour Admit and treat as per progress of labour GESTATIONAL HYPERTENSION Presenting Without Labour Follow up in OPD once a week Presenting in Labour Admit and treat as per Progress of labour PRE-ECLAMPSIA Follow up in OPD twice a week Presenting Without Labour Presenting in Labour Admit and give MgSO4 & do needful SEVERE PRE-ECLAMPSIA Presenting Without Labour Admit and give MgSO4 & do needful Presenting in Labour Stabilize convulsions, position in left lateral, Mouth gag, Do suctioning, clear secretion, Start oxygen, catheterize, give MgSO4 & terminate pregnancy within 12 hrs ECLAMPSIA Presenting Without Labour

13. To Terminate the Pregnancy or Not If she is already in labour, let her progress in labour GESTATIONAL HYPERTENSION PRE-ECLAMPSIA If unstable, give antenatal corticosteroids and terminate within 24hrs If unstable, do not give antenatal corticosteroids and terminate within 24hrs SEVERE PRE-ECLAMPSIA If stable If stable ECLAMPSIA In all cases of eclampsia terminate pregnancy within 12 hrs

14. Calcium Supplementation for Prevention of Pre-Eclampsia/Eclampsia (PE/E) • WHO recommends calcium supplementation for prevention of PE/E in populations whose diets are deficient in calcium GoI recommendations • Every 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 daily • Each tablet shall contain 500mg elemental Calcium and 250 IU Vitamin D3 • To be implemented at all levels of contact of the pregnant women with the health system.

15. Key Messages • Pre-eclampsia/Eclampsiais themajor killer, deathsfrom whichcanbeprevented through proper ANC andifthishappenscanbemanagedwith timelyadministrationofinj. MgSO4 • Propernursingcareandtimely inj.MgSO4administrationiskey inmanagement of eclampsiacase • MgSO4isasafedrugfor mother andcanbegivenwithouthesitation. ToxicityofMgSO4 isveryrare. • Atsub CentreANMcansafelygivefirstdoseof5-5gmsdeep IMoneachbuttockandrefer to higherfacilityfor furthermanagement.