ECLAMPSIA

Eclampsia

Treatment:

  • Controle convulsions with Magnesium Sulfate and/or Valium
  • Treat hypertension  
  • Deliver as rapidly and least traumatically as possible
    • FETUS ALIVE
      • Gestational age > 36 weeks
        • Urgent C/S
      • Gestational age < 36 weeks
        • Vaginal delivery
        • Induction and/or augmentation
          • Oxytocin
    • FETUS DEAD
      • Vaginal delivery
      • Induction and/or augmentation
        • Misiprostol (Cytotec)
      • Destructive delivery if needed
  • Monitor vital signs closely
  • Continue antihypertensive treatment
  • Give regular doses of Magnesium Sulfate and/or Valium to prevent convulsions
  • Keep a syringe with 5-10 mg valium at bedside for immediate i.v. administration to control breakthrough convulsions
  • Watch out for signs of DIC (HELLP)

MEDICATIONS

MAGNESIUM SULFATE

  • 500mg /ml solution

FOR ECLAMPSIA

  • 4 g intravenous loading dose
  • Immediately followed by 10 g intramuscularly – 5 mg in each buttock
  • Followed by 5 g intramuscularly every 4 hours in alternating buttocks
  • Check patellar reflexes before each injection
  • If weak or absent wait another 4 hours before giving next injection

MISOPROSTOL

  • Tablet Cytotec 200 µg

FOR INDUCTION IN IUFD

Gestational age < 26 weeks

  • ORAL ADMINISTRATION (preferred)
    • One tablet diluted in 10 cc
      • 2 cc orally every 6 hours
  • VAGINAL ADMINISTRATION
    • ½ tablet in vagina every 6 hours

Gestational age > 26 weeks

  • ORAL ADMINISTRATION (preferred)
    • One tablet diluted in 10 cc
      • 1 cc orally every 4 hours
  • VAGINAL ADMINISTRATION
    • ¼ tablet in vagina every 4 hours
    • One tablet diluted in 10 cc
      • 1 cc in vagina every 4 hours

Use only exceptionally and with greatest precaution for induction with alive fetus

FOR POSTPARTUM BLEEDING

ORAL ADMINISTRATION (preferred)

  • 2 to 3 tablets orally

RECTAL ADMINISTRATION

  • 2 to 4 tablets rectally

VALIUM

For Eclampsia:

  • 5 to10 mg i.v. or rectally
  • Repeat after 10 to 15 minutes up to a maximum dose of 30 mg
  • If needed repeat after 2 to 4 hours.
  • Keep a syringe loaded with 10 mg at bedside
  • Give immediately i.v. when a seizure is noted

OXYTOCIN

FOR INDUCTION OF LABOUR

  • 10 units in 500 cc Normal Saline solution
  • Start i.v. infusion with 10 ml per hour
  • increase by 20 ml every 20 minutes until contractions occur

FOR POSTPARTUM HEMORRHAGE

  • 30 units in 500 CC Normal Saline
  • Infused over 2 to 4 hours

NEFIDIPINE

For Hypertension:

  • 10 mg 3 times daily

For Premature Labor:

  • 10 to 40 mg
  • Followed by 10 to 20 mg every 6 to 8 hours

LIDOCAINE

For Eclampsia:

  • 2mg/kg i.v. as a bolus

2mg/kg/h i.v. as maintenance

SALBUTAMOL

  • Tablets 4 mg

For Premature Labor:

  • 4 mg four times daily

POST PARTUM HEMORRHAGE (PPH)

Causes:

  • Atony of the uterus
  • Retained placental parts
  • Uterine rupture
  • Cervical and/or vaginal tears
  • DIC (HELLP)

Treatment:

  • Resuscitate with fluids
  • Massage the uterus manually
  • Apply firm and continuous pressure suprapubically with a closed fist for a full 10 minutes
    • Eyes on the watch!
  • Oxytocin infusion i.v. (preferred)
    • 30 units in 500 cc in Normal Saline
    • Infused over 2 to 4 hours
  • Misostoprol (Cytotec) tablets (if oxytocin is not available)
    • 2 – 4 tablets
      • Oral or rectal adminstration

Bleeding does not subside:

  • Bring patient to operating theater
  • Place legs in stirrups
  • Examine by intracavitary palpation
    • Placental parts present:
      • Remove
    • Uterine rupture present:
      • Laparotomy and repair
    • Neither retained placenta nor rupture of the uterus is present:
      • Pack firmly with gauze
      • Remove gauze pack in the operating theater after 24 hours
  • Transfuse one or two units of fresh blood

  • Perform hysterectomy as a last resort

Speculum Examination:

  • It is usually difficult and messy to identify bleeding site(s) from cervical tears
  • Attempts to suture the friable tissue results in further tearing and bleeding
  • Proceed directly with gauze packing in the absence of retained placental parts or ruptured uterus.

RETAINED PLACENTA

Early presentation:

Induce delivery of the retained placenta:

  • Nitroglycerine sublingually or nasally
  • Misostoprol (Cytotec)  
  • Oxytocin

Late presentation:

Manual or instrumental removal:

  • Introduce one hand into the uterus
  • Use the ulnar border of the intrauterine hand to dissect the placenta from the uterine wall
  • Apply contra pressure on outside of the uterus with other hand on abdomen
  • In case a closed or closing cervix does not allow the entire hand to enter the intrauterine cavity, two fingers are usually sufficient
    • If not, use instruments
    • A large sponge forceps (ring forceps) will do
Manual Removal of Placenta

Very late presentation with severe anemia and/or sepsis:

Supravaginal (subtotal) hysterectomy.