MOET Algorithm

Algorithm 16.1 Pre-eclampsia/eclampsia Do not leave patient alone Airway Breathing Circulation Control seizures Control hypertension If not postpartum... Deliver ■ Place in semi-prone position ■ Call for HELP – duty obstetric and anaesthetic SpRs; senior midwife ■ Inform consultants – obstetrician and anaesthetist ■ Assess ■ Protect airway ■ Ventilate as required ■ Loading dose MgSO 4 : 4 g MgSO 4 in 20% solution IV over 10–15 minutes. Add 8 ml of 50% MgSO 4 solution to 12 ml physiological saline ■ Maintenance dose MgSO 4 : 1 g per hour infusion. Add 25 g MgSO 4 (50 ml) to 250 ml physiological saline 1 g MgSO 4 = 12 ml per hour IV ■ If seizures continue or recur: MgSO 4 2 g ≤ 70 kg; 4 g ≥ 70 kg IV as per loading dose over 5–10 minutes. If this fails: diazepam 10 ml IV or thiopentone 50 mg IV paralyse and intubate ■ Monitor: Hourly urine output, respiratory rate, O 2 saturation & patellar reflexes – every 10 minutes for first 2 hours and then every 30 minutes Check serum magnesium if toxicity is suspected on clinical grounds ■ Stop infusion: Check magnesium levels and review management with consultant if: Urine output < 100 ml in 4 hour s or if Patellar reflexes are absent or if Respiratory rate < 16/minute or if Oxygen saturation < 90% ■ Always get suppression of reflexes before respiratory depression ■ Antidote: 10% calcium gluconate 10 ml IV over 10 minutes OBSERVATIONS Pulse oximeter BP Respirations Temperature ECG Test urine for protein Hourly urine output Fluid balance charts FHR – monitor continuously INVESTIGATIONS FBC & platelets U&Es Urate LFT Coagulation screen Group & hold serum MSSU 24-hour urine collections for: ■ total protein & creatinine clearance ■ catecholamines ■ Assess ■ Maintain patency ■ Apply oxygen ■ Evaluate pulse and BP ■ If absent, initiate CPR and call the arrest team ■ Secure IV access as soon as safely possible ■ Tr eat hypertension if systolic BP > 170 mmHg or diastolic BP > 1 10 mmHg or MAP >125 mmHg Aim to reduce BP to around 130–140/90–100 mmHg Beware maternal hypotension and FHR abnormalities – monitor FHR with continuous CTG ■ HYDRALAZINE 10 mg IV slowly Repeated doses of HYDRALAZINE 5 mg IV 20 minutes apart may be given if necessary Close liaison with anaesthetists: may require plasma expansion ■ LABETALOL 50 mg IV slowly if BP still uncontrolled If necessary repeat after 20 minutes or start IV infusion: 200 mg in 200 ml physiological saline at 40 mg/hour , increasing dose at half-hourly intervals as required to a maximum of 160 mg/hour ■ The continuation of pregnancy is not an option if eclampsia occurs ■ STABILISE THE MOTHER BEFORE DELIVERY ■ DELIVERY IS A TEAM EFFORT involving obstetricians, midwives, anaesthetists and paediatricians ■ Ergometrine should not be used in severe pre-eclampsia and eclampsia ■ Consider prophylaxis against thromboembolism ■ Maintain vigilance as the majority of eclamptic seizures occur after delivery 150

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Transcript of MOET Algorithm

8/10/2019 MOET Algorithm

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Algorithm 16.1 Pre-eclampsia/eclampsia

Do not leavepatient alone

Airway

Breathing

Circulation

Control seizures

Controlhypertension

If notpostpartum...

Deliver

■ Place in semi-prone position

■ Call for HELP – duty obstetric andanaesthetic SpRs; senior midwife

■ Inform consultants – obstetrician and

anaesthetist

■ Assess

■ Protect airway

■ Ventilate as required

■ Loading dose MgSO4:4 g MgSO4 in 20% solution IV over10–15 minutes. Add 8 ml of 50%MgSO4 solution to 12 mlphysiological saline

■ Maintenance dose MgSO4: 1 g perhour infusion. Add 25 g MgSO4(50 ml) to 250 ml physiological saline1 g MgSO4 = 12 ml per hour IV

■ If seizures continue or recur: MgSO42 g ≤ 70 kg; 4 g ≥ 70 kg IV as perloading dose over 5–10 minutes. If thisfails: diazepam 10 ml IV orthiopentone 50 mg IV paralyse andintubate

■ Monitor: Hourly urine output,respiratory rate, O2 saturation &

patellar reflexes – every 10 minutes forfirst 2 hours and then every 30minutesCheck serum magnesium if toxicity issuspected on clinical grounds

■ Stop infusion: Check magnesiumlevels and review management withconsultant if:Urine output <100 ml in 4 hours

or if Patellar reflexes are absentor if Respiratory rate < 16/minuteor if Oxygen saturation < 90%

■ Always get suppression of reflexesbefore respiratory depression

■ Antidote: 10% calcium gluconate10 ml IV over 10 minutes

OBSERVATIONSPulse oximeter BPRespirationsTemperatureECGTest urine for proteinHourly urine outputFluid balance chartsFHR – monitor continuously

INVESTIGATIONSFBC & plateletsU&EsUrate LFTCoagulation screenGroup & hold serumMSSU24-hour urinecollections for:

■ total protein &

creatinine clearance■ catecholamines

■Assess

■ Maintain patency

■ Apply oxygen

■ Evaluate pulse and BP

■ If absent, initiate CPR and call thearrest team

■ Secure IV access as soon as safelypossible

■ Treat hypertension if systolic BP> 170 mmHg or diastolic BP

> 110 mmHg or MAP >125 mmHgAim to reduce BP to around130–140/90–100 mmHg Bewarematernal hypotension and FHRabnormalities – monitor FHR withcontinuous CTG

■ HYDRALAZINE 10 mg IV slowlyRepeated doses of HYDRALAZINE5 mg IV 20 minutes apart may begiven if necessary

Close liaison with anaesthetists: mayrequire plasma expansion

■ LABETALOL 50 mg IV slowly if BPstill uncontrolledIf necessary repeat after 20 minutes orstart IV infusion: 200 mg in 200 mlphysiological saline at 40 mg/hour,increasing dose at half-hourlyintervals as required to a maximum of160 mg/hour

■ The continuation of pregnancy is notan option if eclampsia occurs

■ STABILISE THE MOTHER BEFORE

DELIVERY■ DELIVERY IS A TEAM EFFORT

involving obstetricians, midwives,anaesthetists and paediatricians

■ Ergometrine should not be used insevere pre-eclampsia and eclampsia

■ Consider prophylaxis againstthromboembolism

■ Maintain vigilance as the majority ofeclamptic seizures occur afterdelivery

150