1. MANAGEMENT OF SEIZURE DISORDERS IN PREGNANCY

3. On Reaching The Hospital CALL FOR HELP - duty obstetric & anaesthetic registrars; senior midwife INFORM CONSULTANTS - obstetrician & anaesthetist on call Is it safe to approach the patient? - consider hazards around patient that will affect your safety Prevent maternal injury during convulsion – place in semi-prone position in a railed cot ,in an isolated room. • Airway: (a) Assess (b) Maintain patency (c) Apply oxygen • Breathing: (a) Assess and also auscultate Lungs for any aspiration. (b) Protect airway (c) Ventilate as required • Circulation: (a) Evaluate pulse & BP If absent, initiate CPR and call arrest team (b) Left lateral tilt (c) Secure IV access with a 16-18 gauge needle as soon as safely possible Attach pulse oximeter, ECG & automatic BP monitors Urinary catheter - hourly urinometer readings Fluid input / output chart (discussed later)

5. Cont..Approach 3. Principles of fluid balance: BEWARE: Iatrogenic fluid overload is the main cause of maternal death in Pre-eclampsia/Eclampsia Maintenance fluids should be given as crystalloid but additional fluid (colloid) may be necessary prior to vasodilatation to prevent maternal hypotension and fetal compromise. Consideration should also be given to correcting hypovolaemia in women with oliguria 1. Accurate recording of fluid balance (including delivery and postpartum blood loss, input/output deficit) 2. Maintenance crystalloid infusion (R/L) - 85 ml/hour, or urinary output in preceding hour plus 30 ml 3. Selective colloid expansion - prior to pharmacological vasodilatation; oliguria with low CVP 4. Diuretics - only for women with confirmed pulmonary oedema 5. Selective monitoring of CVP- for patients of severe hypertension and reduced Urinary output. NB: Normally, fluid should not exceed 2litres in 24 hours.

9. MAGNESIUM SULPHATE is the anticonvulsant drug of choice MOA: (a) Reduces Motor end plate sensitivity to Ach hence reducing neuromuscular irritability. (b) Blocks Neuronal calcium Influx. (c) Dilates Cerebral and uterine vessels. (d) Prostacyclin production is increased with inhibition of platelet activation. Regimen: (Intravenous regimen) Loading Dose: 4 g IV over 10-15 minutes Add 8 ml of 50% MgSO4 solution to 12 ml of N Saline = 4 g in 20 ml = 20% solution Maintenance 1 g per hour Dose: Add 25 g MgSO4 (50 ml) to 250 ml N Saline 1 g MgSO4 = 12 ml per hour IV 1 g/hour is infused for 24 hours after last fit provided that: • respiratory rate > 16 breaths/minute • urine output > 25 ml/hour, and • patellar reflexes are present Administer via infusion pump A. SEIZURE MANGEMENT:

12. Magnesium Toxicity: (a)Urine output < 100 ml in 4 hours: If no clinical signs of magnesium toxicity, decrease rate to 0.5 g/hour Review overall management with attention to fluid balance and blood loss (b)Absent patellar reflexes: Stop MgSO4 infusion until reflexes return (c)Respiratory depression: (i) Stop MgSO4 infusion (ii)Give oxygen via facemask and place in recovery position because of impaired level of consciousness (iii)Monitor closely (d)Respiratory arrest: Stop MgSO4 infusion Give IV Calcium gluconate Intubate and ventilate immediately (e)Cardiac arrest: Commence CPR Stop MgSO4 infusion Give IV Calcium gluconate Intubate and ventilate immediately If antenatal, immediate delivery Antidote: 10% Calcium gluconate 10 ml IV over

14. (b)Labetalol : If BP still uncontrolled, Labetalol 50 mg IV slowly; if necessary repeat after 20 minutes or IV infusion of 200 mg in 200 ml N Saline, starting at 40 mg/hour, increasing dose at 1/2 hourly intervals as required to a maximum of 160 mg/hour If blood pressure does not respond to the above, discuss with senior renal physicians and anaesthetists. (c)Nifedipine: Oral route is safer and as effective as sublingual route Dose: 10 mg orally. Monitor FH with CTG NOTE: An interaction between nifedipine and magnesium sulphate has been reported to produce profound muscle weakness, maternal hypotension and fetal distress.

15. C. OBSTETRICAL MANAGEMENT A. Initiate steroids if gestation 34 weeks: Inj. Betamethasone 12mg IM two doses 24hour apart. B. If patient in labour: (a)A.R.M. : to cut short second stage of labour (b)C.S. : In case of Obstetrical indications C. If patient not in labour, and fits controlled or not, but baby alive: (a) Termination by A.R.M. or C.S. D. If Patient not in labour, and fits controlled or not, but baby dead: (a) Wait for spontanous expulsion.