Sop Eclampsia KNH 2009

KENYATTA NATIONAL HOSPITAL
NO:
SOP/KNH/OBS/46
ISSUE:
November 2008
REVIEW: November 2010
VERSION: 02
STANDARD OPERATING PROCEDURE
Dept: OBSTETRICS AND GYNAECOLOGY
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TITLE: MANAGEMENT OF PATIENTS WITH

ECLAMPSIA
OBJECTIVE
To reduce maternal & perinatal morbidity and
mortality.
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Kenyatta National Hospital Obs & Gynae Department
NO:
SOP/KNH/OBS/46
ISSUE:
November 2008
VERSION: 02
Page 2 of 11
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1.0 Title
MANAGEMENT OF ECLAMPSIA
2.0 Scope: All women presenting with eclampsia at

Kenyatta National Hospital.
3.0 Purpose
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NO:
SOP/KNH/OBS/46
ISSUE:
November 2008
VERSION: 02
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To reduce maternal & perinatal morbidity and

mortality.
4.0 Terms (definitions)
Eclampsia is the occurrence of convulsions
that cannot be attributed to other causes in
preeclamptic patient.
5.0 Responsibilities
Primary nurse/midwife - Nursing care
SHO Primary doctor
Senior Registrar
Consultant
Anaesthetists
6.0 Method
MANAGEMENT PROTOCOL
Eclamptic convulsions are life threatening
emergencies and require the proper treatment to
decrease maternal morbidity and mortality. All
patients presenting with history of convulsions or
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NO:
SOP/KNH/OBS/46
ISSUE:
November 2008
VERSION: 02
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coma in pregnancy or early postpartum period should

be managed as eclampsia till proved otherwise.
1. Call for help including appropriate personnel e.g.
SHO, Senior Registrar, consultant and
anaesthetist.
2. Gather the ECLAMPSIA KIT
3. Assess the airway, breathing and circulation and
monitor vital signs (BP, Pulse rate, Respiratory
rate, fetal heart) hourly.
4. Clear the airway and administer oxygen by mask
at 4-6L/min
5. Protect the patient against injury during the
convulsion and do not actively restrain her.
6. Put the patient in the left lateral position to help
improve uterine blood flow if pregnant and
prevent aspiration.
7. Two IV lines should be fixed of gauge 16-18.
One line should be dedicated towards
administration of MgSO4 and the other line for
other medications.
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NO:
SOP/KNH/OBS/46
ISSUE:
November 2008
VERSION: 02
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8. Insert a Foleys catheter size 16 0r 18 and balloon

with 5ml of normal saline and connect to a urine
bag.
9. Administer MgSO4
Loading dose
Give 4g of 20% MgSO4 solution IV over
5 minutes in the MgSO4 dedicated line.
Follow immediately with 10grams of
50% MgSO4 solution; give 5grams in
each buttock as a deep IM injection with
1ml of 2% lignocaine in the same syringe.
If convulsions recur within 15 minutes of
the initial dosing give 2 grams of 20%
MgSO4 solution IV over 5 minutes.
Maintenance dosing
This can be done through the IM or IV
route.
The IV route: give 1g of 20% MgSO4
solution every hour by continuous
infusion. To prevent fluid overload
reconstitute as follows: 4g of MgSO4 in
100mls, drain 200ml of saline from the
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NO:
SOP/KNH/OBS/46
ISSUE:
November 2008
VERSION: 02
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litre normal saline bottle. Put 2100ml of

MgSO4 solution (8g) in the now 300 ml
normal saline bottle to make 500ml of 8g
of MgSO4 this is given 8 hourly. This is
given at 16drops/min.
The IM route: give 5g of 50% MgSO4
solution with 1ml of 2% lignocaine in the
same syringe by deep IM alternate buttock
every 4 hours.
The maintenance dosing should be
continued for 24 hours after delivery or
the last convulsion whichever occurs last.
Monitoring for magnesium sulphate toxicity
Before repeat administration ensure:
Respiratory rate is at least 16/minute.
Patellar reflexes are present.
Urinary output is at least 30ml/hr over the
last 4 hours.
Withhold or delay MgSO4 administration if:
Respiratory falls below 16/min.
Absent patellar reflexes.
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SOP/KNH/OBS/46
ISSUE:
November 2008
VERSION: 02
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Urinary output below 30ml/hr over the last

4 hours.
Keep antidote ready
Incase of respiratory arrest
Assist ventilation
Give calcium gluconate 1gram
slowly(10ml of 10% solution)
If repeated convulsions give Diazepam 10mg
IV slowly over 2 minutes.
If convulsions persist, intubate the patient to
protect airway and maintain oxygenation and
transfer
to critical care unit.
10. Nursing care:
These patients should be nursed by
one nurse per patient or one nurse per
acute room in the labour ward.
11. Blood pressure control
The drug of choice is IV hydrallazine.
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ISSUE:
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VERSION: 02
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If diastolic BP remains above 110mmHg

give hydrallazine 5mg IV slowly every 15
minutes till the BP is controlled.
1 vial of 2ml has 20mg of hydrallazine.
Add 18ml water for injection so as to have
20mg in 20ml of solution. Therefore, 5ml
of this solution contains 5mg which is to
be given every 15 minutes until the
desired BP range is achieved.
The goal is to keep the diastolic BP
between 90 and 100mmHg to prevent
cerebral haemorrhage.
12. Fluid balance
The fluid of choice is normal saline.
Maintain a strict fluid balance chart
(monitor the amount of fluids given and
the urine output) to prevent fluid overload
with attendant pulmonary oedema.
Urine output should be maintained at
30ml/hour.
13. Investigations
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ISSUE:
November 2008
VERSION: 02
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Random blood sugar

Blood slide for malaria parasites
Bedside clotting time
Full blood count
Liver function test
Renal function test
Urine dipstick to assess proteinuria
Group and cross match blood.
14. Planning delivery

Delivery should take place as soon as the
womans condition has stabilized.
Delivery should be effected within 12
hours of the onset of convulsions.
Assess the cervix.
Vaginal delivery:
a) If the cervix is favorable do artificial
rupture of membranes and induce labour
with oxytocin.
b) Dead fetus or too premature for survival:
if the cervix is unfavourable ripen the
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ISSUE:
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VERSION: 02
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cervix with prostaglandins or a Foleys

catheter.
Caesarean delivery:
Ensure coagulopathy has been ruled out
(bedside clotting time less than 7 minutes).
a) If the cervix is unfavorable and fetus is
alive.
b) If vaginal delivery is not anticipated
within 12 hours.
c) If there is evidence of non-reassuring fetal
status.
15. Postpartum care
Anticonvulsive therapy should be
maintained for 24 hours after delivery or
last convulsion whichever occurs last.
Continue antihypertensive therapy as long
as the diastolic BP is 110mmHg or more.
Continue to monitor urine output.
16. Prophylactic therapy
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NO:
SOP/KNH/OBS/46
ISSUE:
November 2008
VERSION: 02
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MgSO4 as per the protocol should be used in

patients with severe pre-eclampsia to
prevent
convulsions.
7.0 Reference
Royal college of Obstetrics and
Gynaecology guidelines.
Managing complications in pregnancy and
childbirth: A guide for midwives and
doctors. WHO 2007.
8.0 Appendices
Eclampsia kit
Eclampsia monitoring chart
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KENYATTA NATIONAL HOSPITAL

TITLE: MANAGEMENT OF PATIENTS WITH

All Rights Reserved

KENYATTA NATIONAL HOSPITAL

2.0 Scope: All women presenting with eclampsia at

KENYATTA NATIONAL HOSPITAL

To reduce maternal & perinatal morbidity and

KENYATTA NATIONAL HOSPITAL

coma in pregnancy or early postpartum period should

All Rights Reserved

KENYATTA NATIONAL HOSPITAL

8. Insert a Foleys catheter size 16 0r 18 and balloon

KENYATTA NATIONAL HOSPITAL

litre normal saline bottle. Put 2100ml of

KENYATTA NATIONAL HOSPITAL

Urinary output below 30ml/hr over the last

All Rights Reserved

KENYATTA NATIONAL HOSPITAL

If diastolic BP remains above 110mmHg

KENYATTA NATIONAL HOSPITAL

Random blood sugar

14. Planning delivery

KENYATTA NATIONAL HOSPITAL

cervix with prostaglandins or a Foleys

All Rights Reserved

KENYATTA NATIONAL HOSPITAL

MgSO4 as per the protocol should be used in

All Rights Reserved

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