Surgical Care at the District Hospital

SPECIFIC MANAGEMENT

Pregnancy induced hypertension

Pregnancy induced hypertension can be managed on an outpatient basis:

::	Monitor blood pressure, urine (for proteinuria) and fetal condition weekly
::	If blood pressure rises or proteinuria occurs, manage as mild pre-eclampsia
::	If there are signs of fetal compromise, admit the woman to the hospital for assessment and possible expedited delivery
::	Counsel the woman and her family about danger signals indicating pre-eclampsia or eclampsia
::	If all observations remain stable, allow to proceed with normal labour and childbirth.

Mild pre-eclampsia

Gestation less than 36 weeks

If signs remains unchanged or normalize, follow up twice a week as an outpatient:

::	Monitor blood pressure, urine (for proteinuria), reflexes and fetal condition
::	Counsel the woman and her family about danger signals indicating pre-eclampsia or eclampsia
::	Encourage the woman to eat a normal diet; discourage salt restriction
::	Do not give anticonvulsants, antihypertensives, sedatives or tranquillizers.

If follow-up as an outpatient is not possible, admit the woman to the hospital or set up a hostel beside your hospital where high risk mothers may stay and attend the hospital for regular checks

::	Provide a normal diet without salt restriction
::	Monitor blood pressure (twice daily) and urine for proteinuria (daily)
::	Do not give anticonvulsants, antihypertensives, sedatives or tranquillizers unless blood pressure increases
::	Do not give diuretics; these are harmful and only indicated for use in pre-eclampsia with pulmonary oedema or congestive heart failure

If diastolic pressure decreases to normal levels or the woman’s condition remains stable, send her home:

::	Advise her to rest and watch out for significant swelling or symptoms of severe pre-eclampsia
::	See her twice weekly to monitor blood pressure, proteinuria and fetal condition and to assess for symptoms and signs of severe pre-eclampsia
::	If diastolic pressure rises again, readmit her.

If the signs remain unchanged and if outpatient monitoring is not possible, keep the woman in the hospital

::	Continue the same management and monitor fetal growth by symphysis-fundal height
::	If there are signs of growth restriction, consider early delivery; if not, continue hospitalization until term
::	If urinary protein level increases, manage as severe pre-eclampsia.

Gestation more than 36 weeks

::	If there are signs of fetal compromise, assess the cervix and expedite delivery
::	If the cervix is favourable (soft, thin, partly dilated), rupture the membranes with an amniotic hook or a Kocher clamp and induce labour using oxytocin or prostaglandins
::	If the cervix is unfavourable (firm, thick, closed), ripen the cervix using prostaglandins or Foley catheter or deliver by caesarean section.

Severe pre-eclampsia and eclampsia

Severe pre-eclampsia is present if one or more of the conditions in column three of the table below are present.

Severe pre-eclampsia and eclampsia are managed similarly, with the exception that delivery must occur within 12 hours of the onset of convulsions in eclampsia.

All cases of severe pre-eclampsia should be managed actively. Symptoms and signs of “impending eclampsia” (blurred vision, hyperreflexia) are unreliable and expectant management is not recommended.

Management

Immediate management of a pregnant woman or a recently delivered woman who complains of severe headache or blurred vision, or if a pregnant woman or a recently delivered woman is found unconscious or having convulsions:

Shout for help

Make a quick assessment of the general condition of the woman, including vital signs (pulse, blood pressure, respiration) while simultaneously finding out the history of her present and past illnesses from her or her relatives:

•	Check airway and breathing
•	Position her on her side
•	Check for neck rigidity and temperature.

If she is not breathing or her breathing is shallow:

•	Open airway and intubate, if required
•	Assist ventilation using an Ambu bag and mask
•	Give oxygen at 4–6 L per minute.

If she is breathing, give oxygen at 4–6 L per minute by mask or nasal cannulae.

If she is convulsing:

•	Protect her from injury, but do not actively restrain her
•	Position her on her side to reduce the risk of aspiration of secretions, vomit and blood
•	After the convulsion, aspirate the mouth and throat as necessary. Look in the mouth for a bitten tongue: it may swell.

Give magnesium sulfate (see page 10–6). If a convulsion continues in spite of magnesium sulfate, consider diazepam 10 mg IV.

If diastolic blood pressure remains above 110 mmHg, give antihypertensive drugs (see page 10–6). Reduce the diastolic pressure to less than 100 mmHg, but not below 90 mmHg.

Fluids:

•	Start an IV infusion
•	Maintain a strict fluid balance chart and monitor the volume of fluids administered and urine output to ensure that there is no fluid overload
•	Catheterize the bladder to monitor urine output and proteinuria
•	If urine output is less than 30 ml per hour: – Withhold magnesium sulfate until urine output improves – Infuse a maintenance dose of IV fluids (normal saline or Ringer’s lactate) at 1 L in 8 hours – Monitor for the development of pulmonary oedema.

Never leave the woman alone. A convulsion followed by aspiration of vomit may cause death of the woman and fetus.

Observe vital signs, reflexes and fetal heart rate hourly.

Auscultate the lung bases hourly for rales indicating pulmonary oedema. If rales are heard, withhold fluids and give frusemide 40 mg IV once.

Assess clotting status.

Anticonvulsant drugs

Adequate administration of anticonvulsive drugs is a key factor in anticonvulsive therapy. Convulsions in hospitalized women are most frequently caused by under-treatment. Magnesium sulfate is the drug of first choice for preventing and treating convulsions in severe pre-eclampsia and eclampsia.

Magnesium sulfate schedules for severe pre-eclampsia and eclampsia

Loading dose

::	Magnesium sulfate 20% solution 4 g IV over 5 minutes
::	Follow promptly with 10 g of 50% magnesium sulfate solution, 5 g in each buttock, as deep IM injection with 1.0 ml of 2% lidocaine in the same syringe
::	Ensure that aseptic technique is practised when giving magnesium sulfate deep IM injection; warn the woman that a feeling of warmth will be felt when magnesium sulfate is given
::	If convulsions recur after 15 minutes, give 2 g magnesium sulfate (50% solution) IV over 5 minutes

Maintenance dose

::	5 g magnesium sulfate (50% solution) + 1 ml lidocaine 2% IM every 4 hours into alternate buttocks
::	Continue treatment with magnesium sulfate for 24 hours after delivery or the last convulsion, whichever occurs last.
::	Before repeat administration, ensure that – Respiratory rate is at least 16 per minute – Patellar reflexes are present – Urinary output is at least 30 ml per hour over the last 4 hours
::	Withhold or delay drug if: – Respiratory rate falls below 16 per minute – Patellar reflexes are absent – Urinary output falls below 30 ml per hour over preceding 4 hours
::	In case of respiratory arrest: – Assist ventilation (mask and bag; anaesthesia apparatus; intubation) – Give calcium gluconate 1 gm (10 ml of 10% solution) IV slowly until the drug antagonizes the effects of magnesium sulfate and respiration begins

Diazepam schedules for severe preeclampsia and eclampsia

Intravenous administration

Loading dose

::	Diazepam 10 mg IV slowly over 2 minutes
::	If convulsions recur, repeat loading dose

Maintenance dose

::	Diazepam 40 mg in 500 ml IV fluids (normal saline or Ringer’s lactate) titrated to keep the patient sedated but rousable
::	Do not give more than 100 mg in 24 hours

Use diazepam if magnesium sulfate is not available, although there is greater risk for neonatal respiratory depression because diazepam passes the placenta freely.

A single dose of diazepam to abort a convulsion seldom causes neonatal respiratory depression. Long-term continuous IV administration increases the risk of respiratory depression in babies who may already be suffering from the effects of utero-placental ischaemia and preterm birth. The effect of diazepam may last several days.

Use diazepam only if magnesium sulfate is not available.

Antihypertensive drugs

If the diastolic pressure is 110 mmHg or more, give antihypertensive drugs. The goal is to keep the diastolic pressure between 90 mmHg and 100 mmHg to prevent cerebral haemorrhage. Avoid hypotension.

Hydralazine is the drug of choice:

Give hydralazine 5 mg IV slowly every 5 minutes until blood pressure is lowered. Repeat hourly as needed or give hydralazine 12.5 mg IM every 2 hours as needed.

If hydralazine is not available:

•	Give labetolol 10 mg IV: – If response is inadequate (diastolic blood pressure remains above 110 mmHg) after 10 minutes, give labetolol 20 mg IV – Increase dose to 40 mg and then 80 mg if satisfactory response is not obtained within 10 minutes of each dose
•	Or l Nifedipine 5 mg chewed and swallowed or injected into the oropharynx; may be repeated at 10-minute intervals
•	Or l Nicardipine 1–2 mg at one minute intervals until control is obtained. Then 1–2 mg every hour.

Rectal administration of drugs

::	Give diazepam rectally when IV access is not possible. The loading dose of 20 mg is taken in a 10 ml syringe.
::	Remove the needle, lubricate the barrel and insert the syringe into the rectum to half its length. Discharge the contents and leave the syringe in place, holding the buttocks together for 10 minutes to prevent expulsion of the drug. Alternatively, instill the drug in the rectum through a urinary catheter.
::	If convulsions are not controlled within 10 minutes, inject an additional 10 mg per hour or more, depending on the size of the woman and her clinical response.


	Protect the mother by lowering blood pressure and preventing or controlling convulsions
	Magnesium sulfate is the preferred drug for preventing and treating convulsions.