Question 1

Created on Fri, 05/22/2015 - 22:48
Last updated on Fri, 06/08/2018 - 18:41
Pass rate: 62%
Highest mark: ?

Other SAQs in this paper

Other SAQs on this topic

A 35 year old female is 39 weeks pregnant. Her pregnancy has been complicated by hypertension and  proteinuria. Her blood  pressure is 160/120 mm  Hg. You are called to the labour ward when she suffers a generalised (“grand mal”)  convulsion. Outline  your overall plan of management.

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College Answer

Initial management
ABC
Left side
Terminate the seizure
a.   Diazepam 5-10mg or Mg 4g IV up to 8 g
Monitors / investigations

Management of Hypertension
Hydrallazine
Labetalol
(Other  agents  are  acceptable  –  late  in  pregnancy  –  increasing  trend  to  use
“mainstream” agents)

Treatment of convulsions
MgSO4 bolus followed by maintenance MgSO4
(Shown to be more effective than phenytoin or diazepam in preventing recurrent seizures)
Addition of Benzodiazepine / Barbiturate if recurrent seizures despite MgSO4

Planning for delivery
Brief period of resuscitation once seizures controlled

Post partum management
Continue anti-convulsants until patient improves (diuresis, fall in BP)

Discussion

This question closely resembles Question 23 from the first paper of of 2011. 

Also, that's not how you spell hydralazine.

Anyway, the management should look like this:

  • Attention to the ABCS, with management of life-threatening problems simultanous with a rapid focused examination and a brief history.
  • Airway:
    • Assess the need for airway support in context of post-ictal unconscious state
    • Weigh benefits of intubation against risks in context of the known airway access problems associated with pregnancy
  • Breathing/ventilation
    • Assess oxygenation and briefly examine for aspiration
    • High flow oxygen via NRBM if patient is not in need of immediate intubation
  • Circulatory support
    • Assess cardiovascular stability
      • left lateral 30° tilt if hypotensive
    • Access with widebore cannula
  • Immediate investigations:
    • FBC - looking for thrombocytopenia
    • LFTs - looking for HELLP, hepatic encephalopathy
    • EUC - looking for hyponatremia
    • CMP
    • Coags
    • Antiepileptic drug levels, if relevant
    • CT brain, if the patient fails to awaken
  • Specific management
    • Antihypertensives:
      • labetalol, nifedipine or hydralazine are of equivalent benefit
      • methyldopa and sodium nitroprusside are second line agents
    • Antiepileptic therapy:
      • Loading dose of magnesium sulfate, followed by an infusion, aiming at a serum level of 2.0-3.5mmol/L
      • Diazepam and phenytoin can be considered if seziures are refractory
    • Arrange for a consultation with the obstetrician regarding the safety and practicality of immediate delivery.

References

Heres an article by Baha  Sibai, who came up with the Tennessee classification for the HELLP syndrome:

Sibai, Baha M. "Diagnosis, prevention, and management of eclampsia."Obstetrics & Gynecology 105.2 (2005): 402-410.