PROTOCOL FOR MANAGEMENT OF SEVERE PREECLAMPSIA

 

Swaraj Hospital & Research Institute
(Schematic Flow for Rapid Clinical Use)

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A. TRIAGE & IMMEDIATE ASSESSMENT (Within 10 Minutes)

1. CRITERIA FOR "SEVERE" PREECLAMPSIA (Any ONE of the following):

• Severe Hypertension: Systolic BP ≥ 160 mmHg OR Diastolic BP ≥ 110 mmHg (on 2 readings, 15 min apart).
• Symptoms: Persistent severe headache, visual disturbances, epigastric/RUQ pain, nausea/vomiting.
• Significant Laboratory Abnormalities:
• Thrombocytopenia (Platelets < 100,000/µL)
• Elevated Liver Enzymes (AST/ALT > 2x ULN) + symptoms
• Serum Creatinine rising (>1.1 mg/dL or doubling)
• Pulmonary Edema
• New-onset cerebral or visual disturbances

2. IMMEDIATE ACTIONS:

• Alert: Senior Obstetrician, Anesthetist, Neonatologist.
• Monitor: Continuous BP, Pulse Oximetry, Fetal Heart Rate (CTG).
• IV Access: Secure two wide-bore IV lines.
• Investigations Stat: CBC, LFT, RFT, LDH, Coagulation Profile, Urine Protein/Creatinine ratio.
• Bedside: Urine dipstick, input/output chart.

B. STABILIZATION & ACUTE MANAGEMENT

Step 1: Control Severe Hypertension (Target: SBP 140-150 / DBP 90-100 mmHg)

• First Line: LABETALOL
• IV Bolus: 20 mg over 2 min.
• Repeat: 40 mg after 10 min if BP target not met, then 80 mg after another 10 min if needed. (Max total dose: 220 mg).
• Alternative/If contraindicated (Asthma, Heart Failure): NIFEDIPINE (immediate-release)
• Oral: 10 mg capsule, repeat in 30 min if needed. (Do not sublingual).
• Second Line / If refractory: Consider Hydralazine IV per ICU/Consultant guidance.

Step 2: Prevent Seizures (Magnesium Sulfate - MgSO4)

• LOADING DOSE: 4-6 g IV over 15-20 min (e.g., 4 g in 100 ml NS over 15 min).
• MAINTENANCE DOSE: 1 g/hour IV infusion via infusion pump.
• Preparation: Add 4 g MgSO4 (8 ml of 50% solution) to 92 ml NS → 100 ml total. Infuse at 25 ml/hour.
• Duration: Continue for 24 hours postpartum.
• MONITORING for Toxicity:
• Check patellar reflexes hourly (1st sign of toxicity → absent reflexes).
• Monitor respiratory rate and urine output hourly.
• Antidote: Calcium Gluconate 1 g (10 ml of 10%) IV slow, at bedside.

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C. DEFINITIVE MANAGEMENT: DELIVERY

• DECISION TO DELIVER IS DEFINITIVE TREATMENT.
• Timing:
• ≥ 34 weeks: Deliver once mother is stabilized.
• < 34 weeks: Discuss with senior consultant, consider steroids for fetal lung maturation (if time permits) and transfer to tertiary care unit if needed. Delivery is indicated for uncontrollable BP, deteriorating labs, fetal distress, or maternal danger.
• Mode of Delivery: Based on obstetric factors, but vaginal delivery preferred with careful monitoring. Low threshold for C-section if maternal/fetal condition deteriorates.

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D. POSTPARTUM & MONITORING

• MgSO4: Continue for 24 hours postpartum.
• BP Monitoring: Every 1-2 hours initially. Antihypertensives (oral Labetalol/Nifedipine) to maintain BP < 150/100 mmHg.
• Vigilance: Risk of eclampsia is highest in first 48 hours postpartum. Monitor for headache, visual changes, pain.
• Follow-up: BP can remain elevated for 6-12 weeks. Arrange postpartum follow-up.

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E. FLUID MANAGEMENT (CAUTIOUS!)

• Strict Input/Output Monitoring.
• Avoid Fluid Overload: Total IVF often restricted to 80-125 ml/hour (1 ml/kg/hour) unless significant blood loss.
• Watch for Pulmonary Edema.

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CRITICAL ALGORITHM SCHEMATIC

text

[SEVERE FEATURE(S) IDENTIFIED]

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Alert Senior Team + Monitor (BP, FHR, O2)

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IV Access + Stat Labs

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Control Severe HTN (Labetalol/Nifedipine IV/PO)

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Start MgSO4 (Load → Maintain)

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Assess Gestational Age & Fetal Condition

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Decision for DELIVERY (Mode based on obstetrics)

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Continue MgSO4 x 24h Postpartum

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Close Monitoring (BP, Symptoms, Output)

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 DRUG DOSING TABLE (QUICK REFERENCE)

Drug	Route	Dose for Severe HTN	Caution
Labetalol	IV	20 mg → 40 mg → 80 mg bolus (10 min apart)	Asthma, CHF
Nifedipine	PO	10 mg cap, repeat in 30 min if needed	Tachycardia
MgSO4 Load	IV	4-6 g in 100 ml NS over 15-20 min
MgSO4 Maint	IV	1 g/hour (25 ml/hr of standard soln)	Monitor reflexes