Skip to main content
  1. Right Decisions
  2. GGC - Clinical Guideline Platform
  3. Maternity
  4. Back
  5. Allergy, anaphylaxis and critical care (Maternity)
  6. Hypertension Eclampsia Management (402)
Announcements and latest updates

Right Decision Service newsletter: April 2024

Welcome to the Right Decision Service (RDS) newsletter for April 2024. 

Issues with RDS and Umbraco access

Tactuum has been working hard to address the issues experienced during the last week. They have identified a series of three mitigation measures and put the first of these in place on Friday 3rd May.  If this does not resolve the problems, the second mitigation will be actioned, and then the third if necessary.

Please keep a lookout for any slowing down of the system or getting locked out. Please email myself, mbuchner@tactuum.com and onivarova@tactuum.com if you experience any problems, and also please raise an urgent support ticket via the Support Portal.

Thank you for your patience and understanding while we achieve a full resolution.

Promotion and communication resources

A rotating carousel presenting some of the key RDS tools and capabilities, and an editable slideset, are now available in the Resources for RDS providers section of the Learning and Support toolkit.

Redesign and improvements to RDS

The redesign of RDS Search and Browse is still on-track for delivery by mid-June 2024. We then plan to have a 3-week user acceptance testing phase before release to live. All editors and toolkit owners on this mailing list will be invited to participate in the UAT.

The archiving and version control functionality is also progressing well and we will advise on timescales for user acceptance testing shortly.

Tactuum is also progressing with the deep linking to individual toolkits within the mobile RDS app. There are several unknowns around the time and effort required for this work, which will only become clear as the work progresses. So we need to be careful to protect budget for this purpose.

New feature requests

These have all been compiled and effort estimated. Once the redesign work is complete, these will be prioritised in line with the remaining budget. We expect this to take place around late June.

Evaluation

Many thanks to those of you completed the value and impact survey we distributed in February. Here are some key findings from the 65 responses we received.

Figure 1: Impact of RDS on direct delivery of care

Key figures

  • 93% say that RDS has improved evidence-informed practice (high impact 62%; some impact 31%)
  • 91% report that RDS has improved consistency in practice (high impact 65%, some impact 26%)
  • 85% say that RDS has improved patient safety (high impact 59%, some impact 26%)
  • Although shared decision-making tools are only a recent addition to RDS, and only represent a small proportion of the current toolset, 85% of respondents still said that RDS had delivered impact in this area (53% high impact, 32% some impact.) 92% anticipate that RDS will deliver impact on shared decision-making in future and 85% believe it will improve delivery of personalised care in future.

Figure 2 shows RDS impact to date on delivery of health and care services

 

Key figures

These data show how RDS is already contributing to NHS reform priorities and supporting delivery of more sustainable care.

Saving time and money

  • RDS clearly has a strong impact on saving practitioner time, with 90% of respondents reporting that this is the case. 65% say it has a high impact; 25% say it has some impact on time-saving.
  • It supports devolved decision-making across the multi-professional team (85% of respondents)
  • 76% of respondents confirm that it saves money compared, for example, to investing in commercial apps (54% high impact; 22% some impact.)
  • 72% believe it has impacted already on saving money and reducing waste in the way services are delivered – e.g. reducing costs of referral management, prescribing, admissions.

Quality assurance and governance

  • RDS leads are clear that RDS has improved local governance of guidelines, with 87% confirming that this is the case. (62% high impact; 25% some impact.)

Service innovation and workforce development

  • RDS is a major driver for service innovation and improvement (83% of respondents) and has impacted significantly on workforce knowledge and skills (92% of respondents – 66% high impact; 26% some impact).

New toolkits

A few examples of toolkits published to live in the last month:

Toolkits in development

Some of the toolkits the RDS team is currently working on:

  • SARCS (Sexual Assault Response Coordination Service)
  • Staffing method framework – Care Inspectorate.
  • SIGN 171 - Diabetes in pregnancy
  • SIGN 158 – British Guideline on Management of Asthma. Selected sections will be incorporated into the RDS, and complemented by a new chronic asthma pathway being developed by SIGN, British Thoracic Society and NICE.
  • Clinical pathways from NHS Fife and NHS Lanarkshire

Please contact his.decisionsupport@nhs.scot if you would like to learn more about a toolkit. The RDS team will put you in touch with the relevant toolkit lead.

Quality audit of RDS toolkits

Thanks to all of you who have responded to the retrospective quality audit survey and to the follow up questions.  We still have some following up to do, and to work with owners of a further 23 toolkits to complete responses. An interim report is being presented to the HIS Quality and Performance Committee.

Implementation projects

Eight clinical services and two public library services are undertaking tests of change to implement the Being a partner in my care app. This app aims to support patients and the public to become active participants in Realistic Medicine. It has a strong focus on personalised, person-centred care and a library of shared decision aids, as well as simple explanations and videoclips to help the public to understand the aims of Realistic Medicine.  The tests of change will inform guidance and an implementation model around wider adoption and spread of the app.

With kind regards

Right Decision Service team

Healthcare Improvement Scotland

Hypertension Eclampsia Management (402)

Please report any inaccuracies or issues with this guideline using our online form

Eclampsia is a life threatening complication of pregnancy. 

UK incidence is about 1 per 2000 maternities.

Seizure incidence: 38% pre-labour, 18% during labour, 44% postnatal

Pathophysiology is thought to involve cerebral vasospasm leading to ischaemia, disruption of the blood brain barrier and cerebral oedema. 

Neurological complications may include coma, focal motor defects and cortical blindness. Cerebrovascular haemorrhage is a complicating factor in 1- 2 % of cases.

Eclampsia is usually part of a multisystem disorder. There may be little or no warning that a seizure is imminent and no evidence of existing "pre-eclampsia". All pregnant women regardless of parity are at risk. There is a significant increased risk in women in the 15-19 year age group and women with previous eclampsia. 

Acute management of eclampsia

A

AIRWAY

(Jaw thrust, High flow O2)

& LATERAL TILT & CALL FOR HELP 2222 

B

BREATHING

Assess, ventilate as required.

C

CIRCULATION

Assess (BP, pulse, O2 saturation) & Access

  • Site 2 large bore cannulae (14g ideally, minimum 16g)
  • Obtain blood FBC,U&E, LFT, urate, coagulation screen
  • G&S

C1: CONTROL SEIZURE

C2: CONTROL BLOOD PRESSURE

C3: CONTROL FLUID BALANCE

*** The “Eclampsia” box contains all the necessary drugs, antidotes and instructions ***

D

DELIVERY PLAN

E

EVALUATE

Reassess monitoring and Investigations

C1: CONTROL SEIZURE

Magnesium Sulphate is the drug of choice unless there are specific contra indications to its use.

Magnesium Sulphate:

Loading Dose (by hand):                      

  • 4 grams IV over 5 minutes
    (Add 4 grams (8 mls of 50%) Magnesium Sulphate to 12 mls Normal Saline)          

Maintenance Infusion Dose:

  • IV infusion 1 gram Magnesium Sulphate per hour                 

Maintenance Infusion Preparation:

  • 10 grams (20 mls of 50%) Magnesium Sulphate made up to 50 mls by adding to 30 mls normal saline in a 60 ml luer lock syringe
  • Infusion rate is 1 gram (5 mls) per hour via an syringe driver

Infusion is maintained at 1 gram/hr for 24 hours provided:

  • Respiratory rate > 14 per minute
  • Urine output > 25mls/hour, and
  • Patellar reflexes are present

NB:  The volume of the Magnesium Sulphate infusion must be included as part of  the total fluid maintenance infusion for the patient of 85ml/hour

Recurrent Seizures on Treatment:

  • Give a 2nd bolus dose of Magnesium Sulphate 2 grams over 5 minutes by hand (do not stop infusion)
  • add 2 grams (4 mls of 50%) Magnesium Sulphate to 6 mls of Normal Saline
  • One dose only

If further seizures despite 2nd bolus give Diazepam 10mg IV.  Intubation may be required to protect airway and ensure adequate oxygenation.

Magnesium Sulphate – Patient Monitoring:

Reflexes:

  • Patellar reflexes after completion of loading dose and hourly whilst on maintenance dose (use arm reflexes if functional regional anaesthesia).
  • If reflexes are absent stop infusion until reflexes return and check Magnesium level.

Oxygen Saturation / Respiratory Rate:

  • Continuous O2 saturation should be assessed.
  • Perform respiratory rate every 15 minutes
  • If O2 saturation < 94% or respiratory rate < 14 / min, administer O2 (4 L/min via Hudson mask), stop Magnesium Sulphate infusion and call anaesthetist. Check Magnesium level. Consider antidote

Urine Output:

Monitor hourly.

If >20 ml/h - continue Magnesium Sulphate infusion.

If 10 - 20 ml/h & creatinine <150mmol/l - continue as protocol and recheck Magnesium level every 2 hours.

If 10 - 20 ml/h & creatinine > 150mmol/l (or urea >10) - recheck Magnesium levels immediately and every 2 hours. Decrease infusion rate to 0.5gram/hour.

If < 10 ml/h - stop infusion and check Magnesium level.

Biochemical Monitoring (Magnesium levels):  This is not routine. If required then see below.

The Therapeutic range is 2-4 mmol/l.

Low If < 2 mmol/l - Maintain infusion at current rate.  Recheck in 2 hours.

Therapeutic If 2 -3.5 mmol/l - Continue infusion at current rate. Recheck in 2 hours if clinical indication remains.

High If 3.55 - 5 mmol/l - STOP INFUSION for 15 min and then recommence at half previous infusion rate and recheck in 1 hour.

Very High If > 5mmol/l - STOP INFUSION and consider antidote. See below for further details.

Magnesium Sulphate toxicity and management:

Clinical Features

   Mg level

Action

Loss of Patellar reflexes
Weakness
Nausea, Flushing
Double vision
Slurred speech
Somnolence 

circa 5 mmol/l

STOP INFUSION

GIVE ANTIDOTE
10 ml of 10% Calcium Gluconate (1gram)
Slow IV inject over 10 mins. 
CHECK Magnesium level.  

Muscle Paralysis

circa 6-7.5 mmol/l

STOP INFUSION

GIVE ANTIDOTEAS ABOVECHECK
Magnesium level.  

Respiratory Arrest
Cardiac Arrest 

circa 12 mmol/l

STOP INFUSION

INSTITUTE CPR 
2222 CALL Obstetric and cardiac arrest team INTUBATE AND VENTILATE
GIVE ANTIDOTE AS ABOVE 
CHECK Magnesium level

C2: CONTROL BLOOD PRESSURE

  • MAP > 140 mm Hg is an obstetric emergency

  • No evidence that one particular drug is superior for treatment. Labetalol tends to be the first line drug of choice in this locality.

  • Continuous fetal monitoring is necessary because lowering of maternal BP may lead to fetal distress, particularly if there is associated IUGR

  • Automated oscillometric devices may underestimate BP

  • Commence MEWS chart (one large bold box per hour)

  • MAP >140 mm Hg - measure BP every 5 minutes

  • MAP 125 -140 mm Hg - measure BP every 15 minutes

  • Aim for gradual reduction in BP to around 130-140 / 90 - 100 mmHg (MAP < 125)

  • Site 2 x wide bore IV cannula & check BP bloods (U+E, LFT, urate, FBC +/- coagulation if platelet count is < 150 or previous abnormality) 6 hourly if patient stable, X-match 2 units blood

  • Foley catheter inserted and hourly urine volumes commenced

  • Continuous pulse oximetry

Antihypertensive treatment for hypertensive crisis (flowchart)

If Labetalol contraindicated or above labetalol regime has failed to control blood pressure - Second Line Agent (Hydralazine OR Nifedipine) (flowchart)

Antihypertensive drugs

Labetalol:

Contraindications including:

Asthma, Bronchospasm, Uncontrolled heart failure

IV bolus:    

50 mg over 5 minutes
i.e. 10 mls of 5 mg/ml
Can be repeated; and/or followed by infusion (see chart)

Infusion preparation: 

Prepare 5 mg/ml infusion
i.e.  300 mg Labetalol in 60mls
Commence infusion at 50 mg (10 mls) per hour.

Nifedipine:

Contraindications including: Hypersensitivity to nifedipine, or to other dihydropyridines because of the theoretical risk of cross-reactivity, or to any of the excipients, Angina, Recent MI, Aortic Stenosis
  (Care with Magnesium Sulphate – see note below*)
Preparation:  10 mg capsule orally (swallowed whole)Repeated doses of 10 mg can be given at 6 hourly intervals

Hydralazine:

Contraindications: Hypersensitivity to hydralazine or dihydralazine
Connective tissue disorders
Severe tachycardia and heart failure with high output cardiac failure (e.g. in thyrotoxicosis)
Myocardial insufficiency due to mechanical obstruction (e.g. in the presence of aortic or mitral stenosis or constructive pericarditis)
Isolated right ventricular failure due to pulmonary hypertension (cor pulmonale)
Dissecting aortic aneurysm
IV bolus: 5 mg slowly over 5 minutes
Boluses can be repeated at 20 minute intervals, but may be simpler to start infusion(
A 5 mg dose can be effective for 6 hours)
Infusion preparation:   Prepare 1 mg/ml infusion i.e.  40 mg Hydralazine made to 40mls with normal saline.
Infuse at 10 mg (10 mls) per hour

*Note

There are 2 case reports of neuromuscular blockade resulting from simultaneous use of Nifedipine and Magnesium Sulphate.  However, 1,469 women were assigned to receive Magnesium Sulphate and Nifedipine in the Magpie trial, and no such blockade was reported.  Similarly, no adverse events were reported in RCTs comparing Hydralazine with Nifedipine in which all, or some, women received magnesium sulphate.  The risk of neuromuscular blockade is therefore likely to below. MAP > 140 mm Hg is an obstetric emergency.

C3: CONTROL FLUID BALANCE

  • The main risk is of pulmonary oedema to iatrogenic fluid overload.
  • Patients should be fluid restricted (85mls per hour of total input).
  • Document hourly urine output on MEWS chart
  • Oliguria is common in severe pre-eclampsia.
  • The natural diuresis may not occur for at least 12 hours post delivery.
  • Renal failure is uncommon.

  • Furosemide should be reserved for pulmonary oedema and prescription must be discussed with consultant obstetrician.

  • In persisting oliguria U&Es should be checked 6 hourly.
  • In persisting oliguria: urine osmolality that is not concentrated, or high potassium levels indicates renal failure and renal physicians should be contacted.

  • CVP monitoring can be misleading.
  • Consultant obstetrician on-call must be informed if CVP line is considered.

Delivery

  • Delivery is the definitive treatment for severe pre-eclampsia/eclampsia
  • Mother MUST be stabilised prior to delivery irrespective of circumstances (e.g. fetal distress)
  • HDU support is required post delivery
  • ITU if ventilated

N.B.  Avoid ergometrine use. Skip to next medical treatment if uterine atony (PPH guideline). 

Editorial Information

Last reviewed: 22/12/2015

Next review date: 15/02/2021

Author(s): Janet Brennand.

Approved By: Obstetrics Clinical Governance Group

Document Id: 402