A protocol for the intrapartum management of severe preeclampsia

Inadvertent intrathecal injection of labetalol in a patient undergoing post-partum tubal ligation

After receiving a continuous spinal anesthetic for labor following an inadvertent dural puncture with a 17-gauge epidural needle, a morbidly obese parturient underwent post-partum tubal ligation 12 h after vaginal delivery. The patient received a total of 2 mL of 0.75% hyperbaric bupivacaine for the surgery. In response to moderate hypertension the patient received intravenous labetalol hydrochloride 20 mg. She subsequently was inadvertently administered approximately 15 mg of labetalol through the spinal catheter. The spinal catheter was removed immediately after the procedure. She suffered no apparent adverse neurologic effects.

Maternal and fetal outcome of anaesthesia for caesarean delivery in preeclampsia/eclampsia in Enugu, Nigeria: a retrospective observational study

BACKGROUND

Maternal mortality, for which preeclampsia is a major cause, is a problem in Nigeria. Accurate data are available for caesarean sections in the University of Nigeria Teaching Hospital, Enugu. We therefore studied the outcome of caesarean section among these high-risk patients.

METHOD

We conducted a retrospective survey of hospital records of patients with preeclampsia/eclampsia who had caesarean delivery in this unit over a four-year span from July 1998 to June 2002.

RESULTS

There were 3926 deliveries and 4036 births (3611 live births), with 898 women (23%) delivered by caesarean section. Of these, 125 (14%) had preeclampsia/eclampsia, 103 (82.4%) presenting for emergency caesarean delivery and 22 (17.6%) elective. General anaesthesia was used in 116 patients (92.8%) and spinal in nine. The major indications for surgery were severe preeclampsia/eclampsia in patients with unfavourable cervix (68%), fetal distress/intrauterine growth restriction (7.2%) and previous caesarean section (6.4%). There were six maternal deaths, all with general anaesthesia, giving a case fatality rate of 5.2% of general anaesthetics or 4.8% of caesarean deliveries. The cause of death was anaesthetic in three patients, cerebrovascular accident and pulmonary oedema in two and intraoperative haemorrhage in one. There were 13 stillbirths and 10 neonatal deaths.

CONCLUSION

Maternal and fetal mortality were high. Poverty, late presentation, lack of equipment and inexperienced management were major contributory factors. Use of spinal anaesthesia should be encouraged in view of recent favourable reviews and cheaper cost.

Hydralazine boluses for the treatment of severe hypertension in pre-eclampsia

OBJECTIVE

To audit the use of bolus hydralazine for control of severe hypertension within a protocol for the management of severe pre-eclampsia.

DESIGN

A retrospective review.

SETTING

Three UK teaching hospitals.

SUBJECTS

Seventy consecutive women who received hydralazine for the treatment of sustained severe hypertension. Twenty-five women had more than one episode of hypertension amounting to a total of 109 treatment episodes.

INTERVENTION

Intravenous bolus hydralazine 5 mg, repeated every 15 min to reduce the mean arterial pressure to < 125 mmHg.

MAIN OUTCOME MEASURES

Change in mean arterial pressure in response to bolus hydralazine, fetal condition, as assessed by heart rate changes and umbilical arterial pH at delivery, and protocol violations were analysed.

RESULTS

Mean arterial pressure fell by 12 mmHg (95% CI 10-14) after the first bolus, 9 mmHg (95% CI 6.5-12) after the second bolus and 5 mmHg (95% CI 1-10) after the third bolus. Eighty-two (75%) episodes were managed strictly according to the protocol; of these, blood pressure was controlled by bolus therapy alone in 89%. Of the 27 instances in which the protocol was not adhered to, blood pressure was not controlled in four. There were no significant differences in the incidence of cardiotocographic abnormalities or umbilical acidaemia in the women treated before delivery (n = 36) compared with those in whom treatment was first initiated afterwards (n = 34).

CONCLUSIONS

Hydralazine given in 5 mg boluses is a safe and effective method of treating severe hypertension in pre-eclampsia. Despite clear management guidelines, protocol violations were common, and in 4% of treatment episodes these were potentially serious resulting in failure to control blood pressure.