Fits in the second half of pregnancy

For fits in the first half of pregnancy — see Fits — seizures

Cause of fits — 20 or more weeks pregnant (gestation)

  • Eclampsia — fit occurring in a woman with preeclampsia or pregnancy-associated high BP
    • Can occur up to 3 weeks postpartum
  • Epilepsy, alcohol withdrawal, petrol sniffing, head injury, meningitis, encephalitis, stroke, low blood glucose, electrolyte abnormalities

Do first

  • Call for help — have helper call for urgent medical consult straight away
  • Give oxygen to
    • Target O2 sats 94–98%
    • OR if moderate/severe COPD 88-92%
  • Put in recovery position on left side — Figure 1.20

Figure 1.20   
  • Put in 2 IV cannulas — take blood for BGL, electrolytes 
  • Manage as eclampsia — even if woman epileptic
  • Give magnesium sulfate IV — loading dose 4g, over 10 minutes
    • Draw up 4g (8mL) of magnesium sulfate 50% — in 20mL syringe
    • Add 12mL sterile water or saline to the same syringe to make a 20% solution (4gm in 20mL)
    • Give this 4g magnesium sulfate 20% solution IV over 10 minutes using a burette attached to infusion pump
    • If no infusion pump — give as push over 10 minutes
  • Start magnesium sulfate IV infusion
    • IV infusion — 4g (8mL) at 1g/hr for 24 hour THEN review for cessation/continuation
    • Add 4g (8mL) to 100mL normal saline
    • Run solution at 25mL/hr through infusion pump
    • Label 'Magnesium sulfate 4g in normal saline 100mL'
  • OR if no infusion pump or no IV access  — give magnesium sulfate IM
    • Straight after IV loading dose — give magnesium sulfate deep IM — 10g (20mL) in 2 doses — 1 dose (5g/10mL) in each buttock. Use 21G needle
    • THEN give magnesium sulfate IM — 5g (10mL) every 4 hours — until woman evacuated
  • If fit continues for more than 3–5 minutes OR fits again during maintenance treatment
    • Repeat magnesium sulfate IV loading dose
    • Get ready to give midazolam — see Fits — medical consult
    • Magnesium sulfate and midazolam together can put breathing at risk. Be ready to manage airway and breathing
  • Monitor BP, patella reflexes, RR for respiratory depression, urine output (aim for 0.5mL/kg/hr) and note if further seizures occur
  • Stop maintenance treatment and do medical consult if
    • Patella reflex absent
    • RR less than 16 breaths/min
    • Urine output less than 0.5mL/kg/hr
  • If RR less than 12 breaths/min or woman stops breathing

Do not

  • Do not leave woman unattended
  • Do not leave woman on her back
  • Do not let woman eat or drink anything

Check

  • Airway and breathing — after fit has stopped
  • History in file notes
    • How many weeks gestation (pregnant)
    • BP reading in early pregnancy
    • Medical problems — epilepsy, alcohol or petrol use, high BP, kidney disease
  • Calculate REWS — AVPU, RR, O2 sats, pulse, BP, Temp
  • Weight, BGL 
  • Coma scale score, pupil reactions
  • Head-to-toe exam — with attention to 
    • Observations every 15 minutes for at least 1 hour after seizure — examine carefully for sickness or injury that may have caused fit. Consider meningitis, head injury, stroke
    • Vaginal loss, signs of labour

Do

  • Medical consult — doctor should consult obstetrician early
    • Talk with doctor about sending to hospital, BP control, steroids for foetal lung maturation
  • If airway blocked or noisy breathing — put in nasopharyngeal or oropharyngeal airway. If they spit out or gag — leave out. Consider gentle suctioning of mouth
  • Use tilt/wedge to position on left side
  • If BGL less than 4mmol/L — see Low blood glucose
  • Put in indwelling urinary catheter
    • Measure urine output hourly — aim for 0.5mL/kg/hr