Eclampsia -a neurological condition associated with pre-eclampsia, manifesting with tonic-clonic convulsions in pregnancy that cannot be afributed to other conditions such as epilepsy - Rates of eclampsia have actually decreased in the developed world, due to improved antenatal care, timing of birth and use of magnesium sulphate -Eclampsia can develop any time from 20 weeks' gestation up to 6 weeks postpartum

-44% of cases occur postnatally When a woman has an eclamptic seizure the midwife, initiate Airway, Breathing, Circulation (ABC) principles and then assist the doctor with treatment

M a na g e m e nt o f a n e cla m pt ic se iz ur e Do not leave the convulsing woman alone. Summon medical and senior midwifery aid to gather equipment to site an IVI, administer emergency drugs and set up bed rails. In the community, ambulance is required. Try to reassure the woman and her relatives. Prevent any subsequent injury to the mother with bed rails and by applying padding.

A: Airway. Protect from aspiration by placing woman in left lateral position, assisted by a wedge if still pregnant. Use suction for oral secretions. B: Breathing. Anaesthetist should be called for possible intubation. Consider an oral airway. Administer supplementary oxygen by face mask. C: Circulation. Observe the pulse, and if cardiac arrest occurs commence continuous chest compressions (cardiac massage).

The doctor should site an IVI and take blood samples for: full blood count, group and save, clotting factors, uric acid, liver function tests, serum calcium, and urea and electrolytes. Accurate records of all fluid given should be maintained. A Foley's catheter should be inserted in the bladder to ensure accurate recording of the urinary output and regular urine testing for proteinuria.

D: Drugs. Administration of the anticonvulsant magnesium sulphate is given as 4 g by a slow IVI for 5 minutes. If recurrent seizures occur the IV rate is increased or a further bolus dose of 2–4 g is given. An electrocardiogram (ECG) should be conducted during the loading dose and for one hour afterwards. The maximum IV dose of magnesium sulphate is 9 g over the first hour. If the convulsions do not stop the medical team may consider administering 5 mg diazepam or 1 mg lorazepam

D: Documents. All observations and treatment to be documented in the woman's case notes. E: Environment. Ensure the woman keeps safe. F: Fundus. If the woman is still pregnant, the uterus should be displaced by assisting her into the left lateral position, assisted by a wedge.

The birth -require an emergency caesarean section, so the midwife should prepare her for this type of birth and a potentially preterm baby. -An epidural or spinal anaesthesia is preferred to reduce the consequences associated with general anaesthesia. - vaginal birth , syntometrine and ergometrine should be avoided and oxytocin used instead.

Subsequent care -the Intensive Care Unit (ICU) or the High Dependency Care Unit (HDCU) attached to the labour ward. - to reach a BP of <150/80 mmHg. -The woman will require an electrocardiogram (ECG) for one hour after the loading dose of magnesium sulphate - drug is continued by IVI for at least 24 hours. - A blood sample to measure serum magnesium should be taken as this drug can reach a toxic level. -If the urinary output reduces to <100 ml over 4 hours the magnesium sulphate may be reduced

-accurate fluid balance recording is essential. -Continuous monitoring of the woman's *BP monitoring * pulse * respiration * oxygen saturation * urine output *and reflexes should be undertaken hourly . - antihypertensive therapy should be continued - monitoring continues for 24–48 hours - transferred to the postnatal ward for a few more days until the medical team considers her condition is satisfactory for transfer home. woman should be taken to see her baby as soon as her condition permits. Breastfeeding encouraged and psychological support given

Haemolysis, Elevated Liver enzymes and Low Platelets (HELLP) syndrome -a multisystem disorder that can occur on its own or in association with pre- eclampsia. activation of the coagulation system causing increased deposits of protein fibrin throughout the body resulting in fragmentation of erythrocytes . Fibrin deposits on blood vessel walls initiate clumping of platelets resulting in blood clots and lowering of the platelet count. These deposits decrease the diameter of the blood vessels, raising blood pressure and reducing the blood flow to organs The liver is especially affected, with destruction of liver cells leading to abnormal liver function and a distended liver with symptoms of epigastric discomfort.

-HELLP syndrome presents antenatally in 70% of cases, - in the third trimester - in the postnatal period it occurs in 30% of cases. - If HELLP syndrome occurs before 26 weeks it is usually associated with antiphospholipid syndrome (APS). -It also complicates 20% of severe pre-eclampsia cases resulting in high maternal and perinatal morbidity and mortality rates -The woman will present with non-specific symptoms, malaise, including nausea, vomiting and epigastric pain

-? haematuria or jaundice. - raised blood pressure and proteinuria. -?? D.D AFLP.

Complications can include: disseminated intravascular coagulation (DIC) liver haematoma and rupture placental abruption pulmonary oedema and adult respiratory distress pleural effusions renal failure.

midwifery care being similar to that for severe pre-eclampsia, with emphasis on the administration of magnesium sulphate to prevent convulsions. The condition usually resolves, 2 weeks after the baby's birth.

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