What is the prehospital management of preeclampsia by paramedics?

Prehospital Management of Preeclampsia by Paramedics

Paramedics should administer antihypertensive treatment to patients with severe preeclampsia when systolic blood pressure ≥160 mmHg and/or diastolic blood pressure ≥110 mmHg persists for more than 15 minutes, and should consider administering magnesium sulfate when clinical signs of severity are present. 1

Initial Assessment and Recognition

• Identify severe preeclampsia: hypertension (SBP ≥160 mmHg and/or DBP ≥110 mmHg) after 20 weeks of pregnancy with any of the following severity signs 1:

  • Severe headache
  • Visual disturbances
  • Epigastric pain
  • Altered mental status
  • Hyperreflexia
  • Pulmonary edema
  • Oliguria

• Monitor vital signs continuously, including blood pressure measurements every 15 minutes 1

• Assess for presence of seizures or imminent eclampsia (severe symptoms that may precede seizures) 1

Management Protocol

Blood Pressure Control

• For severe hypertension (SBP ≥160 mmHg and/or DBP ≥110 mmHg persisting for >15 minutes):

  • Administer antihypertensive medication to maintain blood pressure below these thresholds 1
  • The specific antihypertensive agent should be determined by local protocols and in consultation with receiving facility 1

• Ideally, initiation and determination of antihypertensive treatment should be discussed via phone with obstetric and anesthetic-intensivist teams at the receiving specialized facility 1

Seizure Prevention

• For patients with severe preeclampsia showing clinical signs of severity:

  • Administer magnesium sulfate to reduce the risk of eclampsia 1
  • Monitor for signs of magnesium toxicity: loss of patellar reflexes, respiratory depression (less than 16 breaths/min) 2
  • Have injectable calcium salt immediately available to counteract potential magnesium toxicity 2

• Important safety considerations for magnesium sulfate administration:

  • Dilute 50% solution to 20% or less prior to IV infusion 2
  • Administer slowly and cautiously to avoid hypermagnesemia 2
  • Monitor urine output (should be maintained at 100 mL or more during four hours preceding each dose) 2
  • Use with caution in patients with renal impairment 2

Transport Considerations

• Medicalised transport (with advanced medical capabilities) should be systematically considered for patients with severe preeclampsia 1

• Coordinate with the emergency medical assistance service regulating doctor to determine the appropriate level of transport 1

• Provide pre-arrival notification to the receiving facility about the patient's condition, treatments administered, and estimated time of arrival 1

• Transport to a specialized obstetric facility with capabilities for managing severe preeclampsia and potential complications 1

Monitoring During Transport

• Continuous maternal monitoring:

  • Vital signs (blood pressure, heart rate, respiratory rate, oxygen saturation) 1
  • Level of consciousness 1
  • Deep tendon reflexes (particularly patellar reflex) before each dose of magnesium sulfate 2

• Be alert for signs of disease progression:

  • Worsening hypertension 1
  • Development of new symptoms 1
  • Decreased fetal movement (as reported by mother) 3

Cautions and Pitfalls

• Avoid prolonged administration of magnesium sulfate (beyond 5-7 days) as it can lead to fetal hypocalcemia and bone abnormalities, though this is rarely a concern in the prehospital setting 2

• Be aware that magnesium sulfate has additive CNS depressant effects when combined with barbiturates, narcotics, or other hypnotics 2

• Recognize that magnesium is removed from the body solely by the kidneys, so use with caution in patients with renal impairment 2

• Remember that delivery is the only definitive treatment for preeclampsia, and prehospital management focuses on stabilization and safe transport to an appropriate facility 4, 3