PROBLEMS

• A pregnant woman or a woman who recently delivered complains of severe headache or blurred vision.

• A pregnant woman or a woman who recently delivered is found unconscious or having convulsions (seizures).

• A pregnant woman has elevated blood pressure.

GENERAL MANAGEMENT

• If a woman is unconscious or convulsing, SHOUT FOR HELP. Urgently mobilize all available personnel.

• Make a rapid evaluation of the general condition of the woman including vital signs (pulse, blood pressure, respiration) while simultaneously finding out the history of her present and past illnesses either from her or from her relatives.

• If she is not breathing or her breathing is shallow:

- Check airway and intubate if required;

- If she is not breathing, assist ventilation using Ambu bag and mask or give oxygen at 4–6 L per minute via endotracheal tube;

- If she is breathing, give oxygen at 4–6 L per minute by mask or nasal cannulae.

• If she is unconscious:

- Check airway and temperature;

- Position her on her left side;

- Check for neck rigidity.

• If she is convulsing:

- Position her on her left side to reduce the risk of aspiration of secretions, vomit and blood;

- Protect her from injuries (fall), but do not attempt to restrain her;

- Provide constant supervision; 

- If eclampsia is diagnosed (Table S-9), give magnesium sulfate (Box S-3);

- If the cause of convulsions has not been determined, manage as eclampsia and continue to investigate other causes. 

Table S-9  Diagnosis of headache, blurred vision, convulsions or loss of consciousness, elevated blood pressure

Presenting Symptom and Other Symptoms and Signs Typically Present	Symptoms and Signs Sometimes Present	Probable Diagnosis
• Diastolic blood pressure 90 mm Hg or more before first 20 weeks of gestation		Chronic hypertension
• Diastolic blood pressure 90–110 mm Hg before 20 weeks of gestation • Proteinuria up to 2+		Chronic hypertension with superimposed  mild  pre-eclampsia
• Two readings of diastolic blood pressure 90–110 mm Hg 4 hours apart after 20 weeks gestation • No proteinuria		Pregnancy-induced hypertension
• Two readings of diastolic blood pressure 90–110 mm Hg 4 hours apart after 20 weeks gestation • Proteinuria up to 2+		Mild pre-eclampsia
• Diastolic blood pressure 110 mm Hg or more after 20 weeks gestation • Proteinuria 3+ or more	• Hyperreflexia • Headache (increasing frequency, unrelieved by regular analgesics) • Clouding of vision • Oliguria (passing less than 400 mL urine in 24 hours) • Upper abdominal pain (epigastric pain or pain in right upper quadrant) • Pulmonary oedema	Severe pre-eclampsia
• Convulsions • Diastolic blood pressure 90 mm Hg or more after 20 weeks gestation • Proteinuria 2+ or more	• Coma (unconscious) • Other symptoms and signs of severe pre-eclampsia	Eclampsia
• Trismus (difficulty opening mouth and chewing)	• Spasms of face, neck, trunk • Arched back • Board-like abdomen • Spontaneous violent spasms	Tetanus
• Convulsions  • Past history of convulsions • Normal blood pressure		Epilepsy
• Fever • Chills/rigors • Headache • Muscle/joint pain	• Enlarged spleen	Uncomplicated malaria
• Symptoms and signs of uncomplicated malaria • Coma • Anaemia	• Convulsions • Jaundice	Severe/complicated malaria
• Headache • Stiff neck • Photophobia • Fever	• Convulsions • Confusion • Drowsiness • Coma	Meningitisb,c or Encephalitisb,c
• Headache • Blurred vision	• Vomiting	Migrained

^a If a woman has any one of the symptoms or signs listed under severe pre-eclampsia, diagnose severe pre-eclampsia.
^b If a diagnosis of eclampsia cannot be ruled out, continue treatment for eclampsia.
^c Examine spinal fluid and give appropriate treatment for meningitis or encephalitis.
^d Give analgesics (e.g. paracetamol 500 mg by mouth as needed).

Box S-2 Prevention of pregnancy-induced hypertension 

• Restricting calories, fluids and salt intake does NOT prevent pregnancy-induced hypertension and may even be harmful to the fetus.  • The beneficial effects of aspirin, calcium and other agents in preventing pregnancy-induced hypertension have not yet been proven. • Early detection and management in women with risk factors is critical to the management of pregnancy-induced hypertension and the prevention of convulsions. These women should be followed up regularly and given clear instructions on when to return to their health care provider. Education of immediate family members is equally important, not only so that they understand the significance of signs of pregnancy-induced hypertension progression but also to increase social support when hospitalization and changes in work activities are needed.

 

DIAGNOSIS OF HYPERTENSIVE DISORDERS

The hypertensive disorders of pregnancy include pregnancy-induced hypertension and chronic hypertension (elevation of the blood pressure before 20 weeks gestation).  Headaches, blurred vision, convulsions and loss of consciousness are often associated with hypertension in pregnancy, but are not necessarily specific to it. Other conditions that may cause convulsions or coma include epilepsy, complicated malaria, head injury, meningitis, encephalitis, etc. See Table S-9 for more information on diagnosis.

• Diastolic blood pressure is a good indicator of prognosis for the management of hypertensive disorders in pregnancy:

- Diastolic blood pressure is taken at the point at which the arterial sound disappears:

- A falsely high reading is obtained if the cuff does not encircle at least three-fourths of the circumference of the arm;

- A wider cuff should be used when the diameter of the upper arm is more than 30 cm;

- Diastolic blood pressure measures peripheral resistance and does not vary with the woman’s emotional state to the degree that systolic pressure does.

• If the diastolic blood pressure is 90 mm Hg or more on two consecutive readings taken 4 hours or more apart, diagnose hypertension (If urgent delivery must take place or if the diastolic blood pressure is 110 mm Hg or more, a time interval of less than 4 hours is acceptable):

- If hypertension occurs after 20 weeks of gestation, during labour and/or within 48 hours of delivery it is classified as pregnancy-induced hypertension;

- If hypertension occurs before 20 weeks of gestation, it is classified as chronic hypertension.

PROTEINURIA

The presence of proteinuria changes the diagnosis from pregnancy-induced hypertension to pre-eclampsia. Other conditions cause proteinuria and false positive results are possible.  Urinary infection, severe anaemia, heart failure and difficult labour may all cause proteinuria. Blood in the urine due to catheter trauma, schistosomiasis and contamination from vaginal blood could give false positive results.

Random urine sampling such as the dipstick test for protein is a useful screening tool. A change from negative to positive during pregnancy is a warning sign. If dipsticks are not available, a sample of urine can be heated to boiling in a clean test tube. Add a drop of 2% acetic acid to check for persistent precipitates that can be quantified as a percentage of protein to the volume of the total sample. Vaginal secretions or amniotic fluid may contaminate urine specimens. Only clean-catch mid-stream specimens should be used.  Catheterization for this purpose is not justified due to the risk of urinary tract infection.

Diastolic blood pressure alone is an accurate indicator of hypertension in pregnancy.  Elevated blood pressure and proteinuria, however, define pre-eclampsia. 

PREGNANCY-INDUCED HYPERTENSION

Women with pregnancy-induced hypertension disorders may progress from mild disease to a more serious condition. The classes of pregnancy-induced hypertension are:

• hypertension without proteinuria or oedema;

• mild pre-eclampsia;

• severe pre-eclampsia;

• eclampsia.

TABLE S-9 Diagnosis of headache, blurred vision, convulsions or loss of consciousness, elevated blood pressure 

A small proportion of women with eclampsia have normal blood pressure. Treat all women with convulsions as if they have eclampsia until another diagnosis is confirmed. 

Remember:

• Mild pre-eclampsia often has no symptoms.

• Increasing proteinuria is a sign of worsening pre-eclampsia.

• Oedema of the feet and lower extremities is not considered a reliable sign of pre-eclampsia. 

In pregnancy-induced hypertension, there may be no symptoms and the only sign may be hypertension. 

• Mild pre-eclampsia may progress rapidly to severe pre-eclampsia. The risk of complications, including eclampsia, increases greatly in severe pre-eclampsia.

• Convulsions with signs of pre-eclampsia indicates eclampsia. These convulsions:

- can occur regardless of the severity of hypertension;

- are difficult to predict and typically occur in the absence of hyperreflexia, headache or visual changes;

- occur after childbirth in about 25% of cases;

- are tonic-clonic and resemble grand mal convulsions of epilepsy;

- may recur in rapid sequence, as in status epilepticus, and may end in death;

- will not be observed if the woman is alone;

- may be followed by coma that lasts minutes or hours depending on the frequency of convulsions.

Do not give ergometrine to women with pre-eclampsia, eclampsia or high blood pressure because it increases the risk of convulsions and cerebrovascular accidents.   

MANAGEMENT OF PREGNANCY-INDUCED HYPERTENSION

Box S-2 Prevention of pregnancy-induced hypertension 

PREGNANCY-INDUCED HYPERTENSION 

Manage on an outpatient basis: 

• Monitor blood pressure, urine (for proteinuria) and fetal condition weekly.

• If blood pressure worsens, manage as mild pre-eclampsia.

• If there are signs of severe fetal growth restriction or fetal compromise, admit the woman to the hospital for assessment and possible expedited delivery.

• Counsel the woman and her family about danger signals indicating pre-eclampsia or eclampsia.

• If all observations remain stable, allow to proceed with normal labour and childbirth.

MILD PRE-ECLAMPSIA
GESTATION LESS THAN 37 WEEKS

If signs remain unchanged or normalize, follow up twice a week as an outpatient:

• Monitor blood pressure, urine (for proteinuria), reflexes and fetal condition.

• Counsel the woman and her family about danger signals of severe pre-eclampsia or eclampsia.

• Encourage additional periods of rest.

• Encourage the woman to eat a normal diet (salt restriction should be discouraged).

• Do not give anticonvulsants, antihypertensives, sedatives or tranquillizers.

• If follow-up as an outpatient is not possible, admit the woman to the hospital:

- Provide a normal diet (salt restriction should be discouraged);

- Monitor blood pressure (twice daily) and urine for proteinuria (daily); 

- Do not give anticonvulsants, antihypertensives, sedatives or tranquillizers unless blood pressure or urinary protein level increases;

- Do not give diuretics. Diuretics are harmful and only indicated for use in pre-eclampsia with pulmonary oedema or congestive heart failure;

- If the diastolic pressure decreases to normal levels or her condition remains stable, send the woman home:

- Advise her to rest and to watch out for significant swelling or symptoms of severe pre-eclampsia;

- See her twice weekly to monitor blood pressure, urine (for proteinuria) and fetal condition and to assess for symptoms and signs of severe pre-eclampsia;

- If diastolic pressure rises again, readmit her;

- If the signs remain unchanged, keep the woman in the hospital. Continue the same management and monitor fetal growth by symphysis-fundal height;

- If there are signs of growth restriction, consider early delivery. If not, continue hospitalization until term. 

• If urinary protein level increases, manage as severe pre-eclampsia (see below).

Note: Symptoms and signs of pre-eclampsia do not completely disappear until after pregnancy ends.
 

GESTATION MORE THAN 37 COMPLETE WEEKS

If there are signs of fetal compromise, assess the cervix and expedite delivery:

• If the cervix is favourable (soft, thin, partly dilated), rupture the membranes with an amniotic hook or a Kocher clamp and induce labour using oxytocin or prostaglandins.

• If the cervix is unfavourable (firm, thick, closed), ripen the cervix using prostaglandins or a Foley catheter or deliver by caesarean section.

SEVERE PRE-ECLAMPSIA AND ECLAMPSIA

Severe pre-eclampsia and eclampsia are managed similarly with the exception that delivery must occur within 12 hours of onset of convulsions in eclampsia. ALL cases of severe pre-eclampsia should be managed actively. Symptoms and signs of “impending eclampsia” (blurred vision, hyperreflexia) are unreliable and expectant management is not recommended.

MANAGEMENT DURING A CONVULSION

• Give anticonvulsive drugs.

• Gather equipment (airway, suction, mask and bag, oxygen) and give oxygen at 4–6 L per minute.

• Protect the woman from injury but do not actively restrain her.

• Place the woman on her left side to reduce risk of aspiration of secretions, vomit and blood.

• After the convulsion, aspirate the mouth and throat as necessary.

GENERAL MANAGEMENT

• If diastolic blood pressure remains above 110 mm Hg, give antihypertensive drugs. Reduce the diastolic blood pressure to less than 100 mm Hg but not below 90 mm Hg.

• Start an IV infusion and infuse IV fluids.

• Maintain a strict fluid balance chart and monitor the amount of fluids administered and urine output to ensure that there is no fluid overload.

• Catheterize the bladder to monitor urine output and proteinuria. 

• If urine output is less than 30 mL per hour:

- Withhold magnesium sulfate and infuse IV fluids (normal saline or Ringer’s lactate) at 1 L in 8 hours;

- Monitor for the development of pulmonary oedema.

• Never leave the woman alone. A convulsion followed by aspiration of vomit may cause death of the woman and fetus. 

• Observe vital signs, reflexes and fetal heart rate hourly.

• Auscultate the lung bases hourly for rales indicating pulmonary oedema. If rales are heard, withhold fluids and give frusemide 40 mg IV once.

• Assess clotting status with a bedside clotting test. Failure of a clot to form after 7 minutes or a soft clot that breaks down easily suggests coagulopathy.

ANTICONVULSIVE DRUGS

A key factor in anticonvulsive therapy is adequate administration of anticonvulsive drugs. Convulsions in hospitalized women are most frequently caused by under-treatment.  Magnesium sulfate is the drug of choice for preventing and treating convulsions in severe pre-eclampsia and eclampsia. Administration is outlined in Box S-3. 

 If magnesium sulfate is not available, diazepam may be used although there is a greater risk for neonatal respiratory depression because diazepam passes the placenta freely. A single dose of diazepam to abort a convulsion seldom causes neonatal respiratory depression. Long-term continuous IV administration increases the risk of respiratory depression in babies who may already be suffering from the effects of utero-placental ischaemia and preterm birth. The effect may last several days. Administration of diazepam is outlined in Box S-4.

BOX S-3 Magnesium sulfate schedules for severe pre-eclampsia and eclampsia 

BOX S-4 Diazepam schedules for severe pre-eclampsia and eclampsia 

ANTIHYPERTENSIVE DRUGS

If the diastolic pressure is 110 mm Hg or more, give antihypertensive drugs. The goal is to keep the diastolic pressure between 90 mm Hg and 100 mm Hg to prevent cerebral haemorrhage. Hydralazine is the drug of choice.

• Give hydralazine 5 mg IV slowly every 5 minutes until blood pressure is lowered. Repeat hourly as needed or give hydralazine 12.5 mg IM every 2 hours as needed.

• If hydralazine is not available, give:

- labetolol 10 mg IV:

- If response is inadequate (diastolic blood pressure remains above 110 mm Hg) after 10 minutes, give labetolol 20 mg IV;

- Increase the dose to 40 mg and then 80 mg if satisfactory response is not obtained after 10 minutes of each dose;

- OR nifedipine 5 mg under the tongue:

- If response is inadequate (diastolic pressure remains above 110 mm Hg) after 10 minutes, give an additional 5 mg under the tongue. 

Note: There is concern regarding a possibility for an interaction with magnesium sulfate that can lead to hypotension.

DELIVERY

Delivery should take place as soon as the woman’s condition has stabilized. Delaying delivery to increase fetal maturity will risk the lives of both the woman and the fetus. Delivery
should occur regardless of the gestational age. 

In severe pre-eclampsia, delivery should occur within 24 hours of the onset of symptoms.   In eclampsia, delivery should occur within 12 hours of the onset of convulsions. 

• Assess the cervix.

• If the cervix is favourable (soft, thin, partly dilated), rupture the membranes with an amniotic hook or a Kocher clamp and induce labour using oxytocin or prostaglandins.

• If vaginal delivery is not anticipated within 12 hours (for eclampsia) or 24 hours (for severe pre-eclampsia), deliver by caesarean section.

• If there are fetal heart rate abnormalities (less than 100 or more than 180 beats per minute), deliver by caesarean section.

• If the cervix is unfavourable (firm, thick, closed) and the fetus is alive, deliver by caesarean section.

• If safe anaesthesia is not available for caesarean section or if the fetus is dead or too premature for survival:

- Aim for vaginal delivery;

- If the cervix is unfavourable (firm, thick, closed), ripen the cervix using misoprostol, prostaglandins or a Foley catheter. 

Note: If caesarean section is performed, ensure that:

• Coagulopathy has been ruled out;

• Safe general anaesthesia is available. Spinal anaesthesia is associated with the risk of hypotension. This risk can be reduced if adequate IV fluids (500–1 000 mL) are infused prior to administration of the anaesthetic.

Do not use local anaesthesia or ketamine in women with pre-eclampsia or eclampsia. 

POSTPARTUM CARE

• Anticonvulsive therapy should be maintained for 24 hours after delivery or the last convulsion, whichever occurs last.

• Continue antihypertensive therapy as long as the diastolic pressure is 110 mm Hg or more.

• Continue to monitor urine output.

REFERRAL FOR TERTIARY LEVEL CARE

Consider referral of women who have:

• oliguria that persists for 48 hours after delivery;

• coagulation failure [e.g. coagulopathy or haemolysis, elevated liver enzymes and low platelets (HELLP) syndrome];

• persistent coma lasting more than 24 hours after convulsion.
　

COMPLICATIONS OF PREGNANCY-INDUCED HYPERTENSION

Complications may cause adverse perinatal and maternal outcomes. Because complications are often difficult to treat, efforts should be made to prevent them by early diagnosis and proper management. Health care providers should be aware that management can also lead to complications. Manage complications as follows:

• If fetal growth restriction is severe, expedite delivery.

• If there is increasing drowsiness or coma, suspect cerebral haemorrhage:

- Reduce blood pressure slowly to reduce the risk of cerebral haemorrhage;

- Provide supportive therapy.

• If heart, kidney or liver failure is suspected, provide supportive therapy and observe.

• If a clotting test shows failure of a clot to form after 7 minutes or a soft clot that breaks down easily, suspect coagulopathy.

• If the woman has IV lines and catheters, she is prone to infection. Use proper infection prevention techniques and closely monitor for signs of infection.

• If the woman is receiving IV fluids, she is at risk of circulatory overload. Maintain a strict fluid balance chart and monitor the amount of fluids administered and urine output.

CHRONIC HYPERTENSION

• Encourage additional periods of rest.

• High levels of blood pressure maintain renal and placental perfusion in chronic hypertension; reducing blood pressure will result in diminished perfusion. Blood pressure should not be lowered below its pre-pregnancy level. There is no evidence that aggressive treatment to lower the blood pressure to normal levels improves either fetal or maternal outcome: 

- If the woman was on anti-hypertensive medication before pregnancy and the disease is well-controlled, continue the same medication if acceptable in pregnancy;

- If diastolic blood pressure is 110 mm Hg or more, or systolic blood pressure is 160 mm Hg or more, treat with antihypertensive drugs;

- If proteinuria or other signs and symptoms are present, consider superimposed pre-eclampsia and manage as mild pre-eclampsia.

• Monitor fetal growth and condition.

• If there are no complications, deliver at term.

• If pre-eclampsia develops, manage as mild pre-eclampsia or severe pre-eclampsia.

• If there are fetal heart rate abnormalities (less than 100 or more than 180 beats per minute), suspect fetal distress.

• If fetal growth restriction is severe and pregnancy dating is accurate, assess the cervix and consider delivery:

Note: Assessment of gestation by ultrasound in late pregnancy is not accurate.

- If the cervix is favourable (soft, thin, partly dilated), rupture the membranes with an amniotic hook or a Kocher clamp and induce labour using oxytocin or prostaglandins;

- If the cervix is unfavourable (firm, thick, closed), ripen the cervix using prostaglandins or a Foley catheter.

• Observe for complications including abruptio placentae and superimposed pre-eclampsia .

TETANUS

Clostridium tetani may enter the uterine cavity on unclean instruments or hands, particularly during non-professional abortions or non-institutional deliveries. The newborn is usually infected from unclean instruments used in cutting the cord or from contaminated substances applied as traditional cord dressings. 

Treatment should begin as soon as possible.

• Control spasms with diazepam 10 mg IV slowly over 2 minutes. If spasms are severe, the woman may have to be paralyzed and put on a ventilator. This may be possible only at a tertiary care centre.

• Provide general care:

- Nurse in a quiet room but monitor closely; 

- Avoid unnecessary stimuli; 

- Maintain hydration and nutrition;

- Treat secondary infection. 

• Give tetanus antitoxin 3 000 units IM to neutralize absorbed toxin.

• Prevent further production of toxin:

- Remove the cause of sepsis (e.g. remove infected tissue from uterine cavity in a septic abortion);

- Give benzyl penicillin 2 million units IV every 4 hours for 48 hours, then give ampicillin 500 mg by mouth three times per day for 10 days.

BOX S-5 Tetanus immunization 

EPILEPSY

Women with epilepsy can present with convulsions in pregnancy. Like many chronic diseases, epilepsy worsens in some women during pregnancy but improves in others. In the majority of women, however, epilepsy is unaffected by pregnancy.

• Observe the woman closely. In general, pregnant women with epilepsy have an increased risk of:

- pregnancy-induced hypertension;

- preterm labour;

- infants with low birth weights;

- infants with congenital malformations;

- perinatal mortality. 

• Aim to control epilepsy with the smallest dose of a single drug. Avoid drugs in early pregnancy which are associated with congenital malformations (e.g. valproic acid).

• If the woman is convulsing, give diazepam 10 mg IV slowly over 2 minutes. Repeat if convulsions recur after 10 minutes. 

• If convulsions continue (status epilepticus), infuse phenytoin 1 g (approximately 18 mg/kg body weight) in 50–100 mL normal saline over 30 minutes (final concentration not to exceed 10 mg per mL):

Note: Only normal saline can be used to infuse phenytoin. All other IV fluids will cause crystallization of phenytoin.

- Flush IV line with normal saline before and after infusing phenytoin;

- Do not infuse phenytoin at a rate exceeding 50 mg per minute due to the risk of irregular heart beat, hypotension and respiratory depression;

- Complete administration within 1 hour of preparation.

• If the woman is known to be epileptic, give her the same medication that she had been taking. Follow-up with her regularly and adjust the dose of medication according to the
response.

• If the woman is known to be epileptic but cannot recall details of her medication, give her phenytoin 100 mg by mouth three times per day. Follow her up regularly and adjust the dose of medication according to the clinical situation. 

• Folic acid deficiency may be caused by anticonvulsive drugs. Give folic acid 600 mcg by mouth once daily along with antiepileptic treatment in pregnancy. 

• Phenytoin can cause neonatal deficiency of vitamin K-dependent clotting factors. This can be minimized by giving vitamin K 1 mg IM to the newborn.

• Evaluation for underlying causes of convulsions is indicated if convulsions are of recent onset. This may be possible only at the tertiary care level.

SEVERE/COMPLICATED MALARIA

Severe malaria in pregnancy may be misdiagnosed as eclampsia. If a pregnant woman living in a malarial area has fever, headaches or convulsions and malaria cannot be excluded, it is essential to treat the woman for both malaria and eclampsia.  

Pregnant women with severe malaria are particularly prone to hypoglycaemia, pulmonary oedema, anaemia and coma. 

ANTIMALARIAL DRUGS

Quinine remains the first line treatment in many countries and may be safely used throughout pregnancy. Where available, artesunate IV or artemether IM are the drugs of choice in the second and third trimesters. Their use in the first trimester must balance their advantages over quinine (better tolerability, less hypoglycaemia) against the limited documentation of pregnancy outcomes. 

QUININE DIHYDROCHLORIDE
LOADING DOSE

• Infuse quinine dihydrochloride 20 mg/kg body weight in IV fluids (5% dextrose, normal saline or Ringer’s lactate) over 4 hours:

- Never give an IV bolus injection of quinine;

- If it is definitely known that the woman has taken an adequate dose of quinine (1.2 g) within the preceding 12 hours, do not give the loading dose. Proceed with the maintenance dose (see below);

- If the history of treatment is not known or is unclear, give the loading dose of quinine;

- Use 100–500 mL IV fluids depending on the fluid balance state.

• Wait 4 hours before giving the maintenance dose.

MAINTENANCE DOSE

• Infuse quinine dihydrochloride 10 mg/kg body weight over 4 hours. Repeat every 8 hours (i.e. quinine infusion for 4 hours, no quinine for 4 hours, quinine infusion for 4 hours, etc.).

Note: Monitor blood glucose levels for hypoglycaemia every hour while the woman is receiving quinine IV.

• Continue the maintenance dosing schedule until the woman is conscious and able to swallow and then give:

- quinine dihydrochloride or quinine sulfate 10 mg/kg body weight by mouth every 8 hours to complete 7 days of treatment;

- OR in areas where sulfadoxine/pyrimethamine is effective, give sulfadoxine/pyrimethamine 3 tablets as a single dose.

INTRAVENOUS ARTESUNATE
LOADING DOSE

• Give artesunate 2.4 mg/kg body weight IV as a single bolus on the first day of treatment.

MAINTENANCE DOSE

• Give artesunate 1.2 mg/kg body weight IV as a single bolus once daily beginning on the second day of treatment.

• Continue the maintenance dosing schedule until the woman is conscious and able to swallow and then give artesunate 2 mg/kg body weight by mouth once daily to complete 7 days of treatment.

INTRAMUSCULAR ARTEMETHER
LOADING DOSE

• Give artemether 3.2 mg/kg body weight IM as a single dose on the first day of treatment.

MAINTENANCE DOSE

• Give artemether 1.6 mg/kg body weight IM once daily beginning on the second day of treatment.

• Continue the maintenance dosing schedule until the woman is conscious and able to swallow and then give artesunate 2 mg/kg body weight by mouth once daily to complete 7 days of treatment. 

CONVULSIONS

• If convulsions occur, give diazepam 10 mg IV slowly over 2 minutes.

• If eclampsia is diagnosed, prevent subsequent convulsions with magnesium sulfate (Box S-3).

• If eclampsia is excluded, prevent subsequent convulsions with phenytoin (below).

PHENYTOIN
LOADING DOSE

• Infuse phenytoin 1 g (approximately 18 mg/kg body weight) in 50–100 mL normal saline over 30 minutes (final concentration not to exceed 10 mg per mL):

Note: Only normal saline can be used to infuse phenytoin. All other IV fluids will cause crystallization of phenytoin.

- Flush IV line with normal saline before and after infusing phenytoin;

- Do not infuse phenytoin at a rate exceeding 50 mg per minute due to the risk of irregular heart beat, hypotension and respiratory depression;

- Complete administration within 1 hour of preparation.

MAINTENANCE DOSE

• Give phenytoin 100 mg IV slowly over 2 minutes or by mouth every 8 hours beginning at least 12 hours after the loading dose.

FLUID BALANCE

• Maintain a strict fluid balance chart and monitor the amount of fluids administered and urine output to ensure that there is no fluid overload. Assess clinical status regularly. 

Note: Women with severe malaria are prone to fluid overload.

• If pulmonary oedema develops:

- Prop the woman up;

- Give oxygen at 4 L per minute by mask or nasal cannulae;

- Give frusemide 40 mg IV as a single dose.

• If urine output is poor (less than 30 mL per hour):

- Measure serum creatinine;

- Rehydrate with IV fluids (normal saline, Ringer’s lactate).

• If urine output does not improve, give frusemide 40 mg IV as a single dose and monitor urine output.

• If urine output is still poor (less than 30 mL per hour over 4 hours) and the serum creatinine is more than 2.9 mg/dL, refer the woman to a tertiary care centre for management of renal failure.

HYPOGLYCAEMIA

Hypoglycaemia is common and occurs at any time during the illness, especially after initiation of quinine therapy. There may be no symptoms.

• Monitor blood glucose levels using a stix test every 4 hours.

Note: If the woman is receiving quinine IV, monitor blood glucose levels every hour.

• If hypoglycaemia is detected, give 50% dextrose 50 mL IV followed by dextrose (5 or 10%) 500 mL infused over 8 hours.

Note: Monitor blood glucose levels and adjust infusion accordingly.

• Monitor fluid balance carefully.

ANAEMIA

Complicated malaria is often accompanied by anaemia. 

• Monitor haemoglobin levels daily.

• Transfuse as necessary.

• Monitor fluid balance.

• Give frusemide 20 mg IV or by mouth with each unit of blood.

• Give ferrous sulfate or ferrous fumerate 60 mg by mouth PLUS folic acid 400 mcg by mouth once daily upon discharge.