Module 30 · Special populations

Obstetric critical care

NewPhase 2

Obstetric critical care: severe pre-eclampsia and eclampsia, postpartum haemorrhage (WHO 2025 MOTIVE bundle), HELLP and AFLP, maternal sepsis, peripartum cardiomyopathy, and maternal cardiac arrest with amniotic fluid embolism.

6 topics

Drugs in this module

Doses written for this module's context. The same drug may read differently in another module.

Magnesium sulfate

Anticonvulsant

Indications
Eclampsia treatment; seizure prophylaxis in severe pre-eclampsia
Adult dose
Zuspan (IV): 4 g IV over 15-20 min, then 1 g/h for 24 h. Pritchard (IM, widely used in India): 4 g IV (20%) over 15-20 min + 10 g IM (5 g of 50% in each buttock), then 5 g IM every 4 h in alternate buttocks for 24 h. Recurrent seizure: further 2 g IV.
Preparation (India)
50% = 0.5 g/mL (1 g in 2 mL); dilute 4 g in NS to 20 mL (20%) for IV loading.
Renal / hepatic
Oliguria/raised creatinine: reduce or withhold maintenance and check levels.
Cautions
Toxicity: loss of patellar reflexes (~7-10 mEq/L), respiratory depression, cardiac arrest. Antidote: calcium gluconate 1 g IV.
Monitoring
Before each dose: patellar reflex present, RR > 16/min, urine output > 100 mL/4 h.

Labetalol

Alpha/beta-blocker

Indications
Acute severe hypertension in pregnancy (≥ 160/110)
Adult dose
20 mg IV over 2 min; if needed 40 mg after 10 min, then 80 mg every 10 min (max cumulative 300 mg); or infusion 1-2 mg/min.
Preparation (India)
5 mg/mL ampoules (20 mg/4 mL).
Cautions
Asthma, heart block; neonatal bradycardia/hypoglycaemia.

Hydralazine

Arteriolar vasodilator

Indications
Acute severe hypertension in pregnancy
Adult dose
5-10 mg IV over 2 min; repeat 10 mg after 20 min if BP still ≥ 160/110 (max 20 mg bolus doses; then switch agent).
Cautions
Maternal hypotension (give with 250-500 mL crystalloid if dry), tachycardia, headache.

Nifedipine (immediate-release oral)

Calcium-channel blocker

Indications
Acute severe hypertension in pregnancy (no IV access)
Adult dose
10 mg orally; if needed 20 mg after 20 min, then 20 mg after another 20 min; then switch agent.
Cautions
Do not give sublingually; caution with magnesium (theoretical hypotension).

Calcium gluconate 10%

Electrolyte / magnesium antagonist

Indications
Magnesium toxicity; hypocalcaemia with massive transfusion
Adult dose
1 g (10 mL of 10%) IV over 10 min.

Oxytocin

Uterotonic

Indications
PPH prevention and treatment
Adult dose
Treatment: 10 units IV slowly (or IM), then infusion 40 units in 500 mL crystalloid at 125 mL/h (10 units/h).
Cautions
Rapid IV bolus causes hypotension; water intoxication with prolonged high doses.

Tranexamic acid

Antifibrinolytic

Indications
PPH (all causes)
Adult dose
1 g IV over 10 min as soon as PPH is diagnosed and within 3 h of birth; second 1 g if bleeding continues after 30 min or restarts within 24 h.
Renal / hepatic
Reduce repeated doses in severe AKI.

Carboprost (15-methyl PGF2α)

Uterotonic prostaglandin

Indications
Refractory uterine atony
Adult dose
250 mcg IM (or intramyometrial) every 15 min, max 8 doses (2 mg).
Cautions
Asthma (bronchospasm), hypertension, diarrhoea, fever.

Misoprostol

Uterotonic prostaglandin E1 analogue

Indications
PPH when other uterotonics unavailable/adjunct
Adult dose
800 mcg sublingual (single dose).
Cautions
Shivering, pyrexia.

Methylergometrine (ergometrine)

Ergot uterotonic

Indications
Uterine atony
Adult dose
Methylergometrine 0.2 mg IM, may repeat after 15 min (ergometrine 0.5 mg IM per RCOG).
Cautions
Contraindicated in hypertension/pre-eclampsia, heart disease.

Piperacillin-tazobactam

Broad-spectrum beta-lactam

Indications
Maternal sepsis (genital tract, unknown source)
Adult dose
4.5 g IV q6h (± clindamycin for toxin suppression if GAS/toxic shock suspected).
Renal / hepatic
Adjust for CrCl < 40.

Clindamycin

Lincosamide

Indications
Toxin suppression in group A streptococcal/staphylococcal toxic shock
Adult dose
900 mg IV q8h with a beta-lactam.

Bromocriptine

Dopamine agonist (prolactin inhibitor)

Indications
Peripartum cardiomyopathy (with anticoagulation)
Adult dose
2.5 mg orally twice daily for 2 weeks, then 2.5 mg daily for 6 weeks (severe LVEF < 25%/shock); 2.5 mg daily for 1 week in uncomplicated cases.
Cautions
Thrombosis risk: give with at least prophylactic anticoagulation; stops lactation.

Module references (18)

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    European Association for the Study of the Liver. EASL Clinical Practical Guidelines on the management of acute (fulminant) liver failure. J Hepatol 2017;66:1047-81.

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    American College of Obstetricians and Gynecologists. Gestational hypertension and preeclampsia: ACOG Practice Bulletin No. 222. Obstet Gynecol 2020;135:e237-60.

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    Society for Maternal-Fetal Medicine; Pacheco LD, Clark SL, Klassen M, Hankins GDV. Amniotic fluid embolism: principles of early clinical management. Am J Obstet Gynecol 2020;222:48-52.