Peripartum convulsions
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Peripartum convulsions

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Peripartum convulsions Peripartum convulsions Presentation Transcript

  • PERIPARTUMCONVULSIONSDR. RAJEEV SOODDept of OBGIGMC, SHIMLA
  • CONVULSIVE DISORDERS Are episodic neurological dysfunction & leading to sensory or motor manifestations in the form of sensory, cognitive, emotional or abnormal motor movements Always originate from central nervous system May be confined to one area of brain or involve whole brain So can be focal, partial or generalized
  • In obstetrics & gynecology4.Obstetric causes- 98%7.Non obstetric causes- 2%
  • Obstetric cause Eclampsia
  • ECLAMPSIAIs a disease complex confined to pregnancy where patient has2.High blood pressure3.Convulsions4.Proteinuria
  • Non obstetric causes In pregnant constitute 2% of the patientst Epilepsy 0.5-1% (idiopathic)h Focal lesions in the brain Tumours  primary or metastatics Tuberculomas Other infective lesions e.g cystecercosisl Tetanusl Cerebral malaria
  • NON OBSTETRIC CAUSES CONT..Vascular causeso Cerebral venous thrombosiso Thrombosis of cavernous sinuses or other venous sinuses in braino Thromboembolismo Vascular malformations
  • NON OBSTETRIC CAUSES CONT…Metabolic causeso Uremiao Hepatic failureo Hypo or hyperglycemia
  • NON OBSTETRIC CAUSES CONT…o Electrolyte abnormalityHyponatremiaHypernatremiaHypocalcemiaHypercalcemiaPyridoxine deficiencyHypomagnesemia
  • NON OBSTETRIC CAUSES CONT…OthersoFebrile convulsionsoTraumaoPoisoningoAlcohol
  • OBSTETRIC CAUSES 98%ECLAMPSIA:o Obstetric patient with seizure should be treated as eclampsia until proven otherwiseo Eclampsia is occurrence of seizures or coma not attributable to any cause other than pregnancy
  • ECLAMPSIAo Incidence varies from 1 in 30 to 500 pregnancyo Eclampsia can start without any prior symptoms or can have warning symptoms like High blood pressure Excessive weight gain >1 kg/week in last trimester Significant proteinuria >2+ on dipstick
  • ECLAMPSIAMostly a disease ofPrimigravidae- 75%Multiple pregnancyIn low socio economic group
  • TYPES OF ECLAMPSIA Antepartum 50% Intrapartum 30% Postpartum 20% usually within 48 hrs & fits beyond 7 days reasonably rule out eclampsia, but has been reported as long as 23 days after delivery
  • ATYPICAL ECLAMPSIA Before 20 weeks of gestation or 48 hrs after delivery Any patient presents with hypertension & proteinuria & additional feature of blindness without convulsions should be treated as eclampsia About 10% of the eclamptic patients can be normotensive
  • Presentation can be Antepartum 50% Peripartum 30% Postpartum 20% Majority have hypertension but 10% of patients never have high BP Headache 80% Visual disturbances 40-50% Pain epigastrium before seizure 30% Hyperactive deep tendon reflexes 30%
  • ECLAMPTIC CONVULSION OR FITS Premonitary stage(30 sec): twitching of face, tongue, limbs, eye balls turn to one sidey Tonic stage opisthotonus (30 sec): limbs flexed & hands clenched, respiration caeses, tongue protrude in between teeth, cyanosis appeare Clonic stage (1-4 min): alternate contraction & relaxation of voluntary musclesl Stage of coma: for brief period in some or continue to next convulsionStatus eclampticus: in quick succession
  • ECLAMPSIA20-35% of patients have signs & symptoms of pre eclampsia.40% patients have no symptoms & present first time with convulsions
  • CAUSES OF CONVULSIONS• Hypoxia or anoxia  spasm of cerebral vasculature• Cerebral oedema• Cerebral dysrhythmia  due to hypoxia & oedema• Disseminated intravascular coagulation in cerebral microcirculation
  • ECLAMPSIA The convulsions are not related with level of hypertension as they are not as a result of hypertensive encephalopathy, as they are not associated with retinal hemorrhage, exudates & may not be associated with even papillodema
  • INVESTIGATIONSLAB FINDINGS:2. Complete hemogram which include platelet count3. Coagulation profile Bedside BT, CT, CRT Lab findings prothrombin time partial thromboplastin time
  • LAB FINDINGS (CONTD) Haemoconcentration leads to Increased Hb Increased urea Increased serum creatinine level once raised reflects deranged glomerular functiono Serum uric acid level  increased & reflects deranged tubular functiono Tubular functions are knocked out about 4-6 weeks prior to the glomerular functiono Liver function are affected more in patients who have pain epigastrium & is reflected by Increased serum transaminases (increased SGOT, SGPT) more so in HELLP SYNDROME
  • LAB FINDINGS (CONTD) Lactatedehydrogenase are reflection of endothelial damage HELLP syndrome One form of eclampsia showing Hemolysis Elevated liver enzymes 10% of eclamptic Low platelet count patients Urinary protein estimation in clean catch sample and 24 hr urinary protein estimation
  • CT SCAN (OPTIONAL) Cerebral oedema Diffuse white matter low density area Patchy areas of low density Occipital white matter oedema Loss of normal cortical sulci Reduced ventricular size Acute hydrocephaluso Cerebral haemorrhage Intraventricular haemorrhage Parenchymal haemorrhage (high density)o Cerebral infarction Low attenuation areas Basal ganglia infarctionSimilar findings are observed in MRI
  • FUNDUS EXAMINATIONTo differentiate between the chronichypertensive patient and eclampticpatient
  •  Doppler studies shows vasoconstriction Angiography EEG: findings are non specific apart form eclampsia seen in Polycythemia Hypoxia Renal disease Hypocalcemia Hypercalcemia Water intoxication
  • MANAGEMENT
  • MANAGEMENT• PRINCIPLES are• To keep the patient in quiet environment• Keep the airway clear & put patient in left lateral position with head end slightly low on the bed with the rails• Secure the I/V line• Maintain vitals• Avoid injury  bed side rails, mouth gag if patient is unconscious• Control convulsions by anti convulsives (Magsulph)• Treat hypertension (anti- hypertensives)
  • MANAGEMENT
  • MANAGEMENT (CONTD.)• Monitor hypoxia & fluid balance(SpO2 & CVP monitor)• Organize investigation• Prevent recurrence of convulsion• Delivery of the woman safely as soon as possible• Postpartum care• Catheterize the bladder for monitoring hourly urine output
  • MANAGEMENT DURING FITIn premonitary stage:2.Place mouth gag between teeth3.Air passage cleaned4.Patient head turned to one side to prevent aspiration
  •  DON’T DO VIGOROUS TREATMENT DURING THE FIT AS USUALLY TENDENCY IS TO RUSH THE DRUGS IN THE FIT TO CONTROL IMMEDIATELY IT MAY PROVE COUNTERPRODUCTIVE DUE TO RAPID INFUSION OF DRUG (diazepam & magsulf) WHICH MAY DANGEROUSLY INCREASE THE BLOOD LEVEL OF DRUG LEADING TO CARDIAC ARREST
  •  First aid treatment outside hospital Patient should be transferred to tertiary hospital as soon as possible Control of convulsion: zero hour treatment Magnesium sulphate Phenytoin DiazepamMagnesium sulphate should be given zero hour dose at peripheral institution
  • PRITCHARD REGIMEN• (50% magsulph ) 2ml  1 gram• 4 gram 20% I/V slowly in 3-4 minutes• 4 ampoules (8ml) to be diluted to make it 20 ml• 5 gram (5%) in each buttock• Total dose 14 grams• Monitored by7. Tendon reflexes8. Urine output >100ml in 4 hrs9. Respiratory rate > 16/ minute
  • ZUSPAN REGIMEN:Loading dose 4 gm I/V (20%)Followed by 1 gm/ hr I/V infusionSEBAI REGIMEN:Loading dose 6 gm I/VFollowed by 2gm/ hr infusion
  • DHAKA REGIMEN:(Begam R etal) Loading dose 4 gm I/V & 3 gm IM in each buttock(10 gm total) Followed by 2.5 gm I/M every 4 hrly Magnesium sulphate prophylaxis has to be continued 24 hours after delivery A combination of magsulf with nifedipine should be avoided  it decreases the blood pressure dangerously low as both act on calcium channels
  • MAGNESIUM SULPHATE LEVELSCLINICAL FINDINGS SERUM LEVELLoss of patellar reflex 8-10 µg/dlFeeling of warmth, flushing 9-12 µg/dlDouble vision & slurred speech & 10-12 µg/dloliguriaMuscular paralysis 15-17 µg/dlRespiratory difficulty 15-17 µg/dlCardiac arrest 30-35 µg/dl
  • MANAGEMENT OF MAGNESIUMSULPHATE TOXICITY• Discontinue magsulf administration• Begin oxygen administration• Administer 1gm calcium gluconate (10cc of 10% calcium gluconate)• If respiratory arrest occurs then cardio pulmonary resuscitation
  • ANTI HYPERTENSIVES STARTING DOSE MAXIMUM DOSEHYDRALAZINE 5-10 MG I/V every 20 30 mg minLABETALOL 20-40 mg I/V every 220 mg 10-15 minNIFEDIPINE 10-20 mg per orally 120 mg/d every 30 minDILTIAZEM 120-180 mg QID 540 mg/dATENELOL 50 mg QID 100 mg/dAIM is to lower the B P between 95-100 mm Hg diastolic &mean arterial pressure between 105-115 mm Hg
  • PHENYTOIN: Loading dose 15-25 mg/kg I/V in 2 hrs Under ECG tracing 100 mg 6 hrlySIDE EFFECTS:5. Cardiac toxicity6. Nystagmus7. Hypotension8. Ataxia9. Lethargy
  • DIAZEPAM:Lean regimen :10mg I/V every 2 minutes to maximum 40 mgfollowed by 40 mg in 500 ml normal saline in 24 hrs
  • Definitive treatment is termination of PregnancyAfter stabilisation of the patient P/V examination done Ripening agent put & delivery conducted in next 8-12 hrs Labour managed partographically
  • OMINOUS FEATURES OFECLAMPSIA1. Long interval between the onset of fits and commencement of treatment2. Antepartum eclampsia early in pregnancy3. Number of seizures more than ten4. Systolic BP > 200 mm Hg5. Temperature > 102º F6. Oliguria7. Non response to treatment8. Jaundice
  • INDICATION OFLSCS1. Uncontrolled fits inspite vigorous therapy2. General condition of the patient deteriorating very fast3. Patient not responding to ripening agent & induced labour4. Other obstetric indications
  • CARRY HOMEMESSAGE Identification of high risk patient in the antinatal period Early referral of high risk patients to experts Administration of anti hypertensives to the subjects & regular anti natal care in the indoors Procurement & Administration of magsulph to the severely pre-eclamptic and emplamptic patiets in zero hour before referral Management of the severely pre-eplamptic and eplamptic patients in the tertiary institutes under team of experts