Eclampsia

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Managing eclampsia in a tertiary care hospital like MKCG Medical College, Berhampur, Odisha in the era of development

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Eclampsia

  1. 1. MANAGEMENT OF ECLAMPSIA Dr Susanta Kumar Behera ChairpersonDR RITANJALI BEHERA 1
  2. 2. Eclampsia is pre eclampsia withconvulsion and or coma OrDevelopment of Convulsions and/or unexplainedcoma during pregnancy or postpartum inpatients with signs and symptoms ofpreeclampsia What is the most common causePRE EXISTING EPILEPSY of seizure during Pregnancy ? 2
  3. 3.  Incidence :o 1:500 to 1: 30 & Common in Primigravida (75%) than multigravida (25%)o In 80% cases it is proceeded by severe preeclampsiao Commonly occurs between 36th week to term Typesa) Antepartum -50%b) Intrapartum-30%c) Postpartum-20%(Early & Late)d) Intercurrent-Rare 3
  4. 4. ABNORMAL TROPHOBLASTIC INVASION 4
  5. 5. 5
  6. 6. CAUSES OF CONVULSION Cerebral anoxia : spasm of cerebral vessel due tohypertension-increase cerebrovascular resistance-decrease oxygen consumption-convulsion Cerebral edema –irritation Cerebral dysarhythmia : increases following edema& anoxia Stages of convulsiona) Premonitory : 30 Sec• twitching of muscle• rolling of eye ball & fixing. 6
  7. 7. b) Tonic (30 sec) : c) Clonic (1-4 min) :• Tonic spasm of body • Alternate contraction & relaxation of muscle• Ceasing of respiration • Congested face & Cyanosed• Protruding of tongue • Conjunctival Congestion• Fixing of Eye ball • Twitching starting from face & spreading tongue biting• Cyanosis • Stertourous breathing with froths • Involuntary passage of stool & urined) Coma : -Persits for variable period & at times patient confused -Deep coma may occurs (cerebral hemorrhage). -Labor usually starts shortly after the fit. 7
  8. 8. SYMPTOMS SIGNS• Headache • Hypertension• Oedema • Tachycardia and• Visual disturbance tachypnoea• Focal neurology, fits, • Creps or wheeze anxiety, amnesia • Neurological deficit• Abdominal Pain • Hyperreflexia• Decreased urine output • Petechiae, ICH• None • Generalised oedema • Small uterus for dates 8
  9. 9. D/D WITH CONVULSIONS WITH COMA• Epilepsy. • Hypoglycemic .• Hysteria. • Hyperglycemic coma• Meningitis and • Uremic coma. Encephalitis. • Hepatic coma.• Tetanus. • Alcoholic coma.• Strychnine poisoning. • Cerebral coma.• Brain tumors.• Uremic convulsions 9
  10. 10. INVESTIGATION• Hb% • Obstetric Scan• DC, TLC, TPC, BT/CT • CT –Brain & Abdomen• Urinalysis –R & M • CTG• Urinary Protein • Coagulation Profile• LFT • USG of Abdomen &• RFT Pelvis• Serum Uric acid • Color Doppler• FBS • MRI• Ophthalmoscopy • Electrolytes• BPP • ECG 10
  11. 11. MANAGEMENTGeneral1) Maintenance of airway2) Oxygen administration3) Fluid Management4) Organization of investigation Control of Convulsions Control of BP Obstetric Management Complication Management Postpartum Care Prevention 11
  12. 12. THE OBSTETRIC ICU PATIENT INTENSIVE CARE UNITDELIVERY ROOM HDCU POST ANESTHESIAOPERATING ROOM CARE UNIT 12
  13. 13. GENERALTransfer of patient to hospital Place the patient in a railed cot in isolated room. Detailed history taking Vital stabilizing(Control of BP) Continuous drainage facility Monitoring vitals & Urine Output Antibiotics & H2 blockers 13
  14. 14.  Patent airway with tracheal and bronchialsuction. Nasogastric tube may be inserted . IV glucose 25% as a Liver support, increasesUO & improves hemoconcentration. Nursing Carea) Mouth gag in between teethb) Clearing of air passagec) Raising foot end of bed 14
  15. 15. HDCU 15
  16. 16. FLUID THERAPYIATROGENIC FLUID OVERLOAD IS THE MAIN CAUSE OF MATERNAL DEATH IN ECLAMPSIADepends upon a careful balance between restrictionwith possible exacerbation of end organhypoperfusion and renal dysfunction and volumeoverload with pulmonary edemaPRINCIPLES :• Accurate Recording of Fluid Balancea) Delivery & Postpartum Lossb) Input/Output Deficit 16
  17. 17. • Maintenance Crystalloid infusion :1) Crystalloids is the choice of fluid-RL2) Total daily infusion=UO+1000 ml3) Fluid load : 80ml/hr or UO in Preceding hr+30 ml4) No excess use of Crystalloids/Dextrose• Selective Colloid expansion• No unnecessary fluid overload before regional anesthesia - Severe refractory HTN - Pulmonary Edema - Oliguria unresponsive to fluid therapy 17
  18. 18. • Diuretics: Only in presence of PE/CCF• Pulse Oximetry• Selective monitoring of CVP if blood loss is excessive• Intraarterial pressure monitoring indicated - Unstable eclamptic women - BP is very high - Obese women when noninvasive measurement are unreliable - Hemorrhage > 1000ml - Severe Cardiac Disease 18
  19. 19. POSTPARTUM• Urine output recorded hrly & each four hr block summated• Each FOUR hr block should be > 80 ml• If two consecutive four hour block fails to achieve 80 ml Total Input > 750 ml in Total Input < 750 ml in excess of U/O in last 24 hr excess of U/O in last 24 hr  20 mg IV Frusemide 250 ml Colloid  Colloid if diuresis > 200 over 20 min ml in next hr U/O < 200 ml U/O >200 ml 20 mg IV Baseline Fluid Frusemide + 250 ml Gelofusine 19
  20. 20. ANTICONVULSANTS Magnesium Sulphate(1924) Continuous IV1) Continuous IV Regimen Regimen2) Pitchard Regimen3) Sibai Regimen 4-6 gm loading dose4) Zuspan Regimen of Mg So4 in 100 ml of Diazepam fluid IV slowly over Phenytoin 15-20 min Lytic Cocktail Regimena) Chlorpromazine 1-2gm/hr in 100 ml ofb) Promethazine IV maintenancec) Pethidine infusion 20
  21. 21. PITCHARD REGIMENRoute : IM 4gm of 25% MgSO4 IV slowly over 5-10 minfollowed by 5 gm 50% MgSO4 IM into eachbuttock. 5 gm 50% MgSO4 IM 4hrly to alternate buttock.MOA1) motor end plate sensitivity to Ach & reduces neuromuscular irritability2) Blocking neuronal uptake of Calcium3) Inhibits platelet aggregation.4) Increase PGI2 synthesis. 21
  22. 22.  SIBAI REGIMEN(1990)6 gm MgSo4 over 20 min followed by 2 gm MgSO4IV infusion ZUSPAN REGIMEN(1978)4 gm MgSo4 over 5-10 min followed by 1gm/hrMgSO4 IV infusion DIAZEPAM10-40 mg IV slowly followed by 40 mg in 500 ml of 5%D at the rate of 30 drops/min 22
  23. 23. MAGNESIUM SULFATE• Lazard in 1924,intern in California started mgso4.• Given IV 20-25% (most commonly) or IM (50%) or SC(15%)• 6 gram load followed by 2 grams per hour• Total dose should not >24 gm/24hr• Supra therapeutic levels lead to CNS depression, cardiac arrhythmias,• Monitoring : »Patellar reflex. »RR >16/min. »U/O >100ml/4hrs. »Serum Mg++ level. 23
  24. 24. MAGNESIUM TOXICITY Clinical Manifestation Serum Level Physiologic 1.3-2.1 mEq/L Peripheral Vasodilatation/Flushing 3-5 mEq/L /Sense of warmth/Vomiting Therapeutic 4-7 mEq/L Depression of deep reflex ml of Antidote – 10 7-8 mEq/L 10% Calcium Arrest of Deep Reflex 8-10 mEq/L Gluconate slow IV 10-12 mEq/L Respiratory Depression Respiratory Arrest 12-15 mEq/LArrhythmia/Heart Block/Bradycardia 15-20 mEq/L Cardiac Arrest 2424242424 24
  25. 25. LYTIC COCKTAIL REGIMEN Menon in India has started this regimen-1961 25 mg Chlorpromazine & 100 mg Pethidine in 20 mlof 5%D IV + 50 mg Chlorpromazine & 25 mg Promethazine IM 50 mg Chlorpromazine & 25 mg Promethazine IMalternatively 4 hrly X 24 hr IV drip 10%D with 100 mg Pethidine at rate of 20-30drop/min X 24 hr following last fit. 25
  26. 26. PHENYTOIN 10 mg/kg slow IV followed by 5 mg/kg after 2hr 200 mg given orally after 12 hrs X 48 hrsfollowing delivery Side effects : hypotension/cardiac arrhythmia/phlebitis ECG monitoring required MOD. STROGANOFF METHOD MgSO4 6gm IV initially then 4 gm/4hours IM + 20mg Morphine IM. 26
  27. 27. STATUS ECLAMPTICUS• Consult anaesthetist• Nasophayngeal Suction• Intubation , IPPV & Muscle relaxation• Medicationsa) Inj Thiopentone Sodium 0.5 mg in 20 ml of 5D IV slowlyb) Inj Diazepam 10 mg Slowly IV followed by 10 mg in 5D as IV drip• General Anesthesia(PPV + Muscle Relaxants)• Evaluation of Intracranial Abnormalities 27
  28. 28. • Investigations : CT/EEG/Cerebral Doppler Velocimetry/MRI/Cerebral Angiography• Cerebral imaging indicated in1) Patients with Focal Deficits/Prolonged Coma2) Atypical presentations of Eclampsia - Onset before 20 weeks - > 48 hrs following delivery - Refractory to Magnesium Sulphate therapy 28
  29. 29. ANTIHYPERTENSIVES Indicated if BP > 160/110 mm of Hg in spite ofAnticonvulsants & Sedatives Common drugs1) IV Labetalol2) Oral Nifedipine3) IV Hydralazine4) Diuretics in presence of Pulmonary Edema/CCF If C/I of MgSO4 : Phenytoin: 15 mg/kg at 40 mg/minwith monitoring of Cardiac function and BP x 5 min Therapeutic Range : 10-20 μg/ml. 29
  30. 30. COMMON AGENTSAgent MOA Side Effects Fatigue, Bradycardia,Labetalol α β-Blocker Swelling of Feet, Depression Headache, Hypotension,Nifedipine CCB Palpitation, Constipation Flushing, Hypotension M-Dopa Direct PAV Headache, Dry MouthHydralazi Flushing, Headache, Direct PAVne Diarrhea, ConstipationSod. Nitr. Direct PAV Metabolite (Cyanide) 30
  31. 31. Agent Dose Max Dose Oral : 25 mg 8 hrly Oral : 300 mgHydralazine IV : 5-10 mg & repeat IV : 20 mg after every 10-20 min Oral : 100 mg 12 hrly Oral : 2400 mg Labetalol IV : 20 mg & repeat 40- IV : 300 mg 80 mg every 10 minNifedipine Oral :10 mg 6-8 hrly 120 mgMethyldopa Oral : 250 mg 8 hrly 2 gmSodium Nitr. IV : 5 mcg/kg/min 10 mcg/kg/min 31
  32. 32. Eclampsia Anticonvulsants/Antihypertensives+/-Diuretics Not in Labor Labor Fits Fits not ARM LSCScontrolled controlled Ventouse Obstetric Forcep Indication 32
  33. 33. FITS NOT CONTROLLED 6-8 hrs Termination ASSESS INDUCTION SCORE Favourable Unfavourable ARM OXYTOCIN INDUCTIONMISOPROSTOL LSCS 33
  34. 34. FITS CONTROLLED BABY ALIVE DEAD TERMINATION SPONTANEOUS EXPULION INDUCTION LSCSPGE2 GEL/ARM/OXYTOCIN/MISOPROSTOL 34
  35. 35. INDICATION OF LSCS Uncontrolled fits in Spite of therapy Unconscious patient and poorprospect of vaginal delivery Obstetric indicationa) Preterm (< 34 Week)b) IUGRc) Non reassuring FHRd) Oligohydramniose) Malpresentationsf) Suspected AP 35
  36. 36. CARE DURING DELIVERY• Care full monitoring of maternal & fetal status• Delivery : Well Planned, done on the best Day, performed in the best Place, by best Route and with best Support team• H2 antagonists & Antibiotics• Vaginal delivery Preferred if not indicated otherwise• Local infiltration of anesthesia for all VD 36
  37. 37. • No prophylactic MethylEgrometrine/Symtometrine• Cut Short of Second stage of labour• Prophylactic Rectal Misoprostol• Managing 3rd Stage : 5-10 units of IV Syntocinon / Inj Prostaglandin• Vigilant about PPH & Prompt Management• Prophylaxis against thromboembolism 37
  38. 38. POSTPARTUM CARE• Continuing MgSo4 following 24 hr of delivery/last Seizure.• Regular Monitoring of BP 4 hrly• MONITORING OF VITAL X 48 HRS• Antihypertensive till BP < 150/100 mm of Hg• Discharged on 4th Puerperal day• Regular intake of Iron & Calcium 38
  39. 39. CHOICE OF ANESTHESIA• Local Anesthesia• Pudendal Block• Regional Anesthesia : Spinal Or Epidurala) Preferred for LSCS/Laborb) Decreased Maternal Morbidity & Mortalityc) Epidural preferred over spinal due to provocation of excessive hypotension -Superior pain relief 39
  40. 40. -Epidural Promotes Utero-Placental Blood Flow -Extended to Provide Regional Anesthesia for ID/CS• General Anesthesia Indicateda) Coagulopathy / Pulmonary Edema / Impaired Consciousnessb) Failed Spinal /Epidural blockc) Inadequate time to perform/extend a block Difficulty intubation due to laryngeal edema Risk of ICH & Aspiration Pneumonia 40
  41. 41. COMPLICATIONSMaternal :• CVS(4%) : Cardiac failure, Hypertension• Renal (4%): Oliguria/ARF/ ATN/ Cortical Necrosis• Respiratory(5%) : ARDS(7%), Pulmonary Edema• Hepatic : HELLP Syndrome(20%) & Subcapsular Hematoma/DIC• Cerebral(7%): Encephalopathy, Infarction, Hemorrhage, Edema• Eye (10%): Cortical Blindness, Retinal Detachment, Edema,• Reproductive : AP(10%) or PPHFetal :• IUGR/Premature delivery/Fetal distress/Fetal Demise 41
  42. 42. FETAL MONITORING• Done bya) DFMCb) USG-GA/AFI/FWc) BPP/CTGd) Color Doppler of MCA/Ut A/UA/DV• Maternal hypoxemia & hypercarbia : FHR & Uterine Changesa) FETAL : Bradycardia/Transient Late deceleration/decreased beat to beat variability & Compensatory tachycardia 42
  43. 43. b) MATERNAL : frequency & tone of Ut. contractions• FHR changes resolves in 3-10 min spontaneously• If not resolved in 15 min : Suspect AP/NR-FHR 43
  44. 44. RENAL FAILURE Etiology : Renal or Prerenal Diagnosis : S Cr X 3.0, or UO < 300 mL/ for 24 hours Commonly complicated by volume overload/ hyponatremia/hyperkalemia/hypocalcemia/metabolic acidosis. Commonly presented with thirst/hypotension/ tachycardia/reduced JVP/dry mucus membrane/ reduced axillary sweating Sp.Inv. : Serum Urea, Creatinine, Urinary Na+,/urine Osmolality/ Urinay Cast 44
  45. 45.  IP/OP charting daily Input = Output/24hrs + 500ml(non febrile)+ 200 ml/ deg C of inc. in Temp No hypotonic fluid Isotonic fluid to be fluid of choice FCT :1000 ml of isotonic fluid over 1 hrNo UO increases, further UO increases, maintaininfusion will be guarded at 100 ml/hrby CVP/PWP Protein intake of 0.6 g per kg per day 45
  46. 46.  Hyperkalemia, should be treated by1) Decreasing intake2) Controlling intracellular Shifts Dialysisa) Hemodialysis : Hemodynamically Stable patients & following abdominal Surgery(LSCS)b) Peritoneal Dialysis : Hemodynamically Unstable patients Acidosis- 5% Sod. Bicarbonate if S. HCO-3 > 15 mmol/L or arterial PH < 7.2 46
  47. 47. Indication of Dialysis. -Clinical evidence of Uremia -Intractable intravascular overload -Hyperkalemia resistant to conservative tr. -Serum Creatinine > 8 mg/dl Coagulopathy : FFP for a prolonged aPTT, Cryoprecipitate : Fibrinogen < 100 mg/dL, Platelets Transfusion : TPC < 20,000/mm3 Continuous AV hemodiafiltration(CAVH) Continous Venoveno hemodiafiltration(CVVH) 47
  48. 48. HELLP SYNDROME• LOUIS WEINSTEIN (1982)• 0.3% of all Pregnancies• 20% of Severe Preeclampsia & Eclampsia• Delivery is the only cure• More common in white women.• 2/3rd : Antepartum & 1/3rd : Postpartum(48hr) 48
  49. 49. a) Biomarkers to follow disease progression : Platelet Count & Serum LDH, HCG,Maternal AFP,Serum Haptoglobin• Rate of recurrence in subsequent pregnancy : 2-19%• Manifested by nausea, vomiting, epigastric pain, and biochemical and hematological changes.• Two Clinical Types :1) Full HELLP syndrome : Considered for delivery within 48 hours2) Partial HELLP Syndrome : Candidates for more conservative management 49
  50. 50. TYPES & DIAGNOSIS• Class 1 – TPC <50  Hemolysis 000/mm3. 1) Abnormal Peripherical Smear• Class 2 – TPC: 50 000 - 2) Serum Bilirubin >1.2 mg/dl 100 000/mm3.  Elevated Liver Enzymes• Class 3 – TPC :100 a) SGOT/SGPT >72 UI / L 000-150 000/mm3. b) LDH >600 UI / L  Low Platelets Platelet Count < 150 103 /mm3 50
  51. 51. HELLP Syndrome• Microangiopathic hemolytic anemia, consumptive thrombocytopenia, liver dysfunction• Secondary to placental abruption, sepsis or fetal death• Complications : Eclampsia(6%), ARF(5%), ARDS,Pulmonary edema(10%), hemorrhage, placental abruption(10%), liver hematoma with rupture(1.6%)• Maternal Mortality : upto 50%.• Perinatal Mortality : 25% 51
  52. 52. 52
  53. 53. D/D TTP/HUS DIC/ACUTE FATTY LIVER/SEPSIS SEVERA HEMORRHAGE –ABRUPTIO CONNECTIVO TISSUE DISORDERS-SLE PRIMARY RENAL DISEASE-AGN DM• Similar to Pre-eclampsia with – RUQ/epigastric pain – Jaundice – Microangiopathic anaemia – Deranged LFT’s 53
  54. 54. MANAGEMENT• Bed rest• Fluid : Crystalloid /Albumin-5 to 25%• Magnesium Sulphate• Antihypertensive• Volume Expansion & Electrolyte Balance• Corticosteroids: Dex/Pred/Beta(10/10/5/5)• Surveillancea) Maternal : BP/Lab Invest./Hemodynamic Monitoringb) Fetal : FHR & BPP• Transferring patient to ICU where safe delivery can be done 54
  55. 55. • Indication for terminationa) GA 32-34 weeksb) Bleeding/DICc) Abruptio Placentaed) Eclampsiae) Abnormal FHR pattern• Antithrombotics : Low dose Aspirin & Heparin• Steroid : HELLP syndrome with TPC < 100,000 per mm3 55
  56. 56. ADMINSTRATION OF CORTICOSTEROIDSImproves Maternal Outcome1) Improves thrombocyte count2) Improves Urine OutputImproves Perinatal Outcomea) Improves Pulmonary Maturityb) Decreases IVHc) Decreasing Necrotising Enterocolitis 56
  57. 57. Continue till Liver function abnormalities are resolving and TPC > 100,000 per mm3HELLP Syndrome : Prophylactically with magnesium sulfate to prevent seizuresAbsence of improvement of the thrombocytopenia within 72-96 hrs Postpartum : MOF.Patients with DIC should be given fresh frozen plasma and packed red blood cells. 57
  58. 58. MANAGEMENT OF LABORIf transabdominal delivery is required, prefer :a) Vertical Skin Incision.b) Corporeal incision of the uterus .c) SD of Placenta to avoid hemorrhageAdmisión in Obstetric ICU until:(1) Sustained of TPC and a in LDH.(2) Diuresis : UO <100ml/h X 2 hours .(3) Control BP with SBP 150 mm Hg & DBP < 100 mm Hg. 58
  59. 59. MANAGEMENT OF LSCS GA : Platelet count < 75000/cmm Transfuse 6 Packs of platelet if < 40000/cmm Insert Subfascial drain Secondary Skin Closure or leave Observe for bleeding from Upper abdomen before closure 59
  60. 60. INTRACRANIAL HEMORRHAGE• 5% presented with focal neurological deficits.• Gross hemorrhage is due to ruptured arteries caused by severe hypertension.• Eclampsia : Loss of Cerebral auto-regulation , hyper-perfusion similar to hypertensive encephalopathy• Cerebral edema in 95-100% cases of Eclampsia 60
  61. 61.  Widespread edema, ischemia,thrombosis .CT : Hypodense area in Cortex , corresponds toPetechial hemorrhage and infarctions Remarkable changes in area of distribution ofPosterior Cerebral A. MRI : Hyperperfusion due to Vasogenic Edema Eclampsia : 25% were area of infarction Intracranial bleeding is leading cause of mortality 61
  62. 62. Autopsy Specimen from a 40-Year-Old Woman with Eclampsia and Subarachnoid Hemorrhage Greene M. N Engl J Med 2003;348:275-276 62
  63. 63.  Conservative1) Low Dose Aspirin : 30-100 mg/day2) Anticoagulant :Conventional Heparin/LMW Heparin3) Thrombolytics : Heparin/ Stretokinase/ Alteplase/ Urokinase4) Antihypertensives5) Mannitol(20%) :1 g /kg 20% solution IV 8 hrly6) Glycerol : 30 ml 6hrly orally7) Dexamethasone : 10 mg IV followed by 4 mg 6hrlySurgical1) Bore-Hole Aspiration2) Decompression 63
  64. 64. DIC MANAGEMENT• 7-10 % of patients with eclampsia• DIC is defined as presence of thrombocytopenia, low fibrinogen(<300 mg/dl) & FDP >40 mg/dl• Two forms : Acute & Chronic or Overt & Nonovert• Two Stages : Hyper & hypocoagulable• Central pathology : Progressive generation of thrombin in blood due to TF in underlying pathology• Common specific investigations : PT /aPT /TPC /Fibrinogen/D-Dimer or FSP/Antithrombin/ PS/ thrombelastography 64
  65. 65. • Cardinal rule in treatment of DIC is to identify & treat underlying cause.Nonspecific Airway management Restoration of blood volume - Fresh Plasma/Fresh Frozen Plasma - Platelet Concentration - Cryopreciptate Adequate oxygen delivery CPV monitoring Ionotropes Correction of Electrolyte imbalance 65
  66. 66. PLATELET TRANSFUSION Dose : 1 U / every 10 kg Weight. Spontaneous Bleeding : TPC < 50.000/mm3. In PP Period, maintain the Counta) >50.000/mm3 LSCSb) >20.000/ mm3 VD Each pack is 40- Dexamethasone : HELLP & 50 ml raises Sev. thrombocytopenia . count by 7500- Alternatives : Plasmaphersis & 10000/cmm Immunoglobulins 66
  67. 67. FOZEN PLASMA/FFP• Each bag=1Unit containing 100- 600 ml• Contains all procoagulant factors including labile factor• 1U FFP=2U of Frozen Plasma• Dose : 10-15ml/kg(both)• Infuse over 2-3 hr• Infuse < 4 hrs of issue• Each bag raises factors by 25% FFP 67
  68. 68. Specific :1) Heparin : Conventional/LMW2) Fibrinogen Conc.3) Antifibrinolytics4) Thrombodulin5) Activated Factor VII6) Antithrombin Conc.7) Activated Protein C(APC)8) Recomb. TF pathway inhibitor : Tifacogin9) Gabexate Mesylate : Syntheic inhibitor of serine proteases such as thrombin & anticoagulant activity in absence of antithrombin 68
  69. 69. PULMONARY EDEMAAttributed due to1) Increased Capillary Permeability2) Low colloidal Osmotic Pressure3) Pulmonary Endothelial DamageClinically characterized by -Tachypnoea -Respiratory Distress -Crepitations -Bronchospasm -Pink frothing -Desaturation 69
  70. 70. • Titrate Insp. Oxygen Conc. against SpO2• Head tilt/Sit up Position• 100%-Oxygen Inhalation• Restricted Fluid intake• Intubate if necessary• Mechanical Ventilation with CPAP• Evaluate for underlying etiology• Drug therapy :1) Inj Frusemide 40 mg IV 20 mg Mannitol2) IV Aminophylline (if bronchospasm) 70
  71. 71. MORTALITY & MORBIDITY• Maternal : 8-36% most frequently related toseizure activity• Fetal : 13-30% most frequently related toiatrogenic prematurity 71
  72. 72. FOLLOW UP Postnatal follow up for 6 weeks Persistence of HTN > 12 weeks : Medical evaluation Recurrence risk1) Onset at term : 30%2) Onset at 30-37 weeks : 40%3) Onset at < 30 weeks : 70% Permanent Neural Damage Increased risk of Essential Hypertension Contraception :a) POP or Low dose Pillb) No Puerperal tubal ligation 72
  73. 73. PREVENTIONPrimary : Prevention of development of preeclampsia• Folic Acid & Calcium Supplentatation• Fish oil capsules : Modify abnormal PG balance Periodic Monitoring BP & Weight gain Antioxidants• Reduced endothelial cell activation , reduction in preeclampsiaa) Vit-C 1000 mg/dayb) Vit-E 400 mg/day 73
  74. 74. • Periodic Screening :a) Serum Uric Acid > 6.0 mg/dlb) Doppler :Uterine Artery & Umibilical Vein in 2nd trimester.c) Biophysical Testingd) Ultrasonography 4 Weeklye) Roll Over Test at 28-32 Weeksf) Platelet Count(High Platelet Volume)g) Urinary Calcium < 12 mg/dlh) Serum Fibronectini) Urinary Proteinj) Serum Antithrombin-IIIk) Fetal DNA in maternal Serum 74
  75. 75. EnSuRing good exercise during pregnncyTo prevent one case of Eclampsia - 71 women with Preeclampsia need to be treated - 36 women with imminent eclamspia need to be treated - 129 women without symptoms(Gest.Hypertension) 75
  76. 76. Secondary : Pharmacological agents to prevent convulsion in preeclampsia1) Salt restriction2) Inappropriate diuretic therapy3) Low dose aspirin (60mg)/Baby Aspirin4) Magnesium Sulphate5) AntihypertensivesTertiary : Preventing subsequent convulsion in established eclampsia. With optimum Mode of management we can prevent 70% of eclampsia 76
  77. 77. THANK Q 77

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