Obstetric convulsion
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Management of a pregnant patient presenting with first fit. It includes a review of SLCOG sri lanka guidelines of management of eclampsia in emergency medicine point of view
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Obstetric convulsion
- 1. OBSTETRIC CONVULSION DR KTD PRIYADARSHANI REGISTRAR IN EMERGENCY MEDICINE OBSTETRIC & GYNECOLOGY ROTATION NATIONAL HOSPITAL- KANDY
- 2. Case scenario.. 29 yrs old Second pregnancy 31 weeks POA TCTA triplet pregnancy GDM on Metformin Generalized tonic clonic seizure Lasted 3 min
- 3. Case scenario.. A- Patient is talking B- RR-22/min, Spo2 97% without oxygen, BL Lungs clear C – PR- 92 bpm, BP 160/90 mmHg, ECG- sinus rhythm D- AVPU- Alert, GCS- 15/15, Drowsy, pupils-2mm, BL PERTL, CBS 96 mg/dL E- temperature 38 °C, no external injuries
- 4. COMPONENTS OF MANAGEMENT Stabilization and seizure control Blood pressure control Plan for delivery Manage complications
- 5. Stabilization and seizure control A- oxygenation and avoid aspiration Suck out secretions Triple maneuver consider Intubation B 100% oxygen via face mask SpO2 Assist ventilation if inadequate C Recovery position IV access, blood for investigation, fluid, RBS BP Urine catheter and albumin Attach to a monitor Call for help- anesthesia, obstetric, neonatology teams
- 6. Stabilization and seizure control Most eclamptic seizures resolve spontaneously IV MgSO4- 4g in 100ml NS bolus 5-10 min in large vein followed by maintenance of 1g/hr for 24 hours IM- 5g deep IM to each buttock with 1ml of 2% lignocaine in the same syringe Renal function?
- 7. Blood pressure control IV Labetalol 20mg over 2 min Record BP after 10min If BP >160/ 110 mmHg – IV 40 mg over 2 min Record BP after 10 min IV Hydralazine 5-10 mg over 2min+ 5ml/kg fluid bolus (repeat 5-10mg boluses in 15min intervals up to maximum dose 20mg) IV labetalol infusion 40mg/hr, doubling dose at 30 min as required to maximum dose 160mg/hr IV Hydralazine infusion 2mg/hr increasing by 0.5 mg/hr as required
- 8. Plan for delivery Delivery (or induction) once maternal condition is stabilized irrespective of the fetal condition or maturity Fetal bradycardia during a seizure- usually recovers spontaneously following a seizure Fetal bradycardia persisting beyond 10 minutes following the seizure- suspect abruption
- 9. Plan for delivery Eclampsia is not an indication for LSCS Assess favorability of cervix Adequate labor pain relief Spinal and epidural is safe if platelet >80,000/ dL Ergometrine should not be used during the 3rd stage
- 10. Case scenario.. Convulsion Generalized tonic clonic Lasted 3 min LOC Post ictal drowsiness Mild headache, no blurring of vision, no edema First pregnancy- PIH, NVD No previous history of epilepsy or seizures No history of trauma, drug abuse No allergies Last meal 2hrs back
- 11. Case scenario.. General No pallor No icterus No external injuries Nervous system GCS 15/15 No focal neurological signs Reflexes exaggerated Clonus absent pupils- normal Other systems PR 64 bpm BP 160/100 mmHg
- 12. Case scenario.. Urine albumin + FBC- WBC 9.7, Hb 11.4, plt 348 UFR- Protein+, AST 26 U/L, ALT 21 U/L INR 0.98
- 13. Case scenario.. Patient developed 2nd fit in 40 min.
- 14. Recurrence of seizure.. Monitor PR, BP , ECG, RR, SpO2, UOP , GCS, Pupils, FHS Further dose of IV MgSO4 2g diluted to 100ml of NS can be given over 5 min Increase the MgSO4 infusion to 2g/hr with monitoring
- 15. If recur more than one seizure.. Neurology, medical opinion Anesthetic team and arrange intensive care setting 2nd line anticonvulsants- Midazolam 5mg IV If further seizures- move to ICU – paralyze and ventilate Require full neurological evaluation
- 16. Differential diagnoses.. Epilepsy Hypoglycemia Electrolyte imbalances Drug induced Local anesthetic toxicity CNS pathology Infection ICH due to coagulopathy Cerebral infarction due to TTP
- 17. Manage complications CNS ICH Cerebral edema Cortical blindness Retinal edema and blindness Liver HELLP Intra abdominal hemorrhage jaundice
- 18. Respiratory Pulmonary edema Cardiac Cardiac failure Renal Renal cortical necrosis Renal tubular necrosis Coagulation DIC Microangiopathic hemolysis Placental Abruption Infarction Fetal IUGR Premature delivery Perinatal death
- 19. On going care.. Exclude other DD BP control Fluid balance- restrict 80ml/hr Continuous monitoring for complications and drug therapy Mg- UOP= hourly 30ml/hr RR >16/min- 30 min SpO2 >90%- 30 min Presence of patellar reflexes- 30 min
- 20. References SLCOG national guidelines for maternal care- Revision notes for FRCEM intermediate
- 21. Questions?
- 22. Thank you!