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Eclampsia
- 1. ECLAMPSIA Dr Sneha Ronge MBBS, MS OBGY (Pune)
- 2. ECLAMPSIA According to ACOG eclampsia is defined as convulsions occurring in a patient with preeclampsia. OR Preeclampsia complicated with convulsion and / or coma is called eclampsia. It can also occur in patients who have preeclampsia superimposed on essential hypertension or chronic nephritis
- 3. An Eclamptic Fit â«It occurs in four stages: â«Premonitory stage: â« -The head may be drawn to one side with rolling of eyes. â« -Twitching of hands and face. â« -Loss of consciousness. â« -Lasts for 30 sec. â«Tonic stage: â«-Entire body becomes rigid (state of spasm). â«-Arms are flexed, hands are clenched,legs are inverted. â«Face is distorted,tongue protrudes between the teeth.
- 4. An Eclamptic Fit â«Breath holding with cyanosis. â«Lasts for 30 sec. â«Clonic stage: â«All the muscles of the body including facial muscles contract and relax alternatively in rapid succession. Jaws and eyelids begin to open and close violently. Tonguebite may occur. â«Bloodstained ,frothy secretions come out of mouth and nose. â«Cyanosis gradually passes off, face and eyes are congested. â«Lasts for 1-3 min.
- 5. An Eclamptic Fit â«Stage of coma: â«For short period. â«Pulse ,resp rate increases,BP is raised, Temp. may increase. â«On regaining consciousness patient is confused,does not remember the incidence.
- 6. Preeclampsia - Pathophsiology â«Neurological: â«, visual disturbances, CNS hyperexcitability, hyperreflexia â«Seizures = eclampsia â causes â« Hypertensive encephalopathy â« Loss of cerebral autoregulation â« Vasospasm â« Microinfarctions, punctate hemorrhages â« Thrombosis â« Cerebral edema
- 7. ECLAMPSIA Pathogenesis of eclampsia - Unknown - Severe arterial vasospasm Rupture of the vascular endothelium Pericapillary hemorrhage Development foci of abnormal electrical discharge that may generalized Convulsions
- 8. Period of gestation convulsions occur In 50% of cases >36 wks of gestation Antepartum - 46.3% Intrapartum - 16.4% Postparum - 37.3% usually within 48 hrs of delivery Sibai BM et al Obstet Gynaecol 1981, 58 : 609.
- 9. â« Eclampsia â« Epilepsy â« Cerebral malaria in tropics â« Encephalitis â« Meningitis â« Intracranial tumors â« Peripheral cerebral thrombosis â« Poisoning â« Hysteria Differential Diagnosis
- 10. â« Injuries â« Pulmonary edema â« Pneumonia â« Acute LVF â« Cerebral hemorrhage â« Renal failure â« Pulmonary embolism â«Hyperpyrexia â«Hepatic necrosis â«DIC â«Postpartum shock â«Puerperal sepsis â«Disturbed vision â«Psychosis Complications of eclampsia
- 11. â« Cerebral haemorrhage â« Anoxia â« Cardiac failure â« Pulmonary oedema â«Aspiration pneumonia â«Pulmonary embolism â«Postpartum shock â«Puerperal sepsis Causes of maternal / Perinatal mortality Causes of perinatal mortality : âą Prematurity âą Intrauterine asphyxia âą Effects of drugs used to control convulsion âą Trauma during delivery âą Perinatal mortality 30 to 50% âą Sibai BM et al American Journal of Obstet Gynaecol 1983; 146 : 307.
- 12. â« General management â« To control convulsions using MgSO4 â« To control Hypertension â« To avoid Diuretics â« To limit IV fluids unless excessive fluid loss â« To investigate â« To terminate the pregnancy â« Care in puerperium â« Follow up. Principles of Management of Eclampsia
- 13. General management â«To place in a railed cot in an isolated place â«To maintain airway â«To administer oxygen 8-10lit/min â«To take detail history from relatives â«After proper sedation quick examination â«Catheterization and check for proteinuria â«Âœ an hourly Pulse, Temp, RR, BP, uterine contraction, FHS. â«1 hrly urine output â«Maintain fluid balance with CVP monitoring â«To administer antibiotics Management of Eclampsia
- 14. Specific management To control seizures and to prevent its recurrence Magnesium sulfate: the drug of choice Regimens Loading dose Maintenance dose Pritchard 4gm IV over 3 to 4 min 5gm buttock 4 hrly 10gm deep IM Zuspan 4gm IV over 5 to 10 min 1-2gm hrly IV infu Sibai 6gm IV over 20 min 2gm hrly IV infusion Sardesai 4 gm IV or IM 2 gm 3 hrly IV or IM Therapeutic level of MgSO4 â 4 to 7mRQ/litre Monitor Presence of patellar reflex (8 to 10mEQ/litre đĄȘ diagnose) Respiratory rate >16 (>12mEQ /litre đĄȘ depression) Urinary output 30ml/hr Continuation for 24 hrs after the last seizure M.M. 0.4%
- 15. â«It probably works by neuronal calcium blocking through the glutamate channel â«It will nearly always arrest convulsions â«It does not depress the maternal sensorium â«The fetus is least affected â«It is currently the anticonvulsant of choice in eclampsia Magnesium Sulphate
- 16. Magnesium Sulphate Protocol â«4 gms IV as 20% soln @ 1 gm/min â«10 gms of 50% soln. 5 gms in each buttock â«If convulsions persist after 15 min give 2 gms IV again as 20 % soln â«Every 4 hours 5 gms of 50% soln given in alternate buttock â«Discontinued 24 hours after delivery
- 17. â«If Mg levels are monitored it must be between 4 -7 mEq/L â«If clinical monitoring only ïżœ The patellar reflex must be present ïżœ Respiration not depressed ïżœ Urine output > 100 mL in the last 4 hours Magnesium Sulphate Protocol
- 18. Diazepam â« It is a very good agent to terminate a fit (10 mg IV repeated if necessary) â« It is not a good agent to prevent a fit â« If depresses maternal CNS â« Doses more than 40 mg must not be used in 24 hours â« It accumulates in the fetus and results in problems after birth
- 19. Lytic cocktail regimen On admission 25mg chlorpromazine +100mg pethidine in 20ml of 5% solution iv followed by 50mg chlorpromazine + 25 mg promethazine im. Later on Promethazine 25mg and chlorpromazine 50mg given alternately lM till 24 hr of last fit or IV 500ml containing 100mg pethidine drip rate adjusted to 20-30 drops/min till 24 hrs of last fit and not to exceed 300 mg /day. Maternal Mortality (MM): 2.2%
- 20. Diazepam regimen Initial drug of 100mg iv further 40mg in 500ml of Ringer lactate i. v. at 30 drops/min M.M. 5% Phenytoin therapy 10mg/kg IV followed by 5mg/kg 2 hrs later Sedatives can be used with above regimen
- 21. To control hypertension Inspite of sedative if BP >160/110mg then antihypertensive drugs are administered Hydralazine - 5mg iv slowly - rate 10mg every 20 minutes -Monitoring BP every 5 minutes - Repeat the dose when diastolic BP >110mmHg labetalol - 20 mg i.v., repeated every 30 min & can be doubled maximum upto 80 mg Nifedepine : 5 to 10 mg every 15 min to maximum upto 30 mg
- 22. Status eclampticus â«Phenytoin sodium 0.5gm dissolve in 20mg of 5% dextose iv given slowly â«If no response then complete anesthesia, muscle relaxant, assisted ventilation and C. Section is done.
- 23. Planning the delivery âąDelivery is the ultimate cure Vaginal âą LSCS is done for obstetric reasons, or before 32 weeks of gestation. âą Anesthesia â âą General to be avoided, as it increases blood pressure during intubation and extubation. âą Epidural is better than spinal.
- 24. Route of delivery â«Probability of achieving vaginal delivery after induction through an unripe cervix are below 20% Hall DR et al, BJOG 2000 Haddad B et al, AJOG 2004 â«Prolonged labor can be detrimental for mother and fetus â«Caesarean delivery is preferable Sibai BM et al, COG 2005
- 25. Post Partum Care â«Over 40% of maternal deaths occur postpartum â«Post delivery a relative oliguria is not uncommon, occuring in 30% of patients with severe disease â«Continued close monitoring is required in a suitable environment â«Taper antihypertensive agents â«Contraception Counseling and Follow up
- 26. Long term prognosis. â«PE and Eclampsia is a forerunner of later life cardiovascular risk â«It is more in early onset PE. â«Does not affect long term renal function. â«No long term residual hepatic disease. â«Recurrence Risk-20 to 50 %. â«HELLP-2 to 6 %.
- 27. â«Hemolysis Schistocytes in the blood smear S.Bilirubin > or equal to 1.2 mg% Absent Plasma hapatoglobin â«Elevated Liver Enzymes SGOT > 72 IU/L LDH > 600 IU/L â«Low Platelet Count Diagnosis of HELLP Syndrome
- 28. HELLP Syndrome â«Hemolysis, Elevated Liver Enzymes, Low Platelets and PIH â«Differential Dx: â« Hepatitis, gallbladder dz, acute fatty liver of pregnancy, thrombocytopenic purpura (TTP) â« Etiology unknown â« 20% present postpartum, the rest preterm â« Peak is 24-48 hrs postpartum â« Initial c/o RUQ pain â« 80% have PIH before dx
- 29. HELLP Syndrome â«Complications: â« DIC â« Placental abruption â« Need for blood transfusion â« Pleural effusion â« Acute renal failure â« Wound infection â«If develops postpartum there is a higher incidence of pulmonary edema and renal failure
- 30. HELLP Syndrome â«Time course of thrombocytopenia is v. important â« If stable at 80,000 PLT, then regional is OK â« If dropping fast at 80,000, then regional is dangerous â epidural hematoma â«Treatment - delivery
- 31. HELLP Syndrome. â«Prompt delivery , if it develops beyond 34 weeks. â«Dilemma- Before 34 weeks, administrations of corticosteroid for 48 hrs for both maternal and fetal benefits. But the results are variable in different studies.
- 32. Preanesthetic Evaluation â«Fluid status â«Hemodynamic status â«Coagulation status â« Bleeding time â« PLT count â« PT/aPTT
- 33. Anesthetic Mgmt â«Technique â Epidural vs. Spinal â«Treatment of side effects: â« Hypotension â« Difficult airway â« Coagulation â«Urgent C/S â«Postpartum â« Analgesia â« Fluid balance â« MgSO4 â« Hemodynamic control
- 34. Thanks for your attention !