A Clinical case discussion on eclampsia! A glance at how actually a prescription must be! finding rational and irrational prescriptions!

1. CLINICAL CASE
DISCUSSION
- Dr Nikita Ingale
Jr1, Pharmacology
GMCH Nagpur
Guide-
- Dr Vijay Motghare
Professor and Head
Pharmacology
GMCH Nagpur

2. Patients profile
Name-xyz
Age- 22 years
Sex- female
Reg. no.------
DOA- 21-01-2018 at 2.45 pm, Admitted in ward
Diagnosis-Primigravida with 36 weeks with antepartum eclampsia
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3. - Pt admitted to wd 22 through casualty reference from DHW hospital
Amaravati as primi with 32 weeks with eclampsia
- Pt complained of mild headache since last 15 days
- She developed pedal odema over the days with slight abdominal pain
- She did not consult any local doctor for any complaint
Admission Notes
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4. - Patient suddenly suffered from 1st episode of convulsions at 4 am in the
home followed by 2nd episode at 5 am
- she was taken to the Duffrin hospital, Amravati at 5 am
- Patient suffered from 3rd and 4th episodes of convulsion in the hospital
- Patient received 1 loading dose of MgSO4 in the hospital
- Patient had done ANC registration at PHC Pimpalgaon
- Not done any ANC USG
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5. - LMP  14/5/17
- EDD  21/2/18
- On examination –
- conscious, irritable
- afebrile
- pallor +
- pulse 76/min
- BP – 160/100 mm Hg
- CVS RS Normal
- Per abdominal examination –
- 32 weeks uterus
- cephalic presentation
- FHS +
- Per vaginal examination –
- High grade vulval odema
- cervix 33% effaced
- vertex presentation
- membranes intact
- pelvis adequate
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Treatment on admission
- Inj Mannitol stat
- Tablet labet 100 mg stat
- Inj Taxim 1gm IV
- Inj Metro 0.5 gm IV
- Inj Rantac 2cc
- Inj Dexa 12 mg 12 hrly
Advised
- CBC
- LFT KFT
- INR
- Fundus examination
- ANC USG

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Investigations
Hb =11.4 gm %
WBC = 15.6 x 10-3 / mm3
Platelet = 3.2 lakh
INR =1.2
Urea = 23 mg%
Creatinine = 0.5 mg%
Na = 141 mEq/ lit
K = 4.7 mEq / lit

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Treatment on 21-01-18 at 3.45 pm
- Folleys catheter introduced under aseptic condition
- Inj MgSO4 6 gm IV  1ST IV Maintainance dose
BP = 150/100 mm Hg
Resp rate = 16/ min
Urine output = 200 cc
Deep tendon reflexes = brisk

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Treatment on 21-01-18 at 11 pm
- Inj Taxim 1 gm IV
- Inj Mannitol 100 mg
- Inj Metro 100 mg IV
- Conscious
afebrile
pallor +
BP = 150/100 mm Hg
Pulse = 80/ min
Resp rate = 18/ min

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Treatment on 22-01-18 at 00:35 AM
- Inj Lasix 20 mg
- Dextrose 5% 500 ml
- Inj Pitocin 10 units
- Conscious
afebrile
pallor +
BP = 140/100 mm Hg
Pulse = 78/ min
Resp rate = 18/ min

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Treatment on 22-01-18 at 06:00 AM
- Inj Taxim 1 gm IV
- Inj Metro 0.5 gm IV
- Tablet Labet 100 mg
- Tablet Rantac 50 mg
- Tablet Voveron
- Conscious
afebrile
pallor +
BP = 150/100 mm Hg
Pulse = 80/ min
Resp rate = 16/ min

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Fundus examination on 22-01-18 at 5 pm
- Red glow seen
- Disc = clearly seen and normal
- Macula =normal
- No macular odema
- Periphery within normal limits
- Bilaterally fundus was normal

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Lect notes on 22-01-18 at 5.30 pm
- GC – Conscious
- Afebrile
- Pallor +
- Pulse = 90/ min
- BP= 170/100 mm Hg
- Per abdominal
- soft
- FHS +
ADVISED-
-Tablet Labet 200 mg
stat
-NST to be done stat
-BP monitoring 1
hrly

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Reg notes on 22-01-18 at 7.30 pm
- GC – Conscious
- Afebrile
- Pallor +
- Pulse = 84/ min
- BP= 140/90 mm Hg
- ARM Done  liqor clear
- Tablet Misoprostol 25 mg

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Reg notes on 23-01-18 at 00:35 AM
- Baby delivered vaginally ,Male child at 12:20 am
- Baby weight 1.6 kg
- Inj Pitocin 10 units
- Inj Taxim 1 gm IV
- Inj Metro 0.5 gm IV
- Inj Lasix 20 mg IV stat
- Tablet Labet 100 mg
- Tablet voveron
- Continue MgSO4
- Conscious
afebrile
pallor +
BP = 130/90 mm Hg
Pulse = 74/ min
Resp rate = 16/ min

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Reg notes on 23-01-18 at 7:00 AM
- Inj MgSO4 6 gm in infusion pump started 2nd IV Maintainance dose
BP = 130/90 mm Hg
Resp rate = 18/ min
Urine output = 600 cc
Deep tendon reflexes = normal

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Reg notes on 23-01-18 at 10:00 AM
BP = 120/70 mm Hg
Pulse = 72/ min
Resp rate = 18/ min
- GC – Conscious
- Afebrile
- Pallor +
- Inj Taxim 1 gm IV
- Inj Metro 0.5 gm IV
- Tablet Labet 100 mg
- Tablet Rantac 50 mg
- Tablet Voveron
- Continue MgSO4

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Reg notes on 23-01-18 at 4:00 PM
BP = 130/70 mm Hg
Pulse = 74/ min
Resp rate = 18/ min
- GC – Conscious
- Afebrile
- Pallor +
- Inj Taxim 1 gm IV
- Inj Metro 0.5 gm IV
- Tablet Labet 100 mg
- Tablet Rantac 50 mg
- Tablet Voveron
- Continue MgSO4

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Reg notes on 23-01-18 at 5:00 PM
Inj MgSO4 6 gm in infusion pump continued after assessing all parameters
BP = 130/70 mm Hg
Resp rate = 18/ min
Urine output = 800 cc
Deep tendon reflexes = normal

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Current status of patient-
patient’s BP got stabilized
Same medications were continued for 3 more days
She got discharged from the hospital on 27-01-18
Baby is admitted in neonatology department undergoing care for its prematurity

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Discussion

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Hypertension in pregnancy
Hypertension  BP >140/90 measured 2 times in 6 hr interval
Proteinuria urine excretion of > 0.3 gm/ 24 hrs
Gestational hypertension  BP >140/90 for first time in preg after 20 wks wthout proteinuria
Pre eclampsia  gestational hypertension with proteinuria
Eclampsia  preeclampsia complicated with convulsions
Chronic hypertension  hypertension before pregnancy or first time in pregnancy before 20 wks
Superimposed preeclampsia new onset of proteinuria with chronic hypertension

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Etiopathogenesis of eclampsia-
- Basic pathology is endothelial dysfunction and intense vasospasm
Normally in pregnancy
In 1st trimester, trophoblasts invades decidua
In 2nd trimester, trophoblasts invades myometrium
Spiral arterioles become tortuous, distended
Spiral arterioles become low resistance
Low pressure and high flow system
Preeclampsia
/ eclampsia

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Causes of convulsions-
Cerebral odema  may contribute to irritation
Anoxia  spasm of the cerebral vessels
increased cerebral vascular resistance
fall in cerebral oxygen consumption
anoxia

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Onset of convulsions-
Antepartum = 50%
Intrapartum = 30%
Postpartum = 20%

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Management of Eclampsia-
General Specific
- Supportive care
- Detailed history
- Examination
- Monitoring
- Fluid balance

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Specific Management of Eclampsia-
MgSO4 is the drug of choice
Intramuscular
/ pritchard
Intravenous/
zuspan
4 gm IV over 3 mins followed by
10 gm deep IM  LOADING DOSE
5 gm IM 4 hrly in alternate buttock
 MAINTENANCE DOSE
5 gm IV in 20 mins
 LOADING DOSE
2 gm/hr IV infusion 
MAINTENANCE DOSE
Therapeutic level of serum
magnesium should be 3-6
mEQ/L

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Antihypertensives and diuretics-
Only if BP is more
than 160/110 mm Hg
Hydralazine
Labetalol
Calcium channel
blockers
Nitroglycerine

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Antihypertensives and diuretics-
FRUSEMIDE 20-40
mg intravenously
- Presence of
pulmonary odema

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Rationality -
Tablet labetelol  adrenoceptor antagonist[ alpha + beta]
 safe antihypertensive in pregnancy
 appropriate dose used
Injection MgSO4  Drug of choice for eclampsia
 decreases maternal mortality, prevents recurrence

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Injection taxim
Injection metronidazole  taxim is 3rd generation cephalosporin containing cefotaxime
 metronidazole is nitroimidazole antimicrobial
 prevents hospital acquired, superimposed infections
Injection pitocin  content is oxytocin
 used for induction of labor
Injection rantac  H2 blocker
 reduce GI upset if caused by use of antibiotics
Rationality -

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Irrationality -
Injection mannitol  osmotic diuretic
 no indication in this case
Injection dexamethasone  steroid
 no indication during emergency termination of pregnancy
Injection lasix  loop diuretic
 diuretics contraindicated in preg

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Irrationality -
Tablet voveron  diclofenac [ NSAID ]
 No indication
Brand names were used  tab labet, inj taxim, tab voveron
Short forms were used
Doses were not mentioned

34. References
- Hiralal konar, D.C Dutta, Text book of obstetrics, 7th edition, 2011, kolkata,
chapter 17, hypertensive disorders in pregnancy;p219-40
- HL Sharma & KK Sharma. Drugs therapy of hypertension. sharma and
sharma’s principles of pharmacology. 3rd edition. hyderabad, Paras Medical
Publisher;2017.p262-82
- Leveno KJ, Alexander JM, Bloom SL, Casey BM, Dashe JS., Roberts SW, et
al., editors. Williams manual of pregnancy and hypertension. 23rd ed. New
York: McGrawHill Medical; 2013
-The use of magnesium sulphate for the treatment of severe pre-eclampsia
and eclampsia, Annals of African Medicine Vol. 8, No. 2; 2009:76-80

35. NEXT:-
DRUG REVIEW
DR ASHISH GUPTA

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Clinical features of Eclampsia-
Premonitory stage  unconscious, twitching muscles, eye balls roll, stage is for 30 sec
Tonic stage  tonic spasm of body, eye balls fixed, tongue protrudes out, cyanosis, 30 sec
Clonic stage vol muscles go contraction and relaxation, biting of tongue, blood stained frothy
saliva, 2 mins
Coma stage  pt goes in deep coma, last for brief period