highest figure of maternal mortality in india accounting for eclampsia more so in developing country like india and scenaria in ODISHA

1. MANAGEMENT OF ECLAMPSIA
Subudhi Khetrabasi,Behera Susanta Kumar,Subudhi Monalisa,Das Sudhansu Kumar,Jena Soubhagya
Kumar
INTRODUCTION
Eclampsia is development of convulsions and/or unexplained coma during pregnancy or
postpartum in patients with signs and symptoms of preeclampsia, 2 nd most common cause of
seizure during pregnancy. It is common in primigravida. In 80% cases it is preceded by severe
preeclampsia between 36th weeks to term. It can be antepartum (50%), intrapartum (30%),
postpartum (20%).
PATHOGENESIS
It is state of a triad consisting of hypertension, proteinuria > 300 mg/24 hr urine
output and convulsion. The underlying basic pathology is intense vasospasm and endothelial
dysfunction. Causes of convulsion includes (a) Cerebral anoxia due to spasm of cerebral vessel
because of increase cerebrovascular resistance-decrease oxygen consumption (b) Cerebral
irritation (c) Cerebral dysarhythmia .
CLINICAL FEATURE
. It progresses through four stages as follows as premonitory starting with twitching,
tonic spasm of body, ceasing of respiration, protruding of tongue and fixing of eye ball, clonic
phase of alternate contraction & relaxation of muscle, congested face & cyanosed, conjunctival
congestion, twitching starting from face & spreading tongue biting, stertourous breathing with
froths and involuntary passage of stool & urine and finally coma which persists for variable
period. Labor usually starts shortly after the fit. Common symptoms includes headache, edema,
visual disturbance, fits, anxiety, amnesia, abdominal Pain, decreased urine output or none,
tachycardia and tachypnoea, creps or wheeze, petechiae, generalised oedema, small uterus for
dates. 1
DIFFERENTIAL DIAGNOSIS
a) With Convulsions : Epilepsy, Cerebral Malaria, Hysteria, Meningitis and Encephalitis,
Tetanus, Strychnine poisoning, Brain tumors, Uremic convulsions b) With Coma:
Hypoglycemia, Hyperglycemic coma, Uremic coma, Hepatic coma, Alcoholic coma,
cerebral coma.
INVESTIGATIONS
• Routine : Hemoglobin, DC, TLC, TPC, BT/CT, Urine (R & M) and Protein, LFT, RFT,
Serum Uric acid, ECG, FBS, ophthalmoscopy, obstetric USG Scan.
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2. • Special : BPP, CT, CTG, Coagulation Profile, Color Doppler, MRI, electrolytes.2
MANAGEMENT
It consists of general care, control of convulsions, blood pressure, obstetric management,
management of complications including prevention and postpartum Care. General : Consists of
placing the patient in a railed cot in isolated room with raising the foot end of bed, followed by
detailed history taking, continuous draining of urine, monitoring vitals & urine output, tracheo-
bronchial suction and IV 25% Glucose.
Control of Convulsion : convulsions are controlled by different agents in different
scheduled as follows 1) Magnesium Sulphate : Continuous IV Regimen, Pitchard Regimen,
Sibai Regimen, Zuspan Regimen 2) Diazepam 3) Phenytoin 4) Lytic Cocktail Regimen :
Chlorpromazine, Promethazine, Pethidine.
Magnesium Sulphate can be given as IV or IM and SC as 15 % (SC), 20- 25% (IV) and
50% (IM) solution. Monitoring of toxicity can be done by absence of patellar reflex, respiratory
rate < 16/min, urine output < 80-100ml/hr and serum magnesium level. 3 Specific Antidote – 10
ml of 10% Calcium Gluconate slow IV given. Magnesium level in increasing concentration
produces following effects as depicted in table-I.
Table-I
Manifestation Serum Level
Clinical
Therapeutic 4-7 mEq/L
Arrest of Deep Reflex 8-12 mEq/L
Respiratory Arrest 13-19 mEq/L
Cardiac Arrest > 20 m Eq/L
CONTINUOUS IV REGIMEN: 4-6 gm loading dose of mg So4 in 100 ml of fluid IV
slowly over 15-20 min followed by 1-2gm/hr in 100 ml of IV maintenance infusion.
PRITCHARD REGIMEN : 4 gm of 25% mgso4 IV slowly over 5-10 min followed by 5 gm
50% mgso4 IM into each buttock followed by 5 gm 50% mgso4 IM 4hrly to alternate buttock.
SIBAI REGIMEN: 6 gm MgSo4 over 20 min followed by 2 gm MgSO4 IV infusion. ZUSPAN
REGIMEN: 4 gm MgSo4 over 5-10 min followed by 1gm/hr MgSO4 IV infusion.
• DIAZEPAM: 10-40 mg IV slowly followed by 40 mg in 500 ml of 5%D at the rate of
30 drops/min

3.  LYTIC COCKTAIL REGIMEN: Menon in India has started this regimen-1961 which
consists of 25 mg chlorpromazine & 100 mg pethidine in 20 ml of 5%D IV + 50 mg
chlorpromazine & 25 mg promethazine IM, followed by 50 mg chlorpromazine & 25 mg
promethazine IM alternatively 4 hrly X 24 hr. IV drip 10% dextrose with 100 mg
pethidine at rate of 20-30 drop/min for 24 hr following last fit.
 PHENYTOIN : 10 mg/kg slow IV followed by 5 mg/kg after 2 hr followed by 200 mg
given orally after 12 hrs X 48 hrs following delivery.4
Status Eclampticus: Medications like Inj Thiopentone Sodium 0.5 mg in 20 ml of 5D IV
slowly. If failed general anesthesia is administered.
Fluid therapy: It is significant as cause iatrogenic fluid overload is the main cause of
maternal death in eclampsia. Principle includes 1) accurate recording of input output deficit 2)
Crystalloids is the choice of fluid(Ringer Lactate), total daily infusion should be UO+1000 ml or
80ml/hr. Antihypertensives are indicated if BP > 160/110 mm of Hg in spite of anticonvulsants &
sedatives. Common drugs used are Labetalol, Nifedipine, and Methyl Dopa(table-II).5
Table-II
Agent Dose Max Dose
: 100 mg 12 hrly
Oral Oral : 2400 mg
Labetalol
repeat 40-80 mg every 10 min IV : 300 mg
IV : 20 mg &
Nifedipine Oral :10 mg 6-8 hrly 120 mg
Methyldopa Oral : 250 mg 8 hrly 2 gm
Obstetric management: Delivery is the cure for eclampsia and pregnancy is terminated
within 6-8 hrs of hospitalization and decision taken depending on fetal maturity, gestational age,
liquor volume and cervical status. If the woman is presented in labour, ARM to be done followed
by augmentation by oxytocin and delivery by vaccum or forceps. If the woman is not in labor,
induction is done by prostaglandin gel or tablet, ARM and delivery. Caesarian section is
indicated in presence of obstetric conditions like preterm baby, IUGR, Malpresentation,
abruption placentae. No use of prophylactic methyl-egrometrine/Syntometrine, and prophylactic
rectal misoprostol. Third Stage of labor is managed by 5-10 units of IV oxytocin or IM
prostaglandin.6 Epidural is the choice of anesthesia due to provocation of excessive hypotension,
superior pain relief, and promotion of uteroplacental blood flow. It can be extended to provide
regional anesthesia for instrumental delivery or caesarian section.Common complications
encuntered are (i) Maternal : Renal failure, ARDS, pulmonary edema, HELLP Syndrome, DIC,
cerebral hemorrhage, cortical blindness, Abruptio Placentae or PPH (ii) Fetal : IUGR and
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4. premature delivery and managed according to etiopathogenesis.MgSo4 is administered i.e 24 hr
of delivery/last Seizure. Recurrence risk is 30-70%. 7
Preventing eclampsia may be primary, secondary or tertiary. Primary prevention includes
prevention of development of preeclampsia i.e. folic acid, fish oil and periodic screening.
Secondary prevention includes pharmacological agents to prevent convulsion in preeclampsia i.e.
low dose aspirin, magnesium sulphate, etc. Tertiary prevention includes prevention of subsequent
convulsion in established eclampsia.8
REFERENCES
1) F Garry Cunning Ha, C Gilstrap et al. Hypertensive disorders of pregnancy;Williams
Obstetrics. 22nd Edition; 2005; Ch-34; P-783-784.
2) Chesley L C et al. Hypertensive Disorders of Pregnancy. New York; Appleton-Century
Crofts, 2008:1:2.
3) Data M R .Magnesium in eclampsia : A Safe and effective approach. J Obste Gynecol
India 2002;52(3).
4) Lucas M J. A comparision of magnesium sulphate with phenytoin for the prevention of
eclampsia. N Eng. J Med 2005; 333:201-05.
5) Mennon M K. The Evolution of treatment of Eclampsia. J Oph Soc Am.2001; 68:417.
6) Sibai B M. Diagnosis, prevention and management of Eclampsia. J. Obste Gynecol 2005
Feb; 105(2):402-10.
7) Polley L S. Anesthetic Management of hypertension in pregnancy. Clin Obste Gynecol
2003 Sept; 46(3):688-99.
8) Dekker G.Primary, Secondary and tertiary prevention of Preeclampsia. Lancet
2001;51(4):32