SPECIFIC TIM CONTENT TEACHER AV EVALU

OBJECTIV E LEARNER AIDS ATION

ES ACTIVITY

Introduce 2min INTRODUCTION : Teacher:

the Introduce
topic The term eclampsia is derived from a Greek word, meaning ‘like a flash of lightening’. It may the topic
occur quite abruptly, without any warning manifestations. In majority (over 80%), however, the Learner:
disease is preceded by features of severe pre-eclampsia. Thus, it may occur in patients with pre- Listening
eclampsia or in patients who have pre-eclampsia superimposed on essential hypertension or
chronic nephritis. Hypertensive disorders are: [Link]-eclampsia. [Link]. [Link]
Hypertension. [Link] Hypertension.

DEFINITION:
To define Teacher: Define
pre- It is a multisystem disorder of unknown etiology characterized by development of hypertension to Introduce pre-
eclampsia 2min the extent of 140/90 mm Hg or more with proteinuria after the 20th week in a previously the topic eclampsia
and normotensive and nonproteinuric woman. Learner: and
eclampsia. Listening eclampsia
.
Pre-eclampsia when complicated with grandmal seizures (generalized tonic-clonic convulsions)
and/or coma is called eclampsia.
To state the 1min INCIDENCE: Teacher: State the
incidence of Introduce incidence
eclampsia. the topic of
The incidence varies widely from country to country and even between different zones of the
Learner: eclampsia.
same country. While in the developed countries, its prevalence is far and few but in the Listening
developing ones, particularly in the rural areas, it is still high and contributes significantly to the
maternal deaths. The hospital incidence in India ranges from 1 in 500 to 1 in 30. It is more
common in
primigravidae (75 %), five times more common in twins than in singleton pregnancies and occurs Teacher: What are
To enlist the between the 36th week and term in more than 50% cases. Stated the the
etiological 2min etiological causuative
ETIOLOGY
factors of factors of factors
eclampsia 1) Exact etiology is unknown. eclampsia of
2) More common in previous hypertensive disease. Learner: eclampsia?
3) Reading of B.P taken twice at interval of 6 hour. Listening
4) Failure of placentation.
5) Abnormal lipid metabolism.
 6) Decrease calcium in diet.
7) Other causes are :

ACDEPR
A ~ Alchohol.
C ~ Coarctaction of aorta.
D ~ Drugs.
E ~ Endocrine disease.
P ~ Pregnancy induced hypertension.
R ~ Renal disease.

RISK FACTOR
1) Primigravida.
2) Age.
3) Past history.
4) Pre existing disease.
5) Condition in which placenta enlarges.

Teacher: Describe
To describe describe the the
the PATHOPHYSIOLOGY: pathogenesi pathogenesis
pathogenesis s of of
of Since eclampsia is a severe form of pre-eclampsia, the histopathological and biochemical eclampsia eclampsia?
eclampsia. changes are similar; although, intensified than those of pre-eclampsia. Learner:
Listening
 Teacher: Explain
To explain 10mi CAUSE OF CONVULSION: describe the the onset
the Onset of n onset of of fits in
fits. The cause of cerebral irritation leading to convulsion is not clear. The irritation may be eclampsia antepartu
provoked by: Learner: m,
1. Anoxia — Listening intrapartu
 Spasm of the cerebral vessels m and
postpartu
 Increased cerebral vascular resistance m?
  Fall in cerebral oxygen consumption
 Anoxia
2. Cerebral edema — may contribute to irritation,
3. Cerebral dysrhythmia — increases following anoxia or edema.
4. Excessive release of excitatory neurotransmitters (glutamate).
5. Loss of cerebrovascular autoregulation with forced dilatation and vasospasm

ONSET OF FITS:

Fits occur more commonly in the third trimester (> 50%). On rare occasions, convulsion may
occur in early months as in hydatidiform mole.

 Antepartum (50%):

Fits occur before the onset of labor. More often, labor starts soon after and at times, it is
impossible to differentiate it from intrapartum ones.
Teacher:
 Intrapartum (30%): explain the Explain
To explain clinical the
the clinical Fits occur for the first time during labor. features of clinical
features of eclampsia features
eclampsia?  Postpartum (20%): Learner: of
Listening eclampsia
?
Fits occur for the first time in puerperium, usually within 48–72 hours of delivery. Fits occurring
beyond 48 hours but less than 4 weeks after delivery is accepted as late postpartum eclampsia.

 Intercurrent (antenatal):
When the patient becomes conscious after recovery from convulsions and the pregnancy
continues beyond 48 hours. The time limit is arbitrary as a period of 7–10 days has also been
mentioned.

CLINICAL FEATURES

Except on rare occasions, an eclamptic patient always shows manifestations of acute fulminating
pre-eclampsia—called premonitory symptoms.

Eclamptic convulsion or fit:

The fits are epileptiform and consist of four stages.

1. Premonitory stage: The patient becomes unconscious. There is twitching of the muscles
of the face, tongue and limbs. Eyeballs roll or are turned to one side and become fixed.
This stage lasts for about 30 seconds.
2. Tonic stage: The whole body goes into a tonic spasm— the trunk-opisthotonus, limbs are
flexed and hands clenched. Respiration ceases and the tongue protrudes between the teeth.
Cyanosis appears. Eyeballs become fixed. This stage lasts for about 30 seconds.

3. Clonic stage: All the voluntary muscles undergo alternate contraction and relaxation. The
twitchings start in the face then involve one side of the extremities and ultimately the
whole body is involved in the convulsion. Biting of the tongue occurs. Breathing is
stertorous and blood stained frothy secretions fill the mouth; cyanosis gradually
 disappears. This stage lasts for 1–4 minutes. Teacher lists
To list out out the List out
the maternal maternal the
complicatio complication maternal
n of 4. Stage of coma: Following the fit, the patient passes on to the stage of coma. It may last for of complicat
eclampsia. eclampsia. ion of
a brief period or in others deep coma persists till another convulsion. On occasion, the eclampsia
patient appears to be in a confused state following the fit and fails to remember the ?
happenings. Rarely, the coma occurs without prior convulsion. The fits are usually
multiple, recurring at varying intervals. When it occurs in quick succession, it is called
status eclampticus. Following the convulsions, temperature usually rises; pulse and
respiration rates are increased and so also the blood pressure. The urinary output is
markedly diminished; proteinuria is pronounced, and the blood uric acid is raised.
Describe
To describe the the
MATERNAL COMPLICATION OF ECLAMPSIA
prognosis of prognosis
eclampsia in of
Maternal and eclampsia
Fetal. in
Maternal and
Fetal.
PROGNOSIS

MATERNAL:

Immediate:
Once the convulsion occurs, the prognosis becomes uncertain. Prognosis depends on many factors
and the ominous features are:
(1) Long interval between the onset of fit and commencement of treatment (late referral).
(2) Antepartum eclampsia especially with long delivery interval.
(3) Number of fits more than ten.
(4) Coma in between fits.
(5) Temperature over 102°F with pulse rate above 120/minute.
(6) Blood pressure over 200 mm Hg systolic.
(7) Oliguria (<400 mL/24 hours) with proteinuria >5 g/24 hours.
(8) Nonresponse to treatment.
(9) Jaundice.

Mortality: Maternal mortality in eclampsia is very high in India and varies from 2 to 30%, much
more in rural-based hospital than in the urban counterpart. However, if treated early and
adequately, the mortality should be even less than 2%.
 Remote:
If the patient recovers from acute illness, she is likely to recover rapidly within 2–3 weeks.
Recurrence of eclampsia in subsequent pregnancies is uncommon; although, chance of pre-
Teacher :
To explain the eclampsia is about 30%. Lecture Describe
management Learner; the
of eclampsia listening management
. FETAL: of
eclampsia.
The perinatal mortality is very high to the extent of about 30–50%. The causes are:
1. Prematurity—spontaneous or induced.
2. Intrauterine asphyxia due to placental insufficiency arising out of infarction, retroplacental
hemorrhage and spasm of uteroplacental vasculature.
3. Effects of the drugs used to control convulsions.
4. Trauma during operative delivery.

MANAGEMENT

PREDICTION AND PREVENTION:

In majority of cases, eclampsia is preceded by severe pre-eclampsia. Thus, the prevention of
eclampsia rests on early detection and effective institutional treatment with judicious termination
of pregnancy during pre-eclampsia. However, eclampsia can occur bypassing the pre-eclamptic
state (20–40%) and as such, it is not always a preventable condition. Eclampsia may present in
atypical ways; hence, it is at times difficult to predict. Use of antihypertensive drugs, prophylactic
anticonvulsant therapy and timely delivery are important steps. Close monitoring during labor and
24 hours’ postpartum is also important in prevention of eclampsia. Magpie trial (2002) showed
prophylactic use of magnesium sulfate lowers the risk of eclampsia. Unfortunately, 30–85% of
cases of eclampsia remained unpreventable.

FIRST AID TREATMENT OUTSIDE THE HOSPITAL:

The patient, either at home or in the peripheral health centers should be shifted urgently to the
tertiary referral care hospitals. There is no place of continuing the treatment in such places.
Transport of an eclamptic patient to a tertiary care center is important. Such a patient needs
Neonatal and obstetric intensive care management.

Important steps in transport are:

All maternal records and a detailed summary should be sent with the patient.
BP should be stabilized and convulsions should be arrested.
Magnesium sulfate [4 g IV loading dose with 10 g IM is given. Labetalol 20 mg IV is given to
control hypertension. Diuretic is given if there is pulmonary edema. Diazepam, if used, should
be given 5 mg slowly over 1 minute period to avoid apnea or cardiac arrest.
One medical personnel or a trained midwife should accompany the patient in the ambulance
equipped to prevent injury, recurrent fits and to clear air passage.
Medical Management of Eclampsia—Immediate Measures
Medical Management of Eclampsia—Immediate
Measures
 Call for extra help (communication)
 Control of seizures: MgSO4, (IV/IM regimens)
 To put patient in left lateral recumbent position
 Maintain oral airway
 O2 inhalation–non breather mask; 10 L/minute
 Commence IV lines; 1 or 2 wide bore cannulas
 Foley catheter with urometer
 To monitor O2 saturation; pulse oximeter (SPO2 > 95%)
 To monitor vitals; fetal status and magnesium toxicity
 Control of hypertension: labetalol, hydralazine
 Fluids: crystalloids (saline) or colloids (albumin/blood) ≤125 mL/h
 Suction: oropharyngeal
 Diuretics: pulmonary edema
 Investigations to organize: Blood: CBC, AST, ALT, LDH, creatinine, uric acid, urine
analysis - protein
 COMMONLY USED DRUGS IN THE MANAGEMENT OF PRE-ECLAMPSIA

GENERAL MANAGEMENT (MEDICAL AND NURSING)

Supportive care:
(i) To prevent serious maternal injury from fall,
(ii) prevent aspiration,
(iii) To maintain airway and
(iv) To ensure oxygenation.

Patient is kept in a railed cot and a tongue blade is inserted between the teeth. She is kept in the
lateral decubitus position to avoid aspiration. Vomitus and oral secretions are removed by frequent
suctioning, oxygenation is maintained through a face mask (8–10 L/minute) to prevent respiratory
acidosis. Oxygenation is monitored using a transcutaneous pulse oximeter. Arterial blood gas
analysis is needed when O2 saturation falls below 92%. Sodium bicarbonate is given when the
pH is below 7.10. The patient should have a doctor or at least a trained midwife for constant
supervision.

Detailed history is to be taken from the relatives, relevant to the diagnosis of eclampsia, duration
of pregnancy, number of fits and nature of medication administered outside.

Examination:
Once the patient is stabilized, a thorough but quick general, abdominal and vaginal examinations
are made. A self-retaining catheter is introduced and the urine is tested for protein. The continuous
drainage facilitates measurement of the urinary output and periodic urine analysis.

Monitoring:
Half hourly pulse, respiration rate and blood pressure are recorded. Hourly urinary output is to be
noted. If undelivered, the uterus should be palpated at regular intervals to detect the progress of
labor and the fetal heart rate is to be monitored. Immediately after a convulsion, fetal bradycardia
is common.

Fluid balance:
 Crystalloid solution (Ringer’s solution) is started as a first choice. Total fluids should not
exceed the previous 24 hours urinary output plus 1000 mL (insensible loss through lungs
 and skin).
 Normally, it should not exceed 2 liters in 24 hours. Infusion of balanced salt solution
should be at the rate of 1 mL/kg/h. In pre-eclampsia–eclampsia although there is
hypovolemia, the tissues are overloaded.
 An excess of dextrose or crystalline solutions should not be used as it will aggravate the
tissue overload leading to pulmonary edema and adult respiratory distress syndrome.
 Colloids (albumin or hemaccel) remain in the vascular tree and they withdraw fluids from
the interstitial space. Unless used carefully, they can lead to circulatory overload.
 CVP monitoring is needed for a patient with severe hypertension and reduced urine output.
In pre-eclampsia, eclampsia, both the PCWP and CVP appear to be in the low to normal
range. Invasive hemodynamic monitoring is rarely indicated.
Antibiotic:
To prevent infection, Ceftriaxone 1 g IV twice daily is given.

SPECIFIC MANAGEMENT:

 Anticonvulsant regime:
The aim is to control the fits and to prevent its recurrence. In areas where eclampsia is
frequently encountered, it is obvious that the obstetric care is inadequate. In such
circumstances any complicated regime is unlikely to give good result.
 Magnesium sulfate is the drug of choice

It acts as a membrane stabilizer and neuroprotector. It reduces motor endplate sensitivity to

acetylcholine. Magnesium also blocks neuronal calcium influx. It induces cerebral
vasodilatation, dilates uterine arteries, increases production of endothelial prostacyclin and
inhibits platelet activation. It has no detrimental effects on the neonate within therapeutic
level. It has got excellent result with maternal mortality of 3%. It does not control
hypertension. For IV administration, concentration of MgSO4 should not exceed 20%. One
part of 50% MgSO4 injection is diluted with 1.5 parts of water for injection to make it 20%. It
is then given IV slowly.

 Repeat injections are given only if the knee jerks are present, urine output exceeds 30
mL/h and the respiration rate is more than 12/minute. The therapeutic level of serum
magnesium is 4–7 mEq/L. Serum magnesium levels may be monitored in selected cases
(renal insufficiency, absent deep tendon reflexes). To control fits, optimum serum
magnesium level is 4.8–8.4 mg/dL (4–7 mEq/L) to be maintained.
 Magnesium toxicity and serum Mg level is seen as:
(a) Loss of deep tendon reflexes >7 mEq/L;
(b) respiratory depression more than 10 mEq/L and
(c) cardiac arrest more than 25 mEq/L.
 (d) Urine output (<30 mL/h)
(e) Chest pain, heart block, pulmonary edema
(f) O2 saturation monitoring (PaO2 <95%)

 Magnesium sulfate is continued for 24 hours after the last seizure or delivery
whichever is later. For recurrence of fits, further 2 g IV bolus is given over 5 minute in
the above regimens. If the patient seizes, despite magnesium therapy, midazolam 1–2 mg
IV is given (and may be repeated in 5–10 minutes time).Re

REGIMENS OF MgSO4 FOR THE MANAGEMENT OF SEVERE PRE-ECLAMPSIA AND

ECLAMPSIA8.5: Detection of Magnesium Toxicity

Box 18.6: Management for Magnesium Toxicity

Other regimens are:
(1) Lytic cocktail (Menon 1961) using chlorpromazine, promethazine and pethidine.
(2) Diazepam (Lean) and
(3) Phenytoin.
Compared to other regimes, magnesium sulfate has got the following benefits:
(i) It controls fits effectively without any depression effect to the mother or the infant,
(ii) Reduced risk of recurrent convulsions (9%),
(iii) Significantly reduced maternal death rate (3%) and
(iv) Reduced perinatal mortality rate.

Antihypertensives and diuretics:

 In spite of anticonvulsant regime, if the blood pressure remains more than 160/110 mm
Hg, antihypertensive drugs should be administered.
 First-line of antihypertensive drugs are: labetalol and hydralazine (ACOG-2011).
Target level of BP is SBP: 140–160 mm Hg and DBP: 90–100 mm Hg.
Labetalol 20 mg IV is given. Repeat doses may be needed after an interval of 10 minutes.
Alternatively hydralazine 5 or 10 mg IV is given. Repeat dose may be needed if no
response occurs after 20 minutes time. Presence of pulmonary edema requires diuretics. In
such cases, the potent one (furosemide) should be administered in doses of 20–40 mg
intravenously and to be repeated at intervals.
Management during fit:

(a) In the premonitory stage, a mouth gag is placed in between the teeth to prevent tongue bite and
should be removed after the clonic phase is over.
(b) The air passage is to be cleared off the mucus with a mucus sucker. The patient’s head is to be
turned to one side and the pillow is taken off. Raising the foot end of the bed, facilitates postural
drainage of the upper respiratory tract.
(c) Oxygen is given until cyanosis disappears.

Status eclampticus:
 Thiopentone sodium 0.5 g dissolved in 20 mL of 5% dextrose is given intravenously very
slowly. The procedure should be supervised by an expert anesthetist.
 If the procedure fails, use of complete anesthesia, muscle relaxant and assisted
ventilation may be employed.
 In unresponsive cases, cesarean section in ideal surroundings may be a lifesaving attempt.

INDICATIONS OF INTUBATION TIONS OF INTUBATION

 Patient remains unconscious in post-seizure period
 Seizures not controlled
 Signs of aspiration
  Persistent hypoxia

Prevention and treatment of complications :

Prophylactic use of antibiotics markedly reduce the complications like pulmonary and puerperal
infection.
Pulmonary edema:
 Furosemide 40 mg IV followed by 20 g of mannitol IV reduces pulmonary edema and also
prevents adult respiratory distress syndrome.
 Pulse oximeter is very useful to monitor such a patient. Aspiration of the mucus from the
tracheobronchial tree by a suction apparatus is done.
Heart failure:
Oxygen inhalation, parenteral lasix and digitalis are used.
Anuria:
The treatment should be in the line as formulated in the chapter of anuria. Dopamine
infusion (1 µg/kg) is given with oliguria when CVP is above 8 mm Hg. It is often surprising that
urine output returns to normal following delivery.
Hyperpyrexia:
It is difficult to bring down the temperature as it is central in origin. However, cold sponging
and antipyretics may be tried.
 Psychosis:
Chlorpromazine or eskazine (trifluoperazine) is quite effective. Explain the
Obstetrical
To explain  Intensive care monitoring: Management
the Of eclampsia
Patient with multiple organ dysfunction needs to be admitted in an intensive care unit.
obstetrical
management  Multidisciplinary approach:
with use of
Obstetrician, obstetric nurse, anesthesiologist, neonatologist, intensive care unit team
schematic
diagram. should be involved. Cardiac, renal or pulmonary complications are managed effectively.
Use of blood gas analyzer (to detect hypoxia and acidosis), pulse oximeter and central
venous pressure monitoring should be done depending on individual case . A deeply
unconscious patient with raised intracranial pressure needs steroid and/or diuretic therapy.
Neuroradiologic imaging is strongly advised in the postpartum period for cases with
neurologic symptoms and focal deficit.

OBSTETRIC MANAGEMENT:

During pregnancy:
In majority of cases with antepartum eclampsia, labor starts soon after convulsions. But when
labor fails to start, the management depends on—
(i) Whether the fits are controlled or not and
(ii) The maturity of the fetus. The decision to deliver is made once the woman is stable.
Epidural anesthesia can be used during labor and delivery.
 Fits controlled:
 Baby mature:
Delivery should be done.
a. If the cervix is favorable and there is no contraindication of vaginal delivery, surgical
induction by low rupture of the membranes is done. Oxytocin drip may be added, if
needed.
b. When the cervix is unfavorable, cervical ripening with PGE2 gel or pessary could be
achieved before ARM.
c. If the cervix is unfavorable and/or there is obstetric contraindication of vaginal
delivery, cesarean section is done.

 Baby premature (<37 weeks):

Delivery is recommended in a set up with neonatal intensive care unit (NICU). The
underlying disease process of pre-eclampsia and eclampsia persists until the woman
delivers. At times the disease process may flare up. Moreover, there lies the risk of
recurrent convulsions and IUFD. Steroid therapy is given when pregnancy is less than 34
weeks.

Conservative management at very early pregnancy may improve perinatal outcome but this must
be carefully balanced with maternal wellbeing (RCOG- 2006).
  Baby dead: The pre-eclamptic process gradually subsides and eventually expulsion of the
fetus occurs. Otherwise medical method of induction is started.

 Fits not controlled:

If the fits are not controlled with anticonvulsant within a reasonable period (6–8 hours),
termination of pregnancy should be done. If vaginal examination indicates a quick response to
induction, low rupture of the membranes is done. Oxytocin infusion may be added. The uterus
responds well to oxytocin in such cases. In presence of unfavorable factors, cesarean section gives
a quick response.

During labor:
 In the absence of any contraindication to vaginal delivery, as soon as the labor is well
established, low rupture of the membranes is to be done to accelerate the labor.
 The dose schedule of antihypertensive and anticonvulsant drugs may be increased to
quieten the patient.
 Second stage should be curtailed by forceps, ventouse or craniotomy, if the baby is dead.
Prophylactic intravenous ergometrine or syntometrine following the delivery of the
anterior shoulder should not be given as it may produce further rise of blood pressure.
Instead, 10 units of oxytocin IM or IV slowly should be given.
 One should remain vigilant about postpartum hemorrhage and shock.
Indications of cesarean section:
i. Eclampsia before 30 weeks gestation with unfavorable cervix.
ii. Uncontrolled fits in spite of therapy.
iii. Unconscious patient and poor prospect of vaginal delivery.
iv. Obstetric indications (malpresentation).

Follow-up and prognosis:

 Patient should be followed up in the postnatal clinic by 6 weeks’ time. Persistence of
hypertension, proteinuria and abnormal blood biochemistry necessitates further
investigation and consultation with a physician. Further pregnancy should be deferred till
they are controlled.
 Recurrence risk varies between 2% and 25%. The risk of pre-eclampsia and eclampsia to
the daughter of an eclampsia patient is about 25% and 3%, respectively.
 Atypical pre-eclampsia is defined as the development of pre-eclampsia (even eclampsia)
without fulfilling the standard definition or criteria (hypertension or proteinuria). The
common presentations are:
 Early onset pre-eclampsia/eclampsia less than 20 weeks,
 Late postpartum pre-eclampsia, eclampsia more than 48 hours postpartum,
 Women with gestational hypertension or gestational proteinuria presenting with symptoms of
 (a) Pre-eclampsia,
(b) Thrombocytopenia and
(c) Elevated liver enzymes.
Women with atypical pre-eclampsia and who have other diagnostic criteria of severe pre-
eclampsia should be treated as if they have severe pre-eclampsia. Patients are also treated with
parenteral MgSO4.
To
summarize
eclampsia
Managemen
t.
To conclude
the topic