Pre eclampsia complicated by generalized tonic clonic convulsions is termed Eclampsia. Eclampsia is characterized by

·        Hypertension , proteinuria and convulsions

·        The convulsions may occur in the antepartum, intrapartum or postpartum period.

Imminent Eclampsia

-When an eclamptic fit is likely to occur very soon

Symptoms:

Severe headache Drowsiness Mental confusion

Visual disturbances (e.g. blurred vision, flashes of light, doublevision) Epigastric pain

Nausea, vomiting Decreased urinary output

Signs:

A sharp rise in the BP Increased proteinuria Exaggerated knee jerk

High risk factors for Eclampsia

Risk factors for eclampsia are same as that of preeclampsia

Status eclampticus              -

Refers to a state in which convulsions or eclamptic fits continue incessantly one after the other.

It is dangerous for both mother and foetus and can lead to maternal and foetal mortality.

Effects of eclampsia on mother

*       Respiratory    (asphyxia,   aspiration    of    vomitus,      pulmonary     oedema, bronchopneumonia)

*  Cardiac (heart failure)

*  BPain (haemorrhage, thrombosis, oedema)

*  Renal (acute kidney failure)

*  Hepatic (liver necrosis)

*  HELLP syndrome (haemolysis, elevated liver enzymes,low platelet count)

*  Haemorrhage due to coagulation defect, i.e. DIC

*  Visual problems (temporary blindness: due to oedema of the retina)

*  Injuries (fractures, tongue bite)

The most common causes of maternal death in eclampsia:

•            aspiration of vomitus

•            kidney failure,

•            intracereBPal haemorrhage

•            multi-organ failure.

Effects on the foetus

Placental insufficiency leads to:

Hypoxia: This may lead to permanent BPain damage, which may result in

-   physical handicap

-   cereBPal palsy

-   mental retardation

IUGR

·        Prematurity

Management of eclampsia and severe pre-eclampsia

1.               Making sure that the woman can Breathe

Place the woman on her left side so that mucus or saliva can drain out in a dark room. Clean the mouth and nostrils by gentle suction

Give oxygen

Instruct the nursing staff to make sure that:

-            the patient's airway remains clear;

-            injury, especially to the tongue (tongue bite), is prevented

-            by placing padded tongue blades between her teeth (Do NOT attempt this during a  convulsion) also use bed with padded railing for the patient.

·        Catheterise the patient

2.  Controlling the fits

Magnesium sulphate is the drug of choice.

Loading dose: lnj. Magnesium sulphate 4 g (20 ml of 20% solution), slow IV, over 5- 10 minute

Thereafter administer Inj. Magnesium sulphate 5 g (10 ml of 50% solution), deep IM, with 1 ml of 2% Lignocaine in the same syringe in each gluteus (a total dose of 1 Og)

If convulsions recur: After 15 minutes, give an additional 2 g of Magnesium sulphate (10 ml of 20% solution) IV slowly. If the convulsions still continue, give Diazepam 5mg, IV slowly.

If referral is delayed for long, or woman is in late stage of labour, continue treatment as below:

•            Give 5 g of 50% Magnesium sulphate solution IM with 1 ml of 2% Lignocaine every 4 hours alternately in each buttock.

•            Before giving the next dose of Magnesium sulphate, ensure that:

*  The urine output is at least 100 ml per 4 hours;

*  Knee lerk reflexes are present;

*  The RR is at least 16 BPeaths per minute.

•            Postpone the next dose if the above criteria are not met.

•            Precautions: Do NOT give 50% Magnesium sulphate solution IV without diluting it to 20%.

•            Do NOT give a rapid IV infusion of Magnesium sulphate as it can cause respiratory failure or death.

•            If respiratory depression occurs (RR <16 BPeaths/minute) after giving Magnesium sulphate, discontinue the drug.

•            Give the antidote; Calcium gluconate 10 mg IV (10 ml of 10% solution) over a period of 10 minutes.

3.  Controlling the blood pressure

•            Anti hypertensive therapy: If the diastolic BP is 110 mmHg or more antihypertensives are recommended.

•            The goal of treatment is to keep the diastolic pressure between 90 and 100 mmHg to prevent cerebral haemorrhage.

•            There is no good evidence that any one antihypertensive is better than another for reducing the BP

Nifedipine

•            Dose and administration : The dose of Nifedipine is 10 mg orally.

•            To avoid sudden hypotension, After 10 minutes, monitor the BP

•            If the BP is still not BPought under control, another 10 mg of the drug can be repeated similarly.

•            Disadvantage: Nifedipine may cause a sudden and massive fall in BP Hence, it should be used with caution,and the dose delivered slowly.

•            Precaution: Nifedipine, when used in conjunction with Magnesium sulphate, can cause a dangerous fall in BP

•            Hence, when Nifedipine and Magnesium sulphate are used together, the BP should be monitored carefully

Labetalol- is given IV

Dose- 20mg IV slowly. If response is adequate, 40 mg may be given, after 20 minutes. The dose can be further increased to 80 mg after another 20 minutes.

Hydralazine-

Dose of 5-10 mg IV slowly every 15-20 mins until blood pressure is lowered. It should be given only in ICU setting.

4.  Controlling the fluid balance

•            Insert indwelling urinary catheter to measure the urinary output.

•            Record the urine output every 4 hours.

•            Suspect kidney failure if urine output less than 100 ml per 4 hours.

•            Record fluid intake. Give all the necessary fluids slow IV.

•            The patient should receive sodium lactate or5% dextrose @ 60 ml (maximum) per hour unless there is an unusual fluid loss from vomiting, diarrhoea, orexcessive blood loss at delivery.

5.  Delivering the baby

•            Decide on the method of delivery depending on whether or not the woman has gone into labour, and the stage and progress of labour.

•            In severe pre-eclampsia, delivery should occur within 24hours of the onset of symptoms;

•            In eclampsia, delivery should occur within 12 hours of the onset of convulsions.

6.  Giving care after delivery

•            It is important to realize that fits can occur for the first time after delivery, especially during the immediate postpartum period.

•            Fits, if they have occurred before delivery, can also recur after delivery.

•            Therefore, the patient must be carefully observed during the immediate postpartum period.

•            Refer the woman to an FRU one hour after delivery, after ruling out immediate PPH, and ensure that woman's condition is stable.

•            If the patient has fits after delivery, continue to observe and manage her for 48 hours after the last fit.

•            Monitor the BP every hour. Continue giving anti hypertensives as and when required, until the diastolicBP drops below 110 mmHg.

•            Monitor the urinary output

•            Do not give too much fluid intravenously during this period.

•            Advise the woman to have her BP checked regularly.