Pih and eclampsia

PIH and Eclampsia

Dr. V. L. DeshmukhAssociate Professor

Dept. of OBGY

Govt. Medical College

AURANGABAD

Maternal Mortality

Major causes of maternal mortality are

• PIH

• Eclampsia

• APH

• PPH

• Puerperal sepsis

• Obstructed labour

• Unsafe abortions

Introduction

• Hypertensive disorders in pregnancy

• Significant maternal morbidity

• Fetal morbidity and mortality

• Includes PIH, pre-eclampsia, eclampsia, chr. Hypertension, chr. Hypertension with superadded PIH

Definition

• Multi systemic disorder

• After 20 wks

• B.P. > 140/90 mmHg

• Proteinuria

• Edema

• Excessive wt. Gain

ClassificationFinding Mild pre-eclampsia Severe pre-eclampsia

B.P. •The diastolic pressure rises 1`5-20 mmHg above the “usual’ level, OR

•The absolute level of BP is >140/90 mmHg but <160/110 mmHg

The diastolic pressure rises >20 mmhg above the ‘usual’ level; OR

The absolute level of BP is 160/110 mmhg

Proteinuria Present, but 2+ or less 3+ or persistently greater

Generalized edema (including in the face and hands)

May or may not be present

Present

Headache Absent Present

Visual distrubances Absent Present

Upper abdominal pain Absent Present

Oliguria Absent Present

Diminished fetal movement Absent Present

Eclampsia

• Characterized by convulsions and/or coma

• Women has PIH

• Types antepartum, intrapartum and postpartum.

• No lower limit of B.P. for eclampsia can even occur at 120/80 mmHg

Fulminating Eclampsia

Symptoms :• Severe headache• Drowsiness• Mental confusion• Visual distrubances• Epigastric pain• Nausea, vomiting• Decreased urinary output

Signs

• A sharp rise in B.P.

• Increased proteinuria

• Exaggerated knee jerk

Status Eclampticus

• Continuous convulsions

• Dangerous for mother and fetus

• Can lead to fetal and maternal mortality

Stage of Eclampsia

• Premonitory

• Tonic

• Clonic

• Coma

Eclampsia

• Can occur regardless of severity of hypertension

• Difficult to predict • Tonic clonic• Rapid sequence• Can occur in the absence of hyper-

reflexia, headache and visual disturbances.

D/D of Eclampsia

• Epilepsy

• Cerebral malaria

• Meningitis

• Encephalitis

• Tetanus

• Head injury

Effect on Mother

• Asphyxia• Aspiration• Pulmonary edema• Bronchopneumonia• Cardiac failure• Brain hemorrhage• Cerebral thrombosis• Cerebral edema

Effect on Mother

• ARF

• HELLP

• DIC

• Temporary blindness

• Injuries

• Tongue bite

Effect on Fetus

• Hypoxia

* IUGR

* Stillbirth

High risk for Eclampsia

• Teenagers / elderly primi.

• Essential HT

• Twins

• Women with DM, polyhydramnios, V. mole

• H/o eclampsia

• Obese women

Mortality due to Eclampsia

• Failure to monitor B.P. in ANC• Failure to monitor proteinuria• Lack of clear-cut mgt. strategy for PIH• Lack of proper equipment and drugs.• Late referral• Failure to counsel women & her relatives

about S/s of PIH & ANC• Failure to timely manage complications of

Eclampsia.

Diagnosis

• Pregnant women or PNC complaints of severe headache, blurred vision

• Unconscious

• Convulsions

• Elevated B.P.

Mgt. of PIH

• ANC• Check B.P.• Proteinuria• Body edema• Weight• Regular ANC check-up• Rise in B.P.• Refer

Mild PIH

• B.P. 140/90 mmHg but less than 160/110 mmHg.

• < 37 wks

• > 37 wks

- TERMINATE

Mild PIH

< 37 wks.• Bed rest• Wkly visit• Check B.P.• Proteinuria• Wt. Of the patient• Body edema• Exclude S/o severe PIH• DFMC• Check FHS

Mild PIH

BOOK THE PATEINT FOR DELIVERY AT BEmOC CENTER.

Mild PIH

> 37 wks.• Assess cervix• Accelerate delivery• Check B.P. 4 hrly.(2 hrly if severe

PIH)• Bed rest• Proteinuria B.D.• Monitor FHS

Mild PIH

• Give sedation

• Give antihypertensive

• Only if diastolic B.P. is > 110 mmHg

Eclampsia

Six major steps :

1. Maintain airway

2. Control fits

3. Control B.P.

4. Deliver the pt.

5. Maintain fluid balance

6. Give after care of delivery

Eclampsia

Maintain airway :1. LLP2. Gentle section3. Oxygen4. Place padded tongue blade in her mouth

to prevent aspiration and tongue biteDO NOT ATTEMPT THIS DURING

CONVULSIONS

Eclampsia

Control fits :MAGSULF THERAPY

• Dose – Inj. MgSo4 – 4 gm (20 ml of 20% sol.) slow I.V. at the rate of 1 ml / min.

NOT TO BE GIVEN AS BOLUS

• Maintenances dose 5 gm deep I.M. every 4 hrly.

Eclampsia

• If convulsions recur give additional 2 gm magsulf (10 ml of 20% sol.) I.V. over 20 min.

• Wait for 15 min.

• If still convulsions recur – give diazepam

REFER

Eclampsia

Monitoring of MgSo4 therapy

1. Output atleast 100 ml/4 hrs.

2. Knee jerk present

3. Respiratory rate 16 breath/min

POSTPONE THE NEXT DOSE IF ABOVE CRITERIA NOT MET

Eclampsia

Precautions :

Do not give

1. 50% MgSo4 without diluting it to 20%2. Rapid I.V. infusion as it may cause

respiratory failure and deathIf respiratory depression occurs (RR < 16/min)

1. Discontinue MgSo4 2. Give calcium gluconate - 1 gm I.V. (10 ml of

10% solution) over a period of 10 min.

Eclampsia

Other options available are :

1. Diazepam (10 mg I.V. slowly over 2 min.)

2. Phenytoin sodium

3. Largactil

MgSO4 IS SUPERIOR TO ALL ABOVE DRUGS IN ECLAMPSIA

Eclampsia

Controlling the B.P.

• Tab. Depine – 10 mg t.d.s.

• Tab. Labetelol – 50 mg b.d.• Other drugs available – Hydralazine

Eclampsia

Controlling fluid balance :1. Intake output chart2. Output 100 ml/4 hrs.3. 60 ml /hr fluid intake4. Extra fluid if vomiting, excessive blood loss or

diarrhoea.PROPER MAINTENANCE OF FLUID BALANCE

TO PREVENT WATER INTOXICATION, DEHYDRATION, HYPONATREMIA OR PULMONARY EDEMA.

Eclampsia

DIURETICS SHOULD NOT BE USED, IT IS DANGEROUS

Eclampsia

Delivering the baby1. If PIH deliver within 24 hrs.

2. If eclampsia deliver within 12 hrs.

3. If vg. Delivery is not anticepated or Cx is unfavourable or S/o fetal distress, REFER

Eclampsia

Delivery 1. Before labour

- Control B.P.- Control fits

REFER2. Late 1st stage / 2nd stage

- Carry out Vg. deliveryREFER

Eclampsia

Difficult deliveries :1. Labour not progressing quickly

2. Big size baby

REFER

GIVE MgSO4

Rule of Thumb

• Pt. with severe PIH comes early 1st stage of labour – REFER

• Pt. comes in late labour or 2nd stage – conduct delivery, give MgSO4 – REFER

Rule of Thumb

Eclampsia – Postpartum Care

1. Refer pt. After one hr. of delivery after ruling out PPH

2. If pt. Has fits, observe for 48 hrs. after convulsions.

3. Closely observe her consciousness, output

4. Monitor B.P. every hrly.

5. Given anti-hypertensives till B.P. comes down to 100 mmHg diastolic

Eclampsia – Postpartum Care

• Do not give excessive IV fluid• If after 72 hrs. there are no convulsions,

output is good, and B.P. is 100 mmHg diastolic – discharge the pt.

• Arrange for follow-up – 7 to 10 days after delivery.

CONTINUED FITS – REFER WITHOUT DELAY

Eclampsia – Postpartum Care

Following Eclampsia B.P. may :

1. Return to normal within 48-72 hrs.

2. Return to normal after a few wks. May remain high permanently.

Referral• Should be

transported by the quickest mode of transport

• 3 delays

Through a team approach all of the skills of the health care members involved can be combined to provide the best possible approach to meet the pregnancy’s need. The role of patient education can not be

over emphasized. Incorporating the mother as an active member in her health

care is an investment in time and effort that is cost effective both during

pregnancy and labour.

A systematic & a well begun programme with a positive thinking will definitely show

road to success to accept this challenge