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, 2nd 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.

1

• 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

Clinical Manifestation Serum Level

Therapeutic 4-7 mEq/LArrest of Deep Reflex 8-12 mEq/L

Respiratory Arrest 13-19 mEq/LCardiac 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

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

LabetalolOral

: 100 mg 12 hrly

IV : 20 mg & repeat 40-80 mg every 10 min

Oral : 2400 mgIV : 300 mg

Nifedipine Oral :10 mg 6-8 hrly 120 mgMethyldopa 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

3

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