Eclampsia in Labour and Delivery

Mrs. K.Punithalakshmi, M.Sc,(N)

Professor Cum Principal

JIET College of Nursing, Jodhpur

INTRODUCTION

1) Hypertension is most common medical problem encountered during pregnancy.

2) Hypertensive disorder in pregnancy may cause maternal & fetal morbidity & leading cause of maternal mortality.

3) Hypertensive disorders are:

• Pre- eclampsia
• Eclampsia
• Gestational Hypertension
• Chronic Hypertension

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DEFINITION

1) Varadaeus coined the term eclampsia, it is derived from a greek word, meaning “like a flash of lightening‟.

2) Eclampsia is defined as ,A sudden onset of grandmal seizure activity in pregnancy, intrapartum & post partum period.

3) Pre-eclampsia when complicated with generalized tonic clonic seizures &/ or coma is called eclampsia.

ETIOLOGY

1. Exact etiology is unknown.
2. More common in previous hypertensive disease.
3. Failure of placentation.
4. Abnormal lipid metabolism.
5. Decrease calcium in diet.

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Other causes are :”ACDEPR‟

A - Alcohol.

C - Coarctation of aorta.

D - Drugs.

E - Endocrine disease.

P - Pregnancy induced hypertension.

R - Renal disease.

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RISK FACTOR

• Primi gravida
• Age
• Past history
• Pre existing disease
• Condition in which placenta enlarges

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 INCIDENCE

1) Eclampsia occur in 10% of all pregnancy

2) 20% of world maternal mortality rate , next to haemorrhage, pre-eclampsia & eclampsia are direct cause .

3) More common in primigravida 75%.

4) Eclampsia is 3rd leading cause of maternal mortality after thrombo-embolism & non-obstetrical injury.

5) Maternal DBP> 110 are associated with increase risk of placental abruption & fetal growth retardation.

6) Eclampsia result in death in advance or uncontrollable stage.

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CAUSES FOR CONVULSION

• Cerebral irritation leading to convulsion, irritation may be provoked by : Anoxia, cerebral edema , cerebral dysrhthymia.

1) ANOXIA: Spasm of cerebral vessels. Increased cerebral vascular resistance. Fall in cerebral oxygen consumption.

2) CEREBRAL EDEMA : It may contribute to irritation.

3) CEREBRAL DYSRHYTHMIA : It increases following anoxia & edema.

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COURSE OF CONVULSION

1.Seizure last for 60-70sec tonic-clonic type , later goes into coma.

2.Throughtout seizure , diaphragm is fixed , breathing is disturbed or even ceased.

3.First convulsion is forerunner of other. May be 1 or 2 in mild case to continuous result in status eclampticus.

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ONSET OF FITS

Fits occur more commonly in 3rd trimester ( more than 50% ) ,on rare condition fits may occur in early months as in hydatiform mole.

1. ANTEPARTUM (50%) : Fits occur before onset of labour more often, labour starts soon after & at times it is impossible to differentiate it from intrapartum ones.
2. INTRAPARTUM ( 30% ) : Fits occur for first time during labour .
3. POSTPARTUM (20%) : Fits occur for the first time in pueperium, usually with in 48 hour of delivery. Fits occur beyond 48 hr but less than 4weeks after delivery is accepted as, Late Postpartum Eclampsia.

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CLINICAL FEATURE

The eclamptic fits are epileptic form & consist of four stages , that are :

1)PREMONITORY STAGE :

• The patient becomes unconscious.
• There is twitching in the muscles of face, tongue & limbs.
• Eye balls are turned to one side & become fixed.
• This stage lasts for about 30 second.

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2)TONIC STAGE :

• The whole body goes into a spasm called trunk opisthotonus.
• Limbs are flexed & hands clenched.
• Respiration ceases & tongue protrudes between the teeth.
• Cyanosis appears.
• Eye balls become fixed.
• This stage lasts for about 30 seconds.

  3) CLONIC STAGE :

• All the voluntary muscles undergo alternate contraction & relaxation.
• The twitching starts in face then involve one side of extremities & ultimately the whole body is involved in the convulsion.
• Biting of tongue occurs.
• Breathing is strenetorous & blood stained frothy secretions fill the mouth.
• Cyanosis gradually disappears.
• This stage lasts for 1-4 minutes.

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4) STAGE OF COMA :

• Following the fit , the patient passes on the stage of coma.
• It may last for a brief period or in others deep coma persists till another convulsion.
• On occasion, the patient appears to be in a confused state following the fit & fails to remember the happenings.
• Rarely, the coma occurs without prior convulsion.

• The fits are usually multiple, recurring at varying intervals.
• When it occurs continuously it is called status eclampticus.
• Following the convulsion ,temperature rises, pulse & respiration rates are increased & blood pressure also increases.
• The urinary output is markedly diminished, proteinuria is pronounced & blood uric acid is raised.

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COMPLICATION

1.MATERNAL COMPLICATION : Are as follows,

• Tongue biting.
• Head trauma.
• Aspiration.
• Broken bones.
• Permanent CNS damage.
• Intra cranial hemorrhage.
• Renal failure.

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CONTI…..

• Injuries due to falling from bed.
• Disturbed vision.
• Psychosis.
• Shock.
• Death. Acute left ventricular failure.
• Pneumonia.
• Adult respiratory distress syndrome (ARDS)
• Pulmonary oedema.
• Hepatic necrosis.

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2.NEONATAL & FETAL COMPLICATION :

• Prematurity.
• Fetal hypoxia
• IUGR (Intra uterine growth retardation).
• Sepsis.
• Death.

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PROGNOSIS

1.MATERNAL PROGNOSIS : Once convulsion occur prognosis become uncertain, prognosis depends on many factors & features that are :

1.Long interval between onset & commencement of treatment (late referral).

2.Antepartum eclampsia specially with long delivery interval.

3.Number of fits more than 10.

4.Coma in between fits.

5.Temperature over 102 degree F with pulse rate above 120/min.

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6. Systolic Blood pressure above 200mm of Hg.

7.Oligouria with proteinuria.

8.Non response to treatment

9.Respiration rate 40/min.

10.Coma taken 6 hour or more.

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CONT…

• Maternal mortality in eclampsia is very high because of :

1.Cardiac failure

2.Pulmonary oedema.

3.Aspiration & septic pneumonia.

4.Cerebral haemorrhage.

5.Acute renal failure.

6.Cardio-pulmonary arrest.

7.ARDS

8.Pulmonary embolism.

9.Postpartum shock.

10.Puerperal sepsis.

If the patient recovers from acute illness she is likely to recover rapidly in 2-weeks,recurrence of eclampsia is uncommon , although chance of pre-eclampsia is about 30%.

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2.FETAL PROGNOSIS : Mortality rate is high about 30-50 % causes are :

1.Prematurity – Spontaneous or induced.

2.Intra uterine asphyxia – Due to placental insufficiency arising out of infraction, spasm of utero-placental vasculature & retro-placental haemorrage.

3.Effect of drugs – Used to control convulsion & hypertension.

4.Trauma – During operative delivery.

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MANAGEMENT

1.AIM OF MANAGEMENT :

• Arrest convulsion.

• Maintenance of patent airway , breathing & circulation.

• Oxygen administration at the rate 8-10 L/Min.

• Terminate pregnancy.

• Ventilatory support.

• Prevention of complication.

• Hemodynamic stability.

• Prevention of life threatening situation.

• Postpartum care.

• Medicine & regular follow up.

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2.PREDICTION & PREVENTION :

• In majority of cases, eclampsia is preceded by pre-eclampsia.
• Thus prevention of eclampsia rest on early detection & effective institutional treatment with judicious treatment of pregnancy during pre-eclampsia.
• Eclampsia may present in atypical ways , hence it is at times difficult to predict.
• Use of anti-hypertensive drugs , anti-convulsant therapy & timely delivery are important steps.
• Close monitoring during labour & 24 hour of postpartum, are also important in prevention of eclampsia.
• Unfortunately 30-85% of cases of eclampsia remained unpreventable.
• Use of magnesium sulphate lowers the risk of eclampsia.

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3.FIRST AID TREATMENT OUTSIDE THE HOSPITAL

• The patient either at home or in the health center should be shifted urgently to the tertiary referral care hospitals , because there is no place of continuing the treatment in such place.
• Transport of an eclamptic patient to a tertiary care center is very important.
• Such patient needs neonatal & obstetric intensive care management.

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Important steps in transport are :

1.All maternal records & detailed summary should be sent with patient.

2.B.P should be established & convulsions should be arrested.

3.Drugs should be give like : magnesium sulphate, labetalol, diuretics, diazepam.

4.One medical personnel & a trained midwife should accompany the patient in equipped ambulance to prevent injury & complication.

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4.GENERAL MANAGEMENT (MEDICAL & NURSING )

I ) SUPPORTIVE CARE :

• Aim to prevent serious maternal injury from fall, to prevent aspiration, to maintain airway & to ensure oxygenation.
• Patient is kept in railed cot & a tongue depressor is inserted between teeth.
• She is kept in the lateral position to avoid aspiration.
• Vomitus & oral secretion are removed by frequent suctioning , oxygenation is maintained through face mask to prevent respiratory acidosis.

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• Oxygenation is monitored using a transcutaneous pulse oxymeter.
• ABG analysis is needed when oxygen saturation falls below 92%.
• Sodium bicarbonate is given when pH is below 7.10
• The patient should have a doctor or at least a trained midwife for constant supervision.

ii) HISTORY

• Detailed history is to be taken from relatives,

relevant to diagnosis of eclampsia,

• duration of pregnancy,
• number of fits,& nature of medications administered outside.

iii)EXAMINATION

• Once the patient is stabilized, a thorough quick general, abdominal & vaginal examination are made.
• A self retaining catheter is introduced & urine is tested for protein.

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iv)MONITORING

• Half hourly pulse , respiration rate are recorded
• Hourly urine output is to be noted.
• If undelivered the uterus should be palpated at regular intervals to detect the progress of labour & fetal heart rate is to be monitored.
• Immediately after convulsion fetal bradycardia is common.

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V) FLUID BALANCE

• Ringer’s solution started as first choice.
• A excess of dextrose or crystalline solutions should not be used as it will aggravate the tissue overload leading to pulmonary oedema, circulatory overload & ARDS.

VI) ANTIBIOTIC

• To prevent infection, ceftriaxone 1gm IV bd.

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5.SPECIFIC MANAGEMENT

i) ANTICONVULSANT & SEDATIVE THERAPY :

• The aim to control the fits & to prevent it’s recurrence. Magnesium sulphate is drug of choice , it acts as a membrane stabilizer & neuro protector .
• It reduces motor end plate sensitivity to acetylcholine , it induce cerebral vasodilatation , dilates uterine arteries , inhibit platelet activation.

• It has no adverse effects on neonate within therapeutic level, it has got excellent result with maternal mortality of 3%, it doesn’t control hypertension.
• The therapeutic level of magnesium is 4-7mEQ/L
• For recurrence of fit 2gm IV bolus is given over 5 min.

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• BENEFITS OF MAGNESIUM SULPHATE USE :

i)It control fits effectively without any depression effect to the mother or infant.

ii)It reduce risk of recurrent fits.

iii)It reduce maternal death rate at 3% .

iv)It reduce perinatal mortality rate.

OTHER REGIMEN ARE :

1.Phenytoin.

2.Diazepam.

3.Lytic cocktail, MENON 1961 ( chlorpromazine , pethidine , promethazine )

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ii) ANTIHYPERTENSIVE & DIURETICS :

• Inspite of anticonvulsant & sedative regimen, if the blood pressure remains more than 160/110 mm hg ,antihypertensive drugs should be administered.

• Drugs commonly used are : Hydralazine , labetalol, calcium channel blocker or nitroglycerine.

• Presence of pulmonary edema require diuretics, in such case “ Frusemide ” should be administered in doses of 20-40 mg IV & repeated at interval.

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iii) MANAGEMENT DURING FITS

• In premonitory stage : a mouth gag is placed in between teeth to prevent tongue bite & removed after clonic stage or phase is over.

• The air passage is to be clear off the mucus with suctioning, the patient’s head is to be turned to one side, raising the foot end of bed facilitates postural drainage of the upper respiratory tract.

• Oxygen is given until cyanosis disappears.

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iv) STATUS ECLAMPTICUS

• Thiopentone sodium 0.5 gm dissolved in 20 ml of 5% dextrose is given IV very slowly.

• In unresponsive cases, caesarean section in ideal surroundings may be a life saving attempt.

v) TREATMENT OF COMPLICATION

•Prophylactic use of antibiotics markedly reduces the complications like pulmonary & puerperal infection.

For pulmonary edema & ARDS : Frusemide 40 mg I.V followed by 20gm of mannitol I.V ,

Monitoring with pulse oxymeter is very useful in such patient .

Aspiration of mucus from tracheo-bronchial tree by a suction apparatus is done.

For heart failure : Oxygen inhalation , parenteral lasix & digitalis are used.

For anuria : The dopamine infusion is given .

For hyperpyrexia : Cold sponging, & antipyretics are given.

For psychosis : Chlorpromazine or Trifluoperazine is quite effective.

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OBSTETRIC MANAGEMANT

i)DURING PREGNANCY :

In majority cases with antepartum eclampsia , labour starts soon after convulsion.

But when labour fails to starts , the management depends on :

** whether the fits are controlled or not

** the maturity of fetus.

A) FITS ARE CONTROLLED :

There may be 3 conditions like : babymature , baby premature & baby dead.

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a)Baby mature : Delivery should be done ;

• If cervix is favourable & there is no contraindication of vaginal delivery , surgical induction by low rupture of the membrane is done.
• When cervix is unfavourable cervical ripening with PGE2 gel could be achieved before ARM.
• If cervix is unfavourable &/or there is obstetric contraindication for vaginal delivery, caesarean section is done.

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b) Baby premature (<37 weeks) : Delivery is recommended in set of NICU.

• The underline disease process of preeclampsia & eclampsia persist until women delivers.
• The disease process may flare up.
• Moreover there is risk of convulsion & IUFD.
• Steroid therapy is given when pregnancy is less than 34 weeks.
• Conservative management at early pregnancy may improve perinatal outcome.
• But this must be carefully balanced with maternal wellbeing.

c) Baby dead :

• The pre-eclamptic process gradually subsides & eventually expulsion of baby occur ,other wise medical method of induction is started.

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B) FITS ARE NOT CONTROLLED :

• If fits are not controlled with anticonvulsant within a reasonable period (6-8 hours), termination of pregnancy should be done.

ii)DURING LABOUR:

• In absence of any contraindication to vaginal delivery as soon as labour is established, low rupture of membrane is done to accelerate labour.

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SUMMARY

1.Hypertension in pregnancy is most common medical complication.

2.Pre-eclampsia & eclampsia are the leading cause of maternal mortality & morbidity in India & worldwide.

3.The basic pathology is endothelial dysfunction & vasospasm.

4.Eclampsia is a complication of pre-eclampsia & is significant cause of maternal death.

5.Convulsion in eclampsia has got 4 stages ; these are Premonitory stage, tonic stage , clonic stage ,& stage of coma.

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6.Prevention of eclampsia is depend on early detection & management of pre-eclampsia.

7.Magnesium sulphate is drug of choice to control fits.

8.Eclampsia should be managed in a tertiary care hospital.

9.Principle of management involves : general care of patient, to arrest convulsion, to maintain airway, breathing & circulation, to prevent life threatening complication, to terminate pregnancy & postpartum cares.

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