Eclampsia

ECLAMPSIA

Convulsions in association with the features of pre-eclampsia
Incidence 4.9 of 10 000 maternities
Case fatality rate is 1.8% and 35 %of woman will have at least one major complications
of seizures 44% occur postnatal, antepartum 38%, intrapartum 18%

Pathophysiology: is thought to involve cerebral vasospasm leading to ischemia and cerebral edema

DIAGNOSIS :

. second half in pregnancy up to 10 days after delivery
. generalize tonic –clonic in type fallow by brief period of coma
. excitability or hyperreflexia prior to the onset of seizure
. diagnosis straight foreword when convulsion in PE woman.38% do not have established protein urea and hypertension before first fit and a lot with no ANC
.postictal for about 30 min
.coma ,localize signs raise the possibility of cerebral accident

Management:

General measures: call for help , maintain the integrity of the airway ,administer oxygen and avoid supine hypotension
Strict monitoring of the patient (pulse ,BP,RR,O2 saturation every 15 min),reflexes and urine


Treat and prevent further fit :most convulsions are self-limiting and anticonvulsant to prevent further fit
Magnesium sulphate is the treatment of choice
.4 g IV over 5-10 min bolus followed by maintenance infusion of 1 g \h or IM regime
.maintenance therapy should be continued for at least 24 h after last convulsion
.excreted through the kidney so UOP should be monitor
.loss of deep tendon reflexes, confusion then respiratory depression are the sign of toxicity
.calcium gluconate 1 g over 10 min used if toxicity is suspected
.act as cerebral vasodilator

Other anticonvulsant drugs :phenytoin

Diazepam less effective in prevention of fit recurrence

Control hypertension :avoid rapid decrease in BP and hypotension
Use IV infusion of antihypertensive

Termination of pregnancy :

After stabilization for 4-6 hour
Vaginal delivery is indicated if favorable cervix with good anesthesia or analgesia with shortening second stage
Otherwise caesarian section is indicated


Fluid therapy: is important in sever PE and eclampsia
Because low plasma volume, decrease regional perfusion ,increase hematocrit
Accurate recording of fluid balance
Maintenance crystalloid infusion 1 L ringer lactate 12 h
Selective monitoring of CVP (oliguria or hemorrhage )
Selective colloid expansion (oliguria ,low CVP )
Diuretic in patient with pulmonary edema
i

HELLP syndrome

.serious complication
.increase maternal and perinatal mortality
.H (hemolysis) EL (elevated liver enzyme ) LP (low platelet )
.self-limited ,but permanent liver or renal damage may occur
.N&V ,epigastric pain ,RUQ pain ,tea color urine are the main symptoms
. eclampsia may co-exist
. delivery is indicated
Treatment: supportive, treat eclampsia, delivery, plat transfusion if less 40


Pulmonary edema and acute renal failure

.1-2 % in patient with sever PE

.treatment of pulmonary edema with frusemide and oxygen with intensive care unit if persistent hypoxia

postnatal counselling and prevention of pre-eclampsia

.incidence 7 -10 % in first pregnancy
.1 % incidence of sever preeclampsia
.recurrence rate in next pregnancy 7-1o% but increase to up to 20-30% if eclampsia or HELLP in first pregnancy


Low dose aspirin used as early as possible in next pregnancy(before 16 week )
Calcium
Magnesium
Fish oil

CHRONIC HYPERTENSION

Complicate 3-5 % of pregnancy
Pregnant woman with high booking BP
Increase risk of super imposed pre eclampsia
Delivery should be planned around the EDD
The need to treatment is usually reduced in first trimester
Change the type of medication with that with fewer side effect
Increase maternal and perinatal complication usually due to development of PE


High risk woman with CHT
Maternal age more than 40
Duration of hypertension more than 15 year
BP more 160\110
Diabetes
Renal disease
Cardiomyopathy
Coarctation of aorta
Connective tissue disease or APL syndrome
Previous pregnancy with pregnancy loss

1.MOST ECLAMPTIC FIT OCUUR INTRAPARTUM

2.ECLAMPTIC FIT IS AN ABSOLUTE INDICATION FOR CS

3.PHYNTOIN IS THE DRUG OF CHOICE IN PREVENTING FURTHER FIT

4.DELIVERY IS INDICATED WITHIN ONE HOUR OF ECLAMPTIC FIT TO PREVENT FURTHER FIT

5.THE PATIENT SHOULD BE OVERHYDRATED

6.METHYL DOPA IS FIRST LINE TREAMENT FOR HYPERTENSION WITH ECLAMPSIA

7.TEA COLOR URINE IS COMMON PRESENTATION OF RENAL DISEASE WITH PRE ECLAMPSIA

8.ABRUPSIO PLACENTA IS ONE OF COMMON COMPLICATION OF PRE ECLAMPSIA

9.FOCAL FIT MIGHT INDICATE CEREBRAL ACCIDENT

10.ABSCENT REFLEXES INDICATE GOOD CONTROL OF ECLAMPSIA