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4th stage
obstetrics
Lec-Ht تكملة
د.ولدان
6/4/2016
Obstetric measures:
Timing of delivery :
Severe pre-eclampsia is usually treated conservatively till the end of the 36th week to
ensure reasonable maturation of the foetus. Indications of termination before 36th week
include:
1. Foetal: deteriorating placental function as judged by :
intrauterine growth retardation ,
oligohydramnios ,
reduced foetal movements ,
abnormal foetal heart patterns, or
failing biochemical results.
2. Maternal: deteriorating maternal condition as judged by :
blood pressure is sustained or exceeds 180/110 mmHg ,
urine proteinuria > 5 gm/24 hours ,
oliguria ,
evidence of DIC, or
imminent or already developed eclampsia.
Method of delivery:
› Vaginal delivery may be commenced in vertex presentation by:
amniotomy + oxytocin if the cervix is favourable.
prostaglandin vaginal tablet (PGE2) if the cervix is not favourable.
› Caesarean section is indicated in:
Foetal distress.
Late deceleration occurs with oxytocin challenge test.
Failure of induction of labour.
Other indications as contracted pelvis, and malpresentations
.
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Intrapartum care:
› Close monitoring of the foetus is indicated.
› Proper sedation and analgesia to the mother. Hypotensives may be given if
needed.
› 2nd stage of labour may be shortened by forceps.
Postpartum care:
› Methergin is better avoided as it may increase the blood pressure.
› Continue observation of the mother for 48 hours.
› Sedatives and hypotensive drugs are continued in a decreasing dose for 48
hours.
Mild pre-eclampsia: can be treated as an outpatient with sedatives ± hypotensive
drugs with frequent follow up. Pregnancy can be allowed to pass to full term but not
after. Delivery is usually vaginal unless there is other indication for caesarean section.
Eclampsia
Definition
It is the development of convulsions in a pre-existing pre-eclampsia.
Incidence
About 1/1000 pregnancies.
Aetiology
The exact cause is unknown but cerebral ischaemia and oedema were suggested.
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Clinical Picture
Premonitory stage: the eyes are rolled up with twitches of the face and
hands. It lasts for about ½ min.
Tonic stage: generalised tonic contraction of the whole body muscles with
opisthotonus and cyanosis. It lasts for about ½ min.
Clonic stage: convulsions occur where there is alternative contraction and
relaxation of the body muscles. The face is congested, tongue may be
bitten, blood-stained frothy saliva appears on the mouth, breathing is
stertorous, urine and stool may pass involuntarily, temperature rises due
to increased muscular activity patient is unconscious. This lasts for about 1
min.
Coma: it may last for few hours.
Types
Antepartum eclampsia 50%.
Intrapartum eclampsia 25%.
Postpartum eclampsia 25% occurs within 48 hours of delivery. It is usually
the most dangerous one.
Severity of Eclampsia
Eclampsia is considered severe if one or more of the following is present (Eden’s
criteria):
Coma of 6 or more hours.
Temperature 39
0
C or more.
Pulse over 120/min.
Systolic blood pressure over 200 mmHg.
Respiratory rate over 40/min.
More than 10 convulsions.
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Differential Diagnosis:
Epilepsy.
Intracranial haemorrhage.
Hysteria.
Meningitis.
Brain tumours.
Management
General measures
Hospitalisation is mandatory.
Efficient nursing in a single quiet semi-dark room to prevent any auditory or visual
stimuli.
After sedation, a self-retained Foley’s catheter is applied. The hourly output of urine
is charted. Proteinuria, haematuria and specific gravity are noticed.
Care for respiratory system by:
› head-down tilt to help drainage of bronchial secretion,
› frequent change of patient position,
› keep upper respiratory tract clear by aspiration of mucous through a plastic
airway,
› prophylactic antibiotic and
› oxygen is administered during and after fits.
The tongue is protected from biting by a plastic mouth gauge.
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Observation for:
› Maternal:
pulse,
temperature,
blood pressure,
respiratory rate,
tendon reflexes,
urine ,
number of fits and duration of coma,
uterine contraction,
› Foetal:
FHS.
Sedation:
› Morphine 10-20 mg IM or,
› Diazepam one ampule (10mg) IV over 4 min. then maintain by IV infusion 40
mg in 500 ml glucose 5% over 12-24 hours. Diazepam is used as an
anticonvulsant as well.
Antihypertensives:
› Potent and rapidly acting drugs are used when needed.
› Examples are:
Hydralazine IV.
Diazoxide IV.
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Anticonvulsant therapy:
› Magnesium sulphate:
Action:
inhibits neuromuscular transmission,
sedation,
peripheral vasodilatation,
diuresis.
Dose: A loading dose 4 gm of 20% solution is given IV over not less than 3
minutes, followed by 1gm/hour. A total dose of 24 gm/24 hours should not be
exceeded and therapy continues during the 24 hours postpartum. The aim is to
keep the plasma level at 6-8 mEq/L. At this level tendon reflexes are still
present. They disappear at >10 mEq/L and toxic effect including respiratory
failure appears at 15 mEq/L.
Before each maintenance dose the following criteria should be checked :
knee jerk should be present ,
respiratory rate not less than 16/min. and
urine output not less than 30 ml/ hour.
Magnesium sulphate can be given by IM injection of 50% solution. Loading
dose is 6-10 gm divided on both buttocks then 4-5 gm/ 6 hours. This
regimen is not preferred due to ill control of the blood level of MgSo4 in
addition to pain and inflammation of the injection site.
The antidote: is 10 ml of 10% calcium gluconate given slowly IV.
› Phenytoin:
An anti-epileptic drug which can be used to prevent recurrence of fits not for its
termination as it acts after about 20 min.
Dose: 18 gm/kg body weight slowly IV.
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› Sodium thiopentone (Intraval):
It is a short acting general anaesthetic.
Used in emergency as frequent convulsions.
Dose: 25 mg increments IV until convulsions are controlled.
› Muscle relaxants:
usually used prior to procedures that might trigger off a convulsion as
endotracheal intubation.
› Diuretics
The policy is that there is no conservative treatment in eclampsia and the patient
should be delivered but convulsions should be controlled first.
Spontaneous labour usually commences within 6 hours. If not induce labour by
oxytocin as long as there is no other indication for caesarean section and vaginal
delivery is anticipated within 8-12 hours. Otherwise, caesarean section is indicated
but never give general anaesthesia before control of convulsions or if the patient is in
coma.
Intra-and postpartum care: as in pre-eclampsia.
Preexisting (chronic) hypertention:
Causes:
Essential hypertension: of unknown aetiology.
Secondary to chronic renal disorder: e.g.
› Glomerulonephritis.
› Hydronephrosis.
› Pyelonephritis.
› Renal artery stenosis.
Secondary to cardiovascular disease: e.g.
› Coarctation of the aorta.
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› Polyartheritis nodosa.
› Systemic lupus erythematosus.
Secondary to endocrine disorders: e.g.
› Primary aldosteronism.
› Phaeochromocytoma.
› Adrenocortical tumours.
› Diabetes mellitus.
Effect of Pregnancy on Chronic Hypertension
Blood pressure falls by the second trimester in most of cases, but rises during the
third trimester to a level some what above that in early pregnancy.
Deterioration of the underlying disease.
Effect of Chronic Hypertension on Pregnancy
Maternal:
› superimposed pre-eclampsia/ eclampsia in 15-20% of cases.
Foetal:
› Intrauterine growth retardation.
› Intrauterine foetal death.
Treatment:
General and medical treatment
As pre-eclampsia regarding the following:
Rest,
Sedatives,
Antihypertensives,
Diuretics,
Observation.
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Therapeutic abortion: in severe cases not responding to treatment.
Preterm delivery if there is:
› marked deterioration of the underlying disease.
› indication for termination as in pre-eclampsia if it is superimposed.
› intrauterine growth retardation.
Delivery at 37 completed weeks as intrauterine foetal death may result from
deteriorating placental functions.
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