eclamptics in labour by dr. shrinivas gadappa
TRANSCRIPT
“To my Hypertensive's & Eclamptics , I pledge my devotions.In their good outcome& wellbeing alone,lies my happiness.” Dr. Shrinivas Gadappa Professor & HOD Government Medical College & Hospital, Aurangabad.
Monitoring & management of Eclampsia
Dr. Shrinivas Gadappa Professor & HOD,
Government Medical College & Hospital, Aurangabad.
OBJECTIVES• Magnesium sulphate protocol• Antihypertensive• Obstetric Management• Induction & Augmentation agents• Intrapartum monitoring• Postpartum care• Summary
HYPERTENSION CLINIC
WHO SHOULD MANAGE HDP
Monitoring Targets in Pre-Eclampsia.....
HISTORY WITH HIGH RISK CONSENT• Detailed history with
high risk consent is to be taken from relatives regarding
- duration of pregnancy
- number of convulsions
- nature of medication received outside
Monitoring• Maternal• Fetal• Progress of labour• Complications• Supportive speciality• Stage 4• Puerperium
Be ready with ECLAMPSIA TOOL KIT
GENERAL EXAMINATION
• Check Pulse , BP , RR
• Use Pulseoximeter.
Examination•Once patient is stabilised
quick general , abdominal and vaginal examination is done.
•Restrict use of IV fluid
THREE steps in management
- Treat convulsion and Prevent further episode of convulsion
- Control of Hypertension
- Obstetric intervention
Antihypertensive
LABETALOL
Selective α1 receptor blockade
Nonselective ß receptor blockade
Target BP range
• SBP 140-150 mm Of Hg • DBP 95-105 mm Of Hg
MAGNESIUM SULPHATE is
Gold Standard.
Various regimens have been described for magnesium sulphate
administration in eclamptics but most commonly used one is PRITCHARD’S
REGIMEN.
INTRAVENOUS INTRAMUSCULAR
• IM dose is given in upper outer quadrant of buttock with 20 gauge 3 inch needle and 12 cc syringe.
• It is available as 50% w/v, so total loading dose is 20ml ( 10 gm), 5grams in each buttock
•MgSo4 is available as 2ml ampoule(50% w/v).
4gm (8ml) of MgS04 in 100 ml of NS over 10 min.
MgSO4 Loading dose
REGIMENS OF MgSO4 FOR MAINTENANCE
PRITCHARD’S REGIMEN ZUSPAN AND SIBAI REGIMEN
• 5 gm (10ml of 50%) given deep IM in alternate buttock every 4 hourly
• 1-2 gm/hr as IV infusion .
MgSO4 is to be continued till 24hrs of delivery or last episode of convulsion; Whichever is later.
Guidelines for magnesium sulphate administration
Monitoring for magnesium toxicity
• Uine output >30 ml /hr• DTR present• RR > 14 breaths /min.• Pulse oximetry > 96%
RECURRENCE OF CONVULSIONS Within 20 mins of loading dose
Recurrence more than twice
Wait & watchwith the supportive care
Switch over to Phenytoin 10mg/kg in 100ml NS IV over 1/2hour maintenance dose 100mg IV8hrly
After 20 mins of loading dose/while on
maintenance dose
Give 2 gm in 20%of IV MgSO4 over5mins; continue withscheduled dose .
STATUS ECLAMPTICUS : IV Thiopentone sodium given by ANAESTHETIST and intubate patient
Key Message
Key Message
Modified Obstetric Early Warning System (MEOWS)
Preeclampsia Early Recognition Tool
(PERT)
Modified Obstetric Early Warning System (MEOWS)Preeclampsia Early Recognition Tool (PERT)
Monitoring of Non severe PE
Monitoring of Severe PE
Monitoring of Post Eclamptics seizure &Toxicity of drug
Eclampsia - radiographic evaluation• should be reserved for women with
neurological deficit, recurrent seizures, or atypical presentation
• abnormal CT findings - 50%• edema, hemorrhage, infarction
• cerebral angiography has limited use• 90% of EEG evaluations may be
abnormal
INVESTIGATIONS
Indications of Central Venous Catheterization
• Central venous pressure monitoring• Volume resuscitation• Cardiac arrest• Lack of peripheral access• Infusion of hyperalimentation• Infusion of concentrated solutions• Placement of transvenous pacemaker• Cardiac catheterization, pulmonary angiography• Hemodialysis
OBSTERIC MANAGEMENTEclampsia
• Delivery is indicated regardless of gestational age
• Immediate cesarean delivery is not necessary
MATERNAL AND FOETAL OUTCOME IN ECLAMPSIA
• Study location – GMCH ABAD
• Total no of ECLAMPSIA- 335
• Study duration – 2013- 2015
Govt. Medical College & Hospital, Aurangabad (MS)
Distribution on the basis of the mode of delivery in eclampsia patients
Cut short second stage of labour with help of vacuum/ forceps as per requirement.
Second Stage
Onset- delivery Interval
• In severe pre-Eclampsia, delivery should occur within 24 hours of the onset of symptoms.
• In Eclampsia, delivery should occur within 12 hours of the onset of convulsions.
Eclampsia - management of fetus
– fetal bradycardia during seizure • ~ 5 minutes after the onset of the seizure• may be associated with rebound tachycardia• recovery phase may show late decelerations
– monitor for uterine hypertonicity• allow for fetal recovery• monitor for signs of abruption
• This system provides accurate continuous measurements of dilatation and station.
• The method is superior to digital examination and provides real time diagnosis of non-progressive and precipitous labor.
• The system is likely to reduce discomfort and infections associated to multiple vaginal examinations..
COMPUTERIZED LABOR MANAGEMENT
The Fetal Monitoring System is a computer based training system that can be
accessed over the anywhere, anytime, from within a hospital or from a home.
fetal monitoring by CTG.
H D U
In first stage of labour:–Use partograph
e-Partograph
If caesarean section is performed
ensure that:• Coagulopathy has been ruled out;• Safe general anesthesia is available.
Spinal anesthesia is associated with the risk of hypotension..
• Epidural is safer• Do not use local anesthesia or ketamine
AVOID POOR JUDGEMENT
Judgment comes from experienceExperience comes from poor
judgment
Anticipate PPH and PPH prophylaxis is to be given.
Preferably use 2 uterotonics (oxytocin + misoprostol).
Methargin is contraindicated.
PPH - BOXPPH - BOX
GOOD OUTCOME
SUCCESS
NOT YET OVER
•Postpartum care is the second half.
In an Eclamptics movie , delivery is the interval
Fourth stage of labour Intense monitoring of vitals and per vaginal bleeding every 15 min for 1 hour and then every half hourly for the next hour.
(WHO guidelines 2015)
Post Partum Care.
• Kept under close observation.
• MgSO4 infusion continued for prophylaxis.
Careful fluid balance
• Decrease dose of antihypertensive with caution
• 2 weeks therapy of AHT
• FOLLOW UP……….MUST
Fluids should be restricted to 75ml/hr. & AHT
Strict monitoring continued…..
Smoking is injurious to health
Four steps - Treat convulsion and Prevent further episode of convulsion- Control of Hypertension- Obstetric intervention- Post partum care
Possible only after monitoring
Take Home Message
God help those who help themselves
THANK YOU• Sibai BM. Hypertensive disorders in women. 2001.
• Witlin AG, Sibai BM. Magnesium sulfate therapy in preeclampsia and eclampsia. Obstet Gynecol 1998;92:883-9.
• Sibai BM. Diagnosis and management of gestational hypertension and preeclampsia. Obstet Gynecol 2003;102:181-92.
• Sibai BM. Diagnosis, prevention, and management of eclampsia. Obstet Gynecol 2005;105:402-10.
• To my Hypertensive's and to my people I pledge my devotions, in their well being alone lies my happiness
Dr. Shrinivas Gadappa Professor & HOD Government Medical College & Hospital, Aurangabad