MANAGEMENT OF MANAGEMENT OF ECLAMPSIAECLAMPSIA

DR. OKAGUADR. OKAGUA

LEVELS OF PREVENTIONLEVELS OF PREVENTION

Pre-conception carePre-conception care

Prediction of those at riskPrediction of those at risk

Preventive measures for those at riskPreventive measures for those at risk

Early diagnosis/appropriate management Early diagnosis/appropriate management of pre-eclampsia of pre-eclampsia

PRE-CONCEPTION CAREPRE-CONCEPTION CARE

Advice early antenatal careAdvice early antenatal care

Pre-pregnancy hypertension controlPre-pregnancy hypertension control

Pre-pregnancy diabetic controlPre-pregnancy diabetic control

Good nutrition for those at riskGood nutrition for those at risk

PREDICTION PREDICTION Family/Personal HistoryFamily/Personal History→ DM, HT, PE→ DM, HT, PE

Age/ParityAge/Parity

Multiple pregnancy Multiple pregnancy

Roll-over testRoll-over test

Uterine artery Doppler waveformsUterine artery Doppler waveforms

Angiotensin infusion testAngiotensin infusion test

Urine Kallikrein to Creatinine ratioUrine Kallikrein to Creatinine ratio

Plasma FibronectinPlasma Fibronectin

Serum inhibinSerum inhibin

Serum UrateSerum Urate

PREDICTION (cont.)PREDICTION (cont.)

Urinary calciumUrinary calcium

Serum AFP/hCGSerum AFP/hCG

HaematocritHaematocrit

Antithrombin IIIAntithrombin III

Plasminogen activator inhibitors (1&2)Plasminogen activator inhibitors (1&2)

INTERVENTIONS TO INTERVENTIONS TO PREVENT PEPREVENT PE

CalciumCalcium

AspirinAspirin

MagnesiumMagnesium

Fish oilsFish oils

Anti-hypertensive drugsAnti-hypertensive drugs

EARLY DIAGNOSIS OF PEEARLY DIAGNOSIS OF PE

Good antenatal careGood antenatal careEarly bookingEarly bookingRoutine BP, Urine Protein, Weight checksRoutine BP, Urine Protein, Weight checks

Early recognition of Pre-eclampsia & Early recognition of Pre-eclampsia & appropriate management of severe Pre-appropriate management of severe Pre-eclampsiaeclampsia

FEATURES OF IMPENDING FEATURES OF IMPENDING ECLAMPSIAECLAMPSIA

Epigastric pain Epigastric pain → right hypogastric → right hypogastric tenderness tenderness Headache → Papilloedema on FundoscopyHeadache → Papilloedema on FundoscopyVisual symptomsVisual symptomsNausea/vomitingNausea/vomitingHyperreflexia, excessive clonus, twitching Hyperreflexia, excessive clonus, twitching and/or tremorand/or tremor

Benefit from prophylactic Benefit from prophylactic anticonvulsants especially in presence of anticonvulsants especially in presence of diastolic BP ≥ 110mmHg and Proteinuria ≥ 2+diastolic BP ≥ 110mmHg and Proteinuria ≥ 2+

DIAGNOSTICDIAGNOSTICCLINICAL CRITERIACLINICAL CRITERIA

Usually occurs between 20wks gestation and 10 Usually occurs between 20wks gestation and 10 days post-partumdays post-partum

Any fit which does not appear to be of epileptic Any fit which does not appear to be of epileptic origin, metabolic or other known causes should origin, metabolic or other known causes should be classified as eclamptic convulsionbe classified as eclamptic convulsion

The convulsions should have features of grand The convulsions should have features of grand mal convulsions including aura, tonic and clonic mal convulsions including aura, tonic and clonic movements, involuntary activity and a post-ictal movements, involuntary activity and a post-ictal statestate

BRITISH ECLAMPSIA SURVEY BRITISH ECLAMPSIA SURVEY TEAM (BEST)TEAM (BEST)

Defined eclampsia using the above clinical Defined eclampsia using the above clinical criteria with at least 2 of the followingcriteria with at least 2 of the following HypertensionHypertension Proteinuria Proteinuria ThrombocytopeniaThrombocytopenia Liver enzyme elevationLiver enzyme elevation

PRINCIPLES OF PRINCIPLES OF MANAGEMENTMANAGEMENT

Ensure ventilation and correction of Ensure ventilation and correction of hypoxia/ fluid/electrolyte derangementhypoxia/ fluid/electrolyte derangement

Control/prevent convulsionsControl/prevent convulsions

Control blood pressureControl blood pressure

Expeditious delivery of the fetus & Expeditious delivery of the fetus & placenta (for antepartum/ intrapartum placenta (for antepartum/ intrapartum eclampsia)eclampsia)

ANTI-CONVULSANTS ANTI-CONVULSANTS

Magnesium Sulphate: Magnesium Sulphate: better seizure better seizure control, no sedation, no significant neonatal control, no sedation, no significant neonatal effect, cheap?effect, cheap?

DiazepamDiazepam

Lytic Cocktail Lytic Cocktail

PhenytoinPhenytoin

ParaldehydeParaldehyde

Sodium AminobarbitoneSodium Aminobarbitone

BrometholBromethol

MAGNESIUM SULPHATE MAGNESIUM SULPHATE ADMINISTRATIONADMINISTRATION

Intravenous or intramuscular regimenIntravenous or intramuscular regimenIntramuscular regimen used in this Intramuscular regimen used in this centrecentre

→→ Loading dose of 14gLoading dose of 14g →→ Maintenance dose of 5g 4hrly for Maintenance dose of 5g 4hrly for

24hrs 24hrs after after last fit, provided,last fit, provided,

Respiratory rate > 16/minRespiratory rate > 16/minKnee jerk presentKnee jerk presentUrine output > 100mls in last 4 hrsUrine output > 100mls in last 4 hrs

BLOOD PRESSURE CONTROLBLOOD PRESSURE CONTROL

HydrallazineHydrallazine

Nifedipine (sublingual)Nifedipine (sublingual)

LabetalolLabetalol

Sodium nitroprussideSodium nitroprusside

NitroglycerineNitroglycerine

Monitor BP ¼ hrly then ½ hrly when stableMonitor BP ¼ hrly then ½ hrly when stable

GENERAL CAREGENERAL CARE

Resuscitate with cautious correction of Resuscitate with cautious correction of fluid & electrolyte imbalancefluid & electrolyte imbalance

Maintain strict imput/output chartMaintain strict imput/output chart

Maintain airwayMaintain airway

Nurse semi-proneNurse semi-prone

Give oxygenGive oxygen

Patient must be stable before attempts Patient must be stable before attempts at delivery at delivery

DELIVERYDELIVERYMode of delivery will depend on maternal Mode of delivery will depend on maternal status and fetal viabilitystatus and fetal viability

Vaginal delivery preferred were feasibleVaginal delivery preferred were feasible

Continuous FHR monitoringContinuous FHR monitoring

Avoid prolonged laborAvoid prolonged labor

Assisted second stageAssisted second stage

Active management of 3Active management of 3rdrd stage (No stage (No ergometrine)ergometrine)

replace blood loss, volume for volumereplace blood loss, volume for volume

INDICATIONS FOR CESAREAN INDICATIONS FOR CESAREAN SECTIONSECTION

All deeply unconscious patients (unless All deeply unconscious patients (unless delivery is imminent)delivery is imminent)All unco-operative patients due to All unco-operative patients due to restlessnessrestlessnessIf vaginal delivery is unlikely in 6-8hrs from If vaginal delivery is unlikely in 6-8hrs from the 1the 1stst eclamptic seizure eclamptic seizureThere is obstetric indication for C/S There is obstetric indication for C/S including fetal distressincluding fetal distress

POST-NATAL CAREPOST-NATAL CARENurse in intensive care unit for 24-48hrsNurse in intensive care unit for 24-48hrsStop anticonvulsants after 24hrs fit freeStop anticonvulsants after 24hrs fit freeOliguric patients unresponsive to fluid challenge will Oliguric patients unresponsive to fluid challenge will benefit from low dose Dopamine benefit from low dose Dopamine Continue IV antihypertensives & change to oral Continue IV antihypertensives & change to oral when oral intake commenced then tail offwhen oral intake commenced then tail offCounsel about risk of recurrence; advice on Counsel about risk of recurrence; advice on contraception and early booking before dischargecontraception and early booking before dischargeThose with persistent hypertension on discharge Those with persistent hypertension on discharge should be seen weekly and referred to the should be seen weekly and referred to the physicians after 6 weeks for full work-up physicians after 6 weeks for full work-up Long term follow-up for neurological assessmentLong term follow-up for neurological assessment..

COMPLICATIONSCOMPLICATIONSMATERNALMATERNAL

Severe bleeding from abruptio placenta withSevere bleeding from abruptio placenta with its resultant coagulopathyits resultant coagulopathyPulmonary oedemaPulmonary oedemaAspiration pneumoniaAspiration pneumoniaAcute renal failureAcute renal failureCerebrovascular haemorrhageCerebrovascular haemorrhageLiver ruptureLiver ruptureRetinal detachmentRetinal detachmentIncreased operative deliveryIncreased operative deliveryMaternal deathMaternal death

COMPLICATIONSCOMPLICATIONS

FETALFETAL

PrematurityPrematurity

Birth asphyxiaBirth asphyxia

↑↑ MTCT of HIV 1 due to depletion of MTCT of HIV 1 due to depletion of vitamin Avitamin A

Fetal wastageFetal wastage

CONCLUSIONCONCLUSIONEvidence from developed and developing Evidence from developed and developing countries suggest that of the 3 major causes countries suggest that of the 3 major causes of maternal mortality, death from hypertensive of maternal mortality, death from hypertensive disorders of pregnancy are the most difficult to disorders of pregnancy are the most difficult to prevent (Duley, 1992)prevent (Duley, 1992)

However with effective implementation of the However with effective implementation of the above prevention strategies and appropriate above prevention strategies and appropriate treatment based on the best available treatment based on the best available evidence, we can continue the march towards evidence, we can continue the march towards a zero maternal mortality for the benefit of our a zero maternal mortality for the benefit of our mothers, our babies and the nation.mothers, our babies and the nation.

THANK YOUTHANK YOU