Eclampsia and its management

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 ECLAMPSIA 



Definition :
"Pre-eclampsia when complicated with grand mal seizures (generalized tonic - clonic convulsion) and coma is called eclampsia "

The term eclampsia is derived from a Greek word , meaning "like a flash of lightening " 
Eclampsia occurs in patient with pre-eclampsia.

INCIDENCE :
  • Eclampsia occurs in the 10% of all pregnancy.
  • India accounts 20% of world maternal mortality rate , next to haemorrhage
  • More common in primigravida 75%
  • Eclampsia is 3rd leading cause of maternal mortality after thrombo-embolism and non obstetrical injury 
  • Eclampsia result in death in advance or uncontrollable stage 
Causes of convulsion :the causes of cerebral irritation leading to convulsion is not cleared. The irritation may be provoked by....
  1. Anoxia
  2. Cerebral edema may contribute to irritation
  3. Cerebral dysrhythmia
  4. Excessive release of excitatory neurotransmitters ( glutamate )
  5. loss of cerebrovascular autoregulation with forced dilatation and vasospasm
Onset of Fits : Fits occur more commonly in the third trimester (50%)
  1. Antepartum (50% ): fits occur before the onset of labor 
  2. Intrapartum (30%) : fits occur for the first time during labor
  3. Postpartum (20%) : fits occur for the first time in puerperium , usually within 48-72 hour of delivery. Fits occurring beyond 48 hour but less than 4 week after delivery is accepted as late postpartum eclampsia
CLINICAL FEATURES OF ECLAMPSIA :
Premonitory stage :
  • The patient becomes unconscious 
  • There is switching of the muscle of the face , tongue and limbs
  • Eyeballs roll or are turned to one side and become fixed 
  • This stage is lasts for about 30 sec
Tonic stage :
  • The whole body goes into a tonic spasm the trunk - opisthotonus , limbs are flexed and hands clenched
  • Respiration ceases and the tongue protrudes between the teeth 
  • Cyanosis appears 
  • Eyeball become fixed
  • This stage is last for 30 sec
Clonic stage :
  • All the voluntary muscle undergoes alternate contraction and relaxation 
  • The twitching starts in the face then involves one side of extremities and ultimately the whole body involved in the convulsion 
  • Biting of tongue occur
  • Breathing is stertorous and blood stained frothy secretions fill the mouth 
  • Cyanosis is gradually disappears 
  • This stage is lasts for 1-4 minutes.
Stage of comma :
  • Following the fit , the patient passes on to the stage of comma 
  • It may last for a brief period or in other deep coma persists till another convulsion 
Complication of eclampsia :
  1. Injuries
  2. pulmonary edema
  3. pneumonia
  4. acute LVF
  5. Cerebral hemorrhage
  6. Renal failure
  7. Pulmonary embolism
  8. Hyperpyrexia
  9. Hepatic necrosis
  10. Postpartum shock
  11. puerperal sepsis
  12. Disturbed vision 
  13. Psychosis
MANAGEMENT :
First aid treatment outside the hospital :
  • The patient ,either at home or in the peripheral health centers should be shifted urgently to the tertiary referral care hospital.
  • there is no place of continuing the treatment in such a place 
  • Transport of eclamptic patient to tertiary care centre is important 
  • such patient need neonatal and obstetric intensive care management
IMPORTANT STEP IN TRANSPORT OF PATIENT :
  1. All maternal records and a detailed summary should be sent with the patient 
  2. BP should be stabilize and convulsion should be arrested
  3. Magnesium sulphate is given (4 gm iv loading dose with 10 gm IM ) is given
  4. Diuretic is given if there is pulmonary edema
  5. One medical person or trained midwife should accompany the patient in ambulance equipped to prevent injury , recurrent fits and to clear air passage
Medical measure of eclampsia  IMMEDIATE measure : 
  1. Call for extra help (communication )
  2. Control of seizures : MgSO4 (IV/IM regiment )
  3. To put patient in left lateral recumbent position 
  4. Maintained oral airway
  5. O2 inhalation - non breath mask 
  6. Commence IV line , 1 or 2 wide bore canula 
  7. Foleys catheter with urometer
  8. To monitor O2 saturation 
  9. To monitors vitals ,fetal status and magnesium toxicity 
  10. Control hypertension 
  11. Fluids ; crystalloid or collides
  12. Suction : oropharyngeal
General measure ( MEDICAL AND NURSING MANAGEMENT ) :
  • Supportive care
  • Detailed history should be taken
  • Examination once the patient is stabilized
  • Monitoring : once the patient is stabilize
  • Fluid balance 
  • Antibiotics



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