History
23yrs/F non-diabetic, non-hypertensive, non-smoker, non-alcoholic primigravida was admitted to Obstetric ward on with the chief complaints of:
- Cessation of menstruation X 9 months
- Decreased fetal movement X 6 hours
LMP | 2072/04/12 |
EDD | 2073/01/19 |
GA | 41 WOG |
Examination
General condition | Fair |
Pallor | Absent |
Icterus | Absent |
Edema | B/L pitting – pedal |
BP | 120/90 mmHg |
Pulse | 90/min |
Per Abdomen | |
Uterus | Term size |
Lie | Longitudinal |
Presentation | Cephalic |
Head | 5/5 palpable |
FHS | +; 140/min |
Per Vaginal Examination | |
Cervical os | 3 cm |
Effacement | 50% |
Fetal head station | -3 |
Membrane | Present |
Show | Present |
Provisional Diagnosis: Primigravida at 41 WOG in Latent Phase of Labor
- All ANC investigations were normal.
- ARM was done, which showed moderately meconium stained liquor.
- Patient was shifted to OT for Em. LSCS for fetal distress and Em. LSCS was done.
OT findings | |
LUS | Well formed |
Liquor | Moderately meconium stained; adequate |
Presentation | Cephalic |
Placenta | Fundo-posterior |
Tubes & ovaries | B/L normal |
Outcome |
Single, Alive, Term, Male baby with birth weight of 3.2 Kg at 2:16 PM on 2073/1/26 with cord around neck (once; loose) with APGAR Score 8/10 and 9/10 |
Post-op BP | 200/110 mmHg |
Total Blood Loss | 400 ml |
Postoperative Period
- On the day of operation – patient developed GTCS lasting ~30 seconds with BP: 200/120 mmHg; Pulse: 120/min and SpO2: 83%
- Management:
- Patient was placed in left lateral position and Oxygen was given
- Inj. MgSO4 loading dose stat
- Inj. Lorazepam 4 mg iv stat
- Inj. Lasix 20 mg iv stat
- Patient was shifted to ICU
- Patient was kept NPO and IV fluids were given
- Foley’s catheter was insitu
- PIH investigations were sent urgently
- Diagnosed with postpartum eclampsia
Results of PIH investigations
- Uric acid – 5.4 mg/dl (raised)
- LDH – 847
- Urine albumin – Nil
- 24 hour urine protein – 324 mg/24 hour (raised)
- Hb, Platelets, BT/CT, RFT, LFT and Urine R/E were within normal limits
In ICU
- Patient received maintenance dose of MgSO4 every 4 hourly for 24 hours following the seizure (5 doses) as per Pritchard regimen
- Blood pressure, Pulse rate, Respiratory rate, Urine output and Patellar reflex were monitored hourly
- BP range: 120-150/70-90 mmHg
- Pulse rate: 82-120/min
- Respiratory rate: 15-22/min
- Urine output: 50-300 ml/hr
- Patellar reflex: Present
- Patient received Tab. Nifedipine 10 mg PO stat at 6 PM
In Subsequent Postoperative Days
- No further episodes of seizure
- GCS was 15/15; BP ranged from 130-150/70-80 mmHg
- Other vital signs were also stable
- Chest, CVS and CNS examination were normal
- Urine output was maintained
- Involution of uterus was normal
- Patient was transferred out of ICU after 2 days
Discharge
- Patient was discharged on 5th postoperative day
- BP at the time of discharge: 100-130/70-90 mmHg
- Patient was discharged on:
- Antihypertensive: Tab. Depin Retard 20 mg PO BD for 7 days
- Oral antibiotics
- Analgesic and H2 blocker
- Iron and Calcium
- Patient was advised to follow up after 1 week/SOS
Review of Pre-eclampsia and Eclampsia
- Hypertensive Disorders in Pregnancy
- Pritchard Regimen for Magnesium Sulfate
- Approach to hypertensive disorder in pregnancy
![eclamptic fits](https://epomedicine.com/wp-content/uploads/2016/06/nepal-eclampsia.jpg)
Lets revisit the management of Eclampsia in detaile here:
Screening for PIH
- Roll-over test: Rise of DBP by 20 mmHg or more after turning from left lateral to dorsal position
- Hand-grip test: Rise of DBP by 20 mmHg or more at 28-32 WOG after compressing inflated sphygmomanometer for 3 minutes
- Forearm venous tone: Increased tone atleast 6 weeks before diagnosis of PIH (requires sophisticated equipment)
- Urine assays: Micro-albuminuria, lower 24 hr urinary Ca++ excretion, reduced kallikrein/creatinine ratio, increased PG metabolites
- Blood tests: Increased plasma urate, reduced platelet count, reduced anti-thrombin III activity 1
6 Stages of Management of Eclampsia
- Making sure the airways are clear and the woman can breathe
- Controlling the fits
- Controlling the Blood Pressure
- General care and monitoring, including controlling fluid balance
- Delivering the baby
- Monitoring carefully to prevent further fits and identify complications 2
Making sure the woman can breathe
Left lateral position
Oxygen (if available)
- Continue for 5 minutes after each fits
- Or longer if cyanosis persists
Aspirate mouth and throat after convulsion
Stay with woman and ensure her airway is clear
Controlling the fits
Anticonvulsant of choice:
- Magnesium sulfate
- Diazepam (if Magnesium sulfate unavailable)
Diazepam:
Diazepam can cross the placenta and cause neonatal respiratory depression, difficulties with feeding and in maintaining body temperature. Do not give more than 100mg of diazepam in 24 hours.
- Loading dose:
- 10mg IV slowly over 2 minutes
- If convulsions recur: repeat the loading dose
- Maintenance dose:
- 40mg in 500ml IV RL/NS
- Titrate to sedation but arousable
- Complication:
- Maternal depression may occur when >30mg in 1 hour
- Can be given PR:
- Give 20mg in a 10ml syringe → Remove needle → Lubricate barrel → Insert syringe into rectum to ½ the length → Discharge the contents and leave syringe in place → Hold buttocks together for 10 mins to prevent expulsion of contents
Collaborative trial for Eclampsia
- International multi-center Eclampsia trial in 1680 eclamptics
- Magnesium sulfate was found to be superior than Diazepam and Phenytoin
- Fewer recurrent convulsion: 5.7%
- 27.9% for Diazepam
- 17.1% for Phenytoin
- Fewer maternal death: 2.6%
- 5.1% for Diazepam
- 5.2% for Phenytoin 3
Magpie trial
- Prospective RCT conducted at 175 hospitals in 33 countries
- Originally included 8804 women with pre-eclampsia randomized to Magnesium sulfate or placebo
- Concluded the beneficial role of Magnesium sulfate:
- 58% lower relative risk of eclampsia
- 45% lower relative risk of maternal mortality
- Significantly lower risk of placental abruption (2% vs 3.2% with placebo)
Controlling the Blood Pressure
- Indication of antihypertensives: DBP ≥110 mmHg
- Aim: DBP 90-100 mmHg (to prevent cerebral hemorrhage)
- Drug of choice: Hydralazine
- 5 mg IV slowly every 5 min until BP ↓
- Repeat hourly as needed OR give 12.5 mg IM 2 hrly as needed
- Alternative: Labetalol 10 mg IV
- Dose can be doubled every 10 min upto 80 mg (10→20→40→80) until BP ↓
General Care
- Minimum external stimulus (noise, bright lights, handling)
- Never left alone
- Anesthetic instruments, suction apparatus & O2 equipment – at bedside
- Turn the patient 2 hrly – to prevent hypostatic pneumonia
- Mouth care (No oral fluids given)
- Urinary catheterization and monitoring of urinary output
Monitoring
- Restlessness or twitching – may precede another fit
- Color for cyanosis – indicates need for oxygen
- Temperature 4 hrly – hyperpyrexia may occur
- Pulse and respiration hourly or more often
- Blood Pressure atleast hourly
- Fetal heart rate hourly
- Signs of labor
- Fluid balance is recorded accurately
Delivering the baby
- As soon as condition stabilized:
- Within 24 hours from symptom onset in severe pre-eclampsia
- Within 12 hours from convulsion in eclampsia
- Indication of CS:
- Unfavorable cervix
- FHR abnormalities (<100 bpm or >180 bpm)
- If Vaginal delivery is not anticipated within 12 hrs of eclampsia and 24 hrs of severe pre-eclampsia
Care after the delivery
- Fits can:
- Occur for the 1st time after delivery, within the 1st 48 hours
- Recur after delivery
- Continue:
- Careful observation for ≥ 48 hours
- Anticonvulsant for 24 hours after delivery or last convulsion (that occur last)
- Monitoring urinary output (tendency to retain fluid and increase BP)
- Shift to main ward (with 4 hrly BP checks) if after 48 hours:
- No fits
- Good urinary output
- DBP <110 mmHg
Counselling
- Greater risk of having underlying medical condition
- 20-40% develop chronic hypertension – close f/u necessary
- Reccurence:
- 65% if pre-eclampsia develops in midtrimester
- 20% if pre-eclampsia develops at term
- 3% reccurence of HELLP
- 1-2% reccurence for eclampsia 4
Calcium supplementation to prevent PIH
- Randomised trials comparing at least 1 g of calcium daily during pregnancy with placebo
- Twelve studies (15,528 women) were included
- 30% reduction in the risk of gestational hypertension
- 20% reduction in maternal mortality and morbidity
- Low calcium intake may cause high BP by stimulating either:
- Parathyroid hormone or
- Renin release, thereby increasing intracellular calcium in vascular smooth muscle and leading to vasoconstriction
![dr. sulabh kumar shrestha](https://epomedicine.com/wp-content/uploads/2020/07/profile.jpg)
He is the section editor of Orthopedics in Epomedicine. He searches for and share simpler ways to make complicated medical topics simple. He also loves writing poetry, listening and playing music.