Eclampsia Drill

Dr Sharda Patra( Asso. Prof) Prof Manju PuriDepartment of Obstetrics & GynecologyLady Hardinge Medical College & Smt SK Hospital New Delhi

Eclampsia Drill Eclampsia is an important

obstetric emergency which if not managed promptly can lead to life-threatening complications like cerebral haemorrhage, pulmonary edema, abruptio placentae maternal and fetal death

Any pregnant woman presenting with convulsions in later half of pregnancy should be treated as eclampsia until proved otherwise

The management of eclampsia involves

Immediate managementSubsequent management

One should remember that first few minutes following a fit are very crucial and should be handled very fast due to risk of cerebral hypoxia and aspiration which can have serious consequences.

.

Immediate management…. Principles

Speed Skills Priorities

Immediate management …..

Stabilize the woman Call for Help Remember A; B; C of resuscitationControl convulsionControl blood pressure

Initial Resuscitation Airway Place the woman on her left side to reduce the

risk of aspiration of secretions, vomit and blood

Put an airway in between the tongue and palate to prevent tongue bite and falling of tongue

Suction of the secretions is done through this airway by connecting it to a suction machine.

Give oxygen (if available15 l /min ) and continue longer if cyanosis persists

Stay with the patient to ensure that her airway is clear

Initial Resuscitation

Breathing Assess – count respiratory rate .Look, Listen, Feel. Ventilate if necessary

 Circulation Assess pulse , BP. CPR if necessary Secure intravenous access with a cannula

(16G )Send blood for BG, CBC, platelets, clotting

screen, KFT, LFT, Uric acid, Serum electrolytes Catheterize the patient to empty the bladder ,

record output and monitor output subsequentlyDo a urine examination for proteins

Treat and prevent further fits

Administer Magnesium Sulphate (MgS04)

Regimes: Pritchard or Zuspan

Loading dose Maintenance dose

4g IV 20% solution over 5 to 10min plus 10g IM (5 g 50% solution deep I/M in each buttock)

5g I/M every 4h in alternate buttock till 24 hrs after the last seizure or delivery which ever is later

Loading dose Maintenance dose

Loading dose 4g IV 20% solution over 5 to 10min

1 to 2 g / h by controlled infusion pump x 24h after the last seizure

Pritchard

Zuspan

Mg So4 :Preparation and Administration

MagSo4 available in 25%, 50% strength

Initial loading dose 14gms14gms

4gm IV 10 gms

IM

Preparation and administration

IV 4gms

Take 8amps (16ml) dilute with 4ml

saline to make it 20ml

50% amps (2ml) contains 1gm of

magso4

25% ampoules

(2ml) contains 0.5 gm magso4

20ml solution contains 4gms Magso4

( 4gm/20ml 20% Sol)

Take 4amps (8ml) dilute

with 12ml saline to make it 20ml

IV 4gm20ml is given

slow IV over 5-10mins

Keep an eye on respiratory

rate , facial flushing ,

Preparation and Administration

5gms deep IM(10ml) in

each buttock

50% amps (2ml) contains 1gm of magso4

Take 5amps (10ml)

undiluted

10gms IM

If convulsion recurs

Give 2gm IV 20% solution over 5-10mins and continue the maintenance dose

Monitoring during magnesium sulphate TherapyRespiratory rate >14/ minPresence of patellar reflexes (knee jerk)Urinary output- 25ml/hr or 100ml/4hrs

Repeat doses of magnesium sulphate must be withheld or delayed if:

The respiratory rate is less than 14 per minute

Patellar reflexes are absentUrinary output is less than 100 ml over

preceding 4 hours

Antidote:

In case of respiratory depression or arrest:

Give calcium gluconate 1 g (10 ml of 10% solution) IV slowly

Assisted ventilation using mask and bag, anesthetic apparatus or intubation

CAUTION

Magnesium sulfate should be used with caution in women with

Impaired renal function.Patients with a heart block or

myocardial damage including a history of cardiac ischaemia

Controlling blood pressureAntihypertensive drugs should be

given if the diastolic blood pressure is 110 mmHg or more.

The aim is to keep the diastolic blood pressure between 90–100 mmHg to prevent cerebral haemorrhage

Drug of choice- Labetolol, Nifedepin

Labetolol

1. 20 mg I.V over 2mins

wait for 10 mins if no response 40 mg iv

80 mg iv (can be increased upto 220 mg)

2. 10 mg IV 20 mg iv

40 mg iv

Target : 40 mg ivDecrease in diastolic BPTo 90-100 mgHg 80 mg iv

Nifedipine

10 mg tabs orally to repeat every 20 mins up to a maximum dose of 200 mg

Subsequent management Once the patient is stabilized and

fits have ceased , then a pervaginum examination is done to assess cervical status

Consider for termination of pregnancy if not in labor

Essential careTurning the woman two–hourly to

avoid hypostatic pneumoniamouth care, (no oral fluids are

given)monitor the urinary output.

Observations:

Restlessness or twitching which may herald the onset of another fit

Color is observed for cyanosis which indicates the need for oxygen

Temperature four hourly. Hyperpyrexia may occur

Pulse and respirations are recorded hourly, or more often

Blood pressure is recorded at least hourly earlier if >=160/110

Ut contractions and FHS is checked Input output is recorded accurately.

Do not leave the patient alone

Place in left lateral position

CALL FOR HELP

Airway

Breathing

Circulation

AssessMaintain patency

Give oxygen

Assess Protect Airway

Ventilate if required

Evaluate pulse and BP

Secure IV access

Observation

Pulse, BP, resp rate,

temp, urinary output, level

of consciousnessUrine proteins

Investigations

BG, CBC, platelets,

clotting screen, KFT, LFT, Uric acid, Serum electrolytes

ALGORITHM

Control of convulsio

ns

Control of Hypertensio

n

Loading dose : 4gm IV

20ml is given slow IV over 5-10mins followed by 10gms , 5gms deep IM (10ml) in each buttock

If fits recur- 2gms , 20% IVMaintenance dose- 5gms IM in alternate

buttocks 4 hourly Monitor- Resp rate>16

Presence of Knee jerk Urinary output >25ml/1hr

If Mag toxicity- Inj Calcium Gluconate , 10% 10ml , 10mins IV

Labetolol 10mg IV , give 20mg IV if noresponse after

10mins, then 40mg, 40mg, 80mg max 220mgNifedipine

10mg orally , repeat after 20mins if noresponse , max 200 mg, target BP- dbp-90-100 mmHg

Delivery

A DRILL …….. Eclampsia The need for good clinical skills to be

able to recognize and act promptlyBe in control of the situation Need to care for the family, who will

be extremely distressed to see the woman have a fit;

Need for gentleness, so as not to harm the woman if she is unconscious, or stimulate further fits;

Need to respect the woman’s dignity at all times;

Need for strict attention

Thanks