Management of eclampsia by nursing staff

ABSTRACT
The research on the topic “Evaluation of staff nurses regarding the management of eclampsiaat
the Laquintinie hospital. The objective of this studywas to assess the knowledge of staff nurses
regarding management of eclampsia at the Laquintinie hospitals, from the period of August to
September 2014, by knowledge score.The aim of the study was to contribute to the improvement
of nurse’s knowledge and practice in the management of eclampsia so as to reduce the majority
of maternal and foetal deaths due to eclampsia.Theeclamptic period is the period in which there
is high blood pressure during pregnancy, systolic pressure > or = to 144mm and diastolic blood
pressure > or = 90mmHg, characterized by elevated blood pressure, protein in urine. The study
population was 50 nurses working at the maternity unit of the laquintiniehospital. Eclampsia is
an unpredictable multi organ disorder, unique to human pregnancy. It is associated with
significant maternal and fetal morbidity and mortality. World-wide treatment of this disorder
remains a challenge. Even to the most experienced obstetrician, mainly because of the exact
etiology is not known.

A self developed questionnaire was used to elicit responses from 50 midwifery nurses, at
the maternity ward during the period of research. Research design of the study was qualitative,
descriptive and cross-sectional survey design.

The main findings were: the overall knowledge score of staff nurses on management of
eclampsia is very high (74.4%), regarding independent score on various areas of analysis,
nursing management has got highest score (89.1%).Health personnel especially the nurses
midwife, play important role in early detection of high risk factors of eclampsia.Management of
antennal mother with eclampsia for which midwife require adequate knowledge. Data
waspresented using frequency tables and charts.

KEYWORDS: Eclampsia, Hypertension, morbidity, mortality, nursing management

 INTRODUCTOIN

1.1. BACKGROUND
Pregnancy is being most precious period in every woman’s life. It needs continuous care
for safe confinement, early detection of difficulties and prompt treatment in an appropriate
period. Women in general and also during pregnancy stage are vulnerable segment of the
population.Eclampsia refers to the onset of convulsions in a woman with
preeclampsia that cannot be attributed to other causes. The seizures are generalized and may
appear before, during, or after labour . It is a serious manifestation that is associated with
increased risk of mortality and morbidity in the pregnant women and poor perinatal outcomes.
Eclampsia is a medical condition in which hypertension arises in pregnancy (pregnancy induced
hypertension), in association with significant amount of protein in urine (Sibaiet al., 2005).
The incidence of eclampsia in hospital practice varies widely from 5-15%,
primigravidae is about 10% and in multigravidae 5% . In developing countries, the incidence is
expected to be higher; comparative low figures are reported in the hospital
statistics due toinclusion of only severe degrees of the syndrome, the minor being
ignored.Eclampsia is a major cause of poor pregnancy outcome, including maternal and fetal
mortality and severe obstetric morbidity (Lind et al., 2009).Eclampsia occurs more frequently in
young prime gravid. It is more common in mothers over -35 years of age and multiple
pregnancies with diabetics and obese mothers. It is equally common in women, from low socio-
economic group who are not likely to have received adequate antenatal care.
Both mother and foetus are adversely affected by maternal hypertension. eclampsia is
recognized as the death in which requires the united efforts of all members of the health care
team in close collaboration with other than medical personal eclampsia is a condition in which
the pregnant woman presents an elevated blood pressure during pregnancy or puerperium as
defined in 1986 by the American College of Obstetricians and Gynecologists and adopted by the
World Health Organization (WHO) .
 Eclampsia still account for 20 percentages of maternal deaths World–wide. The current
annual World–wide mortality can be estimated to be about 1, 50,000 women. Sub- standard care
also adds to the maternal mortality. Farookrecorded a 20-24 percentage maternal mortality due
to eclampsia, while Hashmi reported eclampsia mortality to be 9 percentages over a five year
period. Bashir et al reported a prevalence of Eclampsia of 1.2 percentages and maternal
mortality from eclampsia to be 8.35 to 10.3 percentages during 1991- 93 in Russia.
The incidence of Eclampsia is commonly cited to be about 5 percentage, although remarkable
variations are reported. The incidence is influenced by parity. It is related to racial, and thus, to
genetic predisposition and environmental factors may also have a role. Incidence of Eclampsia is
approximately 1 in 1500 pregnancies. Of this about 50 percentages occurs in the antenatal
period, 30 percentages occurs during the intra partum period and 20 percentages takes place
within the first few hours after delivery. Deaths due to eclampsia occur because of cerebral
hemorrhage and adult respiratory distress syndrome. Maternal Mortality due to eclampsia varies
between 2-30 percentages and is much higher in rural areas. Eclampsia is the most common
hypertensive disorder during pregnancy affecting an estimated 10-15% of pregnant women in
Cameroon and 5-8% of pregnant women in the united state of America, about 70% of which are
first time-pregnancies (Lansacet al., 1990). In 1998, more than 146,320 cases of eclampsia alone
were diagnosed.
According to WHO, 8-10 percent of this hypertensive disorder during pregnancy is a
great health problem worldwide? In black Africa, the prevalence of preeclampsia rises to
about 25% and 50 % worldwide, all of these increase in percentages, calls for strict attention to
this pathology. According to Noreset al., high blood pressure during pregnancy is a topical issue
which has to be followed up closely and attentively, because eclampsia can be devastating and
life threatening for both mother and baby (Shireen, 2004),
I.2. PROBLEM STATEMENT

Eclampsia has been documented as the period from 20 week gestation, third trimester of
pregnancy and even six weeks post partum. It is known to be a very delicate period for the
mother and fetus, the midwives are aware of the dangers that exist in this pathology and are
taking great care to follow up the situation in order to avoid complications. Despite the attention
given to this pathology, it still remains a greater cause of preterm births and even neonatal and
maternal death. That is why knowing how nurses manage this condition was considered
necessary, because it can help pregnant women to attend their antenatal visits and take advice on
how to prevent this pathology if not present or take medications to control the situation, if
present.

OPERATIONAL DEFINITION OF TERMS

1. Gestational hypertension: Gestational hypertension is usually defined as having a

bloodpressure higher than 140/90 measured on two separate occasions, more than 6 hours
apart, without the presence of protein in the urine and diagnosed after 20 weeks of gestation.
2. Preeclampsia: Pre-eclampsia is gestational hypertension plus proteinuria (>300 mg of
protein in a 24-hour urine sample). Severe preeclampsia involves a blood pressure greater
than 160/110, with additional medical signs and symptoms.
3. Eclampsia: This is when tonic-clonic seizures appear in a pregnant woman with high blood
pressure and proteinuria.
4. HELLP syndrome: This is a dangerous combination of three medical conditions:
hemolytic anemia, elevated liver enzymes and low platelet count.
5. Hypertention: Hypertension is defined as either: A systolic pressure consistently at 140 or
higher or a diastolic pressure consistently at 90 or higher.

Nurses and midwives in the maternity unit are those who practically manage pregnant women
with eclampsia, therefore they are the main actors in stopping complications of this condition.
Eclampsia has been documented to occur as from 20weekofgestation, third trimester of
pregnancy and even six weeks post partum. The period is known to be a very delicate for the
mother and foetus. Despite the attention given to this pathology, it still remains a greater cause of
preterm births and even neonatal and maternal death. That is why knowing the nurses’knowledge
and practice in the management of this condition was considered necessary, because it would
help nurses to improve their knowledge and practice in the management of womensuffering from
eclapmsia so as to reduce the majority of deaths due to eclampsiathatcan be avoidable through
the provision of timely and effective care to the women presenting with this complication.

1.3. SIGNIFICANCE OF THE STUDY

The study wouldidentifyvarious obstacles faced by nurses in the managementofwomen with

eclampsia.The study would come up with practicable recommendations for nurses, other health
personnel’s and the government for appropriate strategies to improve the quality of care for
women suffering from eclampsia.

1.4. RATIONALE

The aim of the study was to contribute tothe improvement of nurse’s knowledge and
practice in the management of eclampsia so as to reduce the majority of maternal and foetal
deaths due to eclampsia can be avoidable through the provision of timely and effective care to
the women presenting with this complication.

1.5. RESEARCH QUESTION

Do nurses have adequate knowledge on the management of eclampsia?

1.6. HYPOTHESIS

1.4.1 Null hypothesis: Nursesdo not have adequate knowledge on the management of eclampsia

1.4.2 Alternative hypothesis: Nurses have adequate knowledge on the management of

eclampsia.

1.7. RESEARCH OBJECTIVES

1.7.1. General objective

To assess the knowledgeand practice of s nurses inthe management of eclampsia

1.8.2. Specific objectives

1) To identify study participants with respects to age, professional experience

2) To assess nurses’ knowledge oneclampsia
3) Toevaluate nurses practice in the management of eclampsia
 LITERATURE REVIEW

2.0 INTRODUCTION

Eclampsia is the most dangerous pregnancy complication, it may affect both mother and
the unborn child (Drife, 1775).develops after 20 weeks gestation or six week post partum, it’s a
condition in which there is less oxygen travelling through the placenta, thus putting the fetus and
mother’s health in danger(Lind, 2009). Eclampsia, in which the pregnant woman enters into fits
and complicates pregnancy.

An experimental study by KUMARI (1992) revealed that the self instruction model on
selected self care activities by nurses considerably enhanced the knowledge ofprimi gravid
women with eclampsia to practice selected self care activities (SSCA). Eclampsiawhich includes
both gestational hypertension, is a common and morbid pregnancy complication for which the
pathogenesis remains unclear. Emerging evidence suggests that insulin resistance, which has
been linked to essential hypertension, may play a role in eclampsia. Hypertension is the most
common medical disorder encountered during pregnancy. Hypertensive disorders are one of the
major causes of pregnancy-related maternal deaths in the United States.

2.1. CHARACTERISTICS OF ECLAMPSIA

Elamptic period is characterized by changes that occurs in the pregnant woman between two
weeks of gestation and six weeks post partum. Some of these characteristics include:

2.1.1. HYPERTENTION

This is the case in which blood pressure rises up during pregnancy. Normally a woman’s blood
pressure drops during the second trimester, then it returns to normal by the end of the pregnancy,
but in some women, blood pressure goes up very high in the second or third trimester .This is
sometimes called gestational hypertension and can lead to preeclampsia(Johnson 2009). The
blood pressure normally range from > or =111 for systolic pressure and 70-80mmHg for
diastolic blood pressure, but in this case, high blood pressure is

 Systolic blood pressure > or = 140mmHg

 Diastolic blood pressure > or =90mmHg

2. I.2 PROTEIN IN URINE (proteinuria)

This is the case where there is excess protein in urine during pregnancy, greater o.3g in 24
hours.

2.1.3 HEADACHE: In this case, there is severe headach and stong

2.1.4 CONVULSION: This is a condition in which the pregnant woman enters into fits

2.1.5 OEDEMA

Edema is swellings that occur in a particular tissue, it can be:

 Edema of the legs,

 Edema of the hands
 Edema of the feet,

so if pregnant women are presented with edema, the midwives must surely fine out if the blood
pressure and sugar level is normal, before he or she can conclude if the edema is alarming or
not.Edema in a pregnant woman does not automatically means the woman would have
preeclampsia, edema is just one of the signs associated to elevated BP and proteinuria, making it
to be concluded with the diagnosis of eclampsia
2.6. RISK FACTORS

 PREDISPOSING FACTORS

Risk factors for eclampsia are factors that do not seem to be a direct cause of the disease,
but seem to be associated in some way. Having a risk factor for eclampsia makes the chances of
getting a condition higher but does not always lead to eclampsia. Also, the absence of any risk
factors or having a protective factor does not necessarily guard you against getting
Preeclampsia. For general information and a list of risk factor.

Factors that can be measured early in pregnancy that increase the likelihood of pre-eclampsia
developing in any given pregnancy (Duckitt, et al; 2005)

 Women with chronic hypertension (high blood pressure before becoming pregnant).

 Women who developed high blood pressure or eclampsia during a previous pregnancy,
especially if these conditions occurred early in the pregnancy.
 Women who are obese prior to pregnancy.
 Pregnant women under the age of 20 or over the age of 40.

 Women who are pregnant with more than one baby.

 Women with diabetes, kidney disease, rheumatoid arthritis, lupus, or scleroderma

2.2 PATHOPHYSIOLOGY

2.1.6) Pathophysiology of eclampsia

Eclampsia is a disease which appears only during pregnancy, characterized by hypertension,
proteinuria and oedema.it is widely widespread, and in the underdeveloped countries, is the
leading cause of maternal mortality; Its pathogenesis is thought to be associated to a hypoxic
placenta, which is responsible for the maternal vascular dysfunction. It occurs more commonly
in first pregnancies and primarily affects maternal, renal, cerebral, hepatic and clotting functions
while elevating blood pressure and the delivery of the placenta is the only way to control this
pathology.

Although the exact cause of eclampsia remains unclear, many theories center on problems of
placental implantation and the level of trophoblastic invasion (Positivist et al., 2001). It is
important to remember that although hypertension and proteinuria are the diagnostic criteria for
preeclampsia, they are only symptoms of the pathophysiologic changes that occur in the
disorder. One of the most striking physiologic changes is intense systemic vasospasm, which is
responsible for decreased perfusion of virtually all organ systems (Roberts et al., 2001).
Perfusion also is diminished because of vascular hemoconcentration and third spacing of
intravascular fluids. In addition, preeclampsia is accompanied by an exaggerated inflammatory
response and inappropriate endothelial activation.

Nowadays, it is considered as a disease originated in the activation of the vascular

endothelium, triggered by placenta ischemia.

2.3. CAUSES OF ECLAMPSIA

It is not known what causes eclampsia. But it is known that eclampsia causes blood vessels to
tighten which blocks blood flow. Theeclamptic syndrome is thought in many cases to be caused
by a shallowly implanted placenta which becomes hypoxia leading to an immune reaction
characterized by secretion of unregulated inflammatory mediators from the placenta (Jerome et
al., 2006). The exact causes of eclampsia are not known, although some researchers suspect

Genetic

Poor nutrition
 Insufficient blood flow to the uterus
 endothélial cell injury
 immune rejection of the placenta
 compromised placenta perfusion
 altered vascular reactivity
 imbalance between prostacyclin and thromboxane
 decreased glomerular filtration rate with retention of salt and water
 decreased intravascular volume
 increased central nervous system irritability
 disseminated intravascular coagulation
 uterine muscle stretch (ischemia)
 dietary factors, including vitamin deficiency
 genetic factors
 air pollution
 obesity

2.4. SIGNS AND SYMPTOMS

Eclampsia can be found early during your prenatal visits. The following are signs and symptoms
of eclampsia.

 Being 20 or more weeks pregnant with a blood pressure that is 140/90 or higher.
 Blurry vision (cannot see clearly).

 Breathing problems.

 Urinating small amounts.

 Feeling very sluggish.

 Gaining 3 to 5 pounds (1.4 kg to 2.3 kg) in 1 week (7 days).

 Having very bad pain over your stomach (belly) or under your ribs.
  Seeing spots in your eyes or having light flashes before your eyes.

 Sudden swelling of your face, hands, or feet.

 Increased blood pressure.

 Protein in the urine.
 Edema (swelling).
 Sudden weight gain.
 Nausea, vomiting.
 Severe headache

2.8 DIAGNOSIS

Eclampsia is diagnosed when a pregnant woman develops high blood pressure (two separate
readings taken at least 6 hours apart of 140/90 or more) and 300 mg of protein in a 24-hour urine
sample (proteinuria). A rise in baseline blood pressure (BP) of 30mmHg systolic or 15mmHg
diastolic, while not meeting the absolute criteria of 140/90, is still considered important to note,
but is not considered diagnostic. Swelling or edema (especially in the hands and face) was
originally considered an important sign for a diagnosis of eclampsia, but in current medical
practice only hypertension and proteinuria are necessary for a diagnosis. Pitting edema (unusual
swelling, particularly of the hands, feet, or face, notable by leaving an indentation when pressed
on) can be significant, and should be reported to a health care provider.

Severe eclampsia" involves a BP over 190/150mm Hg (Robbins et al., 2000) and additional
symptoms.

Proteinuria: 8 g or more of protein in a 24-hour urine collection or 3plus or greater on urine

dipstick testing of two random urine samples collected at least four hours apart
Other features: oliguria (less than 500 mL of urine in 24 hours), cerebral or visual disturbances,
pulmonary edema or cyanosis, epigastric or right upper quadrant pain, impaired liver function.

DIFFERENTIAL DIGNOSES
Eclampsia can be mimic and be confused with many other diseases, including chronic
hypertension, chronic renal disease, primary seizure disorders, gallbladder and pancreatic
disease, immune or thrombotic thrombocytopenic purpura, antiphospholipid syndrome and
hemolytic-uremic syndrome. It must always be considered a possibility in any pregnant woman
beyond 20 weeks of gestation. It is particularly difficult to diagnose when preexisting disease
such as hypertension is present (American medical network; 2003).

DIAGNOSTIC TEST

 Blood pressure measurement

 Urine testing to rule out preeclampsia 

 Assessment of edema

 Frequent weight measurements

 Liver and kidney function tests to rule out preeclampsia 

 Blood clotting tests to rule out preeclampsia 

2.9 PREVENTION

Prevention of gestational hypertension

Early identification of women at risk for gestational hypertension may help prevent some
complications of the disease. Education about the warning symptoms is also important because
early recognition may help women receive treatment and prevent worsening of the disease.

Title of figure

Unfortunately, there is no guaranteed way to prevent eclampsia; the best way of ensuring that
neither you nor your baby comes to any harm is to go to all your antenatal appointments. If you
have to cancel your appointment for any reason, arrange another time to see your midwife as
soon as possible. Each time your midwife tests your urine for protein and measures your blood
pressure she is checking for the early signs of pre-eclampsia.preventive measures can only be
needed to avoid complications (Padayatty, et al., 2006).

(NCCWCH 2008: 218)The prevention of eclampsia does not automatically mean that it can be
controlled in such a way that the pregnant woman would not develops eclampsia , but in a
certain way to detect the risk factor and fight towards them such as;

 Identification and appropriate action for those women with known risk factors at booking.
 Early recognition and appropriate action for those women with symptoms and signs of
eclampsia.
 Antiplatelet agents, e.g. low-dose aspirin, have moderate benefits when used for
prevention of pre-eclampsia (Duleyet al., 2007)

 Avoid stress
 Regular antenatal visits

Enough rest as much as possible, for the prevention of eclampsia and its complications for
women with normal blood pressure. (Meher et al., 2006

2.10 TREATMENT

There is no specific treatment, but is monitored closely to rapidly identify eclampsia and its life-
threatening complications (HELLP syndrome and eclampsia). Drug treatment options are
limited, as many antihypertensive may negatively affect the fetus. Methyldopa, hydralazine, and
labetalol are most commonly used for severe pregnancy hypertension.The only known treatment
for eclampsia is abortion or delivery, either by labor induction or Caesarean section. However,
post-partum eclampsia may occur up to 6 weeks following delivery even if symptoms were not
present during the pregnancy. Post-partum eclampsia is dangerous to the health of the mother
since she may ignore or dismiss symptoms as simple post-delivery headaches and edema.
Hypertension can sometimes be controlled with anti-hypertensive medication, but any effect this
might have on the progress of the underlying disease is unknown
 Antihypertensive may reduce maternal and fetal mortality among pregnancy patients with
hypertension as compared to placebo according to a randomized controlled trial (Wide-
Swenssonet al., 1995). Overall, after three weeks of treatment, MAP was lower in the isradipine
group, but when compared with the placebo group, the difference in MAP did not have statistical
significance. After treatment with isradipine, those patients with no proteinuria experienced a
decrease of between 8.5 and 11.3 mmHg, whereas those with proteinuria experienced about only
1 mmHg difference in systolic blood pressure. Those treated with placebo in both groups did not
experience much change in systolic blood pressure, regardless of proteinuria being present or
not. Therefore, the authors concluded proteinuric patients may respond differently from
nonproteinuric patients to this treatment, where the nonproteinuric patients responded the most to
treatment with isradipine. Labetolol or Nicardipine are also often times the antihypertensive of
choice for eclampsia or pre-eclampsia according to the CHEST 2007 study. Especially Labetolol
as it has little placental transfer.

Women with underlying inflammatory disorders such as chronic hypertension or

autoimmune diseases would likely benefit from aggressive treatment of those conditions prior to
conception, tamping down the overactive immune system.

Smoking reduces risk of pre-eclampsia(Jeyabalanet al., 2008) (though smoking is discouraged in

pregnancy in general.)

Diets and proteins

Studies of protein/calorie supplementation have found no effect on pre-eclampsia rates,

and dietary protein restriction does not appear to increase pre-eclampsia rates (Kameret al.,
2003). No mechanism by which protein or calorie intake would affect either placentation or
inflammation has been proposed.

Studies conducted on the effect of supplementation with antioxidants such as

vitamin C and E found no change in pre-eclampsia rates (Rumboldet al., 2006).

If the baby is pre-term, the condition can be managed until your baby can be safely
delivered. Your health care provider may prescribe bed rest, hospitalization, or medication to
prolong the pregnancy and increase your unborn baby's chances of survival. If your baby is close
to term, labor may be induced.

The treatment for more severe eclampsia (having vision problems, lung
problems, abdominal pain, fetal distress, or other signs and symptoms) may require more
emergent treatment -- delivery of the baby -- irrespective of the baby's age.

 Corticosteroids.If you have severe eclampsia or HELLP syndrome, corticosteroid

medications can temporarily improve liver and platelet functioning to help prolong your
pregnancy. Corticosteroids can also help your baby's lungs become more mature in as little as 48
hours an important step in helping a premature baby prepares for life outside the womb.

 Anticonvulsive medications. If the eclampsia is severe, the doctor may prescribe an

anticonvulsive medication, such as magnesium sulfate to prevent seizures

2.11 COMPLICATIONS

Eclampsia can occur after the onset of pre eclampsia. Eclampsia, which is a more serious
condition, complicates 1 in 2000 maternities in the United Kingdom and carries a maternal
mortality of 1.8 percent (Douglas et al., 1994). The HELLP syndrome is more common,
probably about 1 in 500 maternities, but may be as dangerous as eclampsia itself. These two
major maternal crises can present unheralded by prodromal signs of pre-eclampsia.

Cerebral hemorrhage is a lesion that can kill with pre-eclampsia or eclampsia. In that
cerebral hemorrhage is a known complication of severe hypertension in other contexts, it must be
assumed that this is a major predisposing factor in this situation, although this has not been
proven.

Cardiovascular disease. Having preeclampsia may increase your risk of future cardiovascular
disease

 Lack of blood flow to the placenta.Preeclampsia affects the arteries carrying

blood to the placenta. If the placenta doesn't get enough blood, your baby may receive less
oxygen and fewer nutrients. This can lead to slow growth, low birth weight, preterm birth and
breathing difficulties for your baby.
 Placental abruption.Eclampsia increases the risk of placental abruption, in
which the placenta separates from the inner wall of the uterus before delivery. Severe abruption
can cause heavy bleeding, which can be life-threatening for both you and baby

Other complications
these include:

 liver and kidney failure

 strokes (cerebral hemorrhage)
 fluid in the lungs (pulmonary edema)
 blindness (RCOG 2007, NHS 2009)
 maternal and foetus death

2.12. MANAGEMENT

Management in hospital is multidisciplinary with involvement of the obstetric team, anesthetics

and hematology, liaison with pediatrics, and appropriate arrangements for in utero transfer if
required and once the woman's condition is stable. ;( Greer, 2005).the management of eclampsia
is also to be considered (Hibbard et al., 1997)

 (Antenatal care: routine care for the healthy pregnant women ,march 200)
 Reassure and calm the pregnant woman
 Put the patient on bed rest
 Give IV fluids
 Monitor the blood pressure regularly
 Take the fetal heart beat
 Induction of labour if possible
 Prompt diagnosis with prevention and treatment of complications
 Blood pressure
 Anti-hypertensive treatment should be started in women with a systolic blood pressure
over 160 mmHg or a diastolic blood pressure over 110 mmHg. In women with other markers of
potentially severe disease, treatment can be considered at lower degrees of hypertension.

o Labetalol (given orally or intravenously), oral nifedipine or intravenous

hydralazine can be used for the acute management of severe hypertension.
o Atenolol, ACE inhibitors, angiotensin receptor-blockers and diuretics should be
avoided.

Anti-hypertensive medication should be continued after delivery, as dictated by the

blood pressure. It may be necessary to maintain treatment for up to 3 months, although most
women can have treatment stopped before this.

 Prevention of seizures:

Magnesium sulfate should be considered when there is concern about the risk of
eclampsia.In women with less severe disease, the decision is less clear and will depend on
individual case assessment.

 Control of seizures:
 Magnesium sulfate is the therapy of choice to control seizures. A loading dose of
4 g is given by infusion pump over 5-10 minutes, followed by a further infusion of
1 g/hour maintained for 24 hours after the last seizure.
 Recurrent seizures should be treated with either a further bolus of 2 g magnesium
sulfate or an increase in the infusion rate to 1.5 g or 2.0 g/hour.

 Fluid balance:
o Fluid restriction is advisable to reduce the risk of fluid overload in the intrapartum and
postpartum periods. Total fluids should usually be limited to 80 ml/hour or 1 ml/kg/hour.
 Delivery:
o The decision to deliver should be made once the woman is stable and with
appropriate senior personnel present.
o If the fetus is less than 34 weeks of gestation and delivery can be deferred,
corticosteroids should be given, although after 24 hours the benefits of conservative management
should be reassessed.
o Conservative management at very early gestations may improve the perinatal
outcome but must be carefully balanced with maternal wellbeing.
o The mode of delivery should be determined after considering the
presentation of the fetus and the fetal condition, together with the likelihood of success of
induction of labor after assessment of the cervix (Johnson 2009)

The third stage should be managed with 5 units intramuscular/slow intravenous

Syntocinon. Ergometrine and Syntometrine® should not be given for prevention of hemorrhage,
as this can further increase the blood pressure

2.12. NURSING RESPONSIBILITIES DURING ECLAMPSIA

During the period in which the pregnant woman is diagnosed with preeclampsia, the midwives
have to take precautions for the woman, because the life of the mother and foetus can be in
danger. What the midwives have to do are as follows:

 Prepare the woman psychologically

 Arrange for regular antenatal visits as much as possible, in order to monitor the vital
signs, especially the blood pressure.
 Advised the pregnant woman to stay away from stress and have enough rest as possible
 Advised the woman not to take a lot of salt and spices, and to control her diet.
 Take her medications as ordered.
 Respect her antenatal visits, so that her blood pressure and sugar level can be taken note
of and control.
 Avoid noisy environment and quarrels
 METHODOLOGY

3.1. STUDY AREA: The study was carried out at Laquintiniehospital.

3.1.2 DESCRIPTION OF STUDY AREA: This is a government hospital; Laquintinie which is

one of the biggest in the littoral region.It has almost all the hospital wards and hasmore than 350
health personnel’s. It receives per day more than 200 patients. TheLaquintinie hospital is found
in the economic capital of Cameroon, it is situated in the centre town of Douala (Akwa). As a
reference hospital, it receives people from different backgrounds, for various problems, these
amongst other reasons justifies the choice of the studying area.

3.3. STUDY POPULATION: The study population was nursing staff working in the maternity
service of the Laquintinie hospital.

3.4 SAMPLE SIZE:50 nurses were included in the study

3.5 SAMPLING TECHNIQUE: Participants were selected using the non-probabilist accidental
sampling technique

3.5.1 Inclusive criteria: nurses present at the maternity ward of the Laquintinie hospital during
the period of collection.

3.5.2 Exclusive criteria: all nurses who do not work at the maternity unit during the period of
collection.

3.6STUDY DESIGN

The research design was a qualitative, descriptive and cross-sectional study design

3.7 DURATION OF STUDY: The study lasted for 5months from May 2014 to September 2014

3.8 DATA COLLECTION:Data was collected with used ofstructured questionnaire. The
questionnaire was divided into three sections namely: identification of
participants,knowledgeand practice of nurses in the management of eclampsia.The questionnaire
was a self -administered. It was given to the participants to fill and was returned hours or days
afterwards.
3.9 DATA ANALYSIS: Data was analyzed with the aid of computer programs like Microsoft
excel and access. The results were presented in the form of tables, Pie chart and bar charts.

3.10 RESEARCH MATERIALS

The following Materials were used for the project:

 Questionnaire and a table of observation was used for data collection

 Books from the library and information from the internet were used for literature.
 Pens, pencils, rulers and eraser were used in writing
 Computer was used for data analysis, typing, editing and printing of the work

3.11 ETHICAL CONSIDERATIONS

The following considerations were made

- A letter of authorization was given by the school which was presented to the director of
the hospital before data collection
- The Nurses consent were sought before giving out the questionnaire
- Confidentiality of participants information was highly respected
 RESULTS

4.1: DEMOGRAPHIC INFORMATION

7%

25%

28% 20-29
30-39
40-49
50-55

40%

Fig 1: Distribution of participants with respect to age

From fig 1 above, majority of the nurses’involved in the study fell under age group 40-49, with a
percentage of 40%.

Fig 2: Distribution of participants according to sex

2%

FEMALE
MALE

98%

According to fig 2, most of the participants (96.4%) were women

 6% 18%

NA
51%
SRN
BSC
RHN

25%

Fig 3: Participant distribution according to their qualification:

From this figure 51% were reproductive health nurses or midwives

10 years and above; 38

40 3-5 years; 30
35
30 1-2 years; 22
25
20 6-9 months; 10
15
10
5
0
6-9 months 1-2 years 3-5 years 10 years and above

Fig 4: Distribution of participants according to the number of years in the profession

From fig 4, most of the participants 38% had 10 years and above in the profession
4.2 NURSES KNOWLEDGE ON ECLAMPSIA

Table 1: Nurses knowledge on the definition of eclampsia

DEFINITION NA/N SRN/N° BSC/N° RHN/N° %

°
It’s a normal condition due to 0 0 0 0 0%
pregnancy
It’s a condition that occurs only after 0 0 0 0 0%
delivery
It’s when tonic-clonic seizures or 3 11 12 24 100
convulsion appear in a pregnant
woman with high blood pressure and
proteinuria + oedema
TOTAL 6% 18% 24% 52% 100%
From the data obtained, 100% gave the right definition of eclampsia, so everyone knew
what eclampsia was all about

Table 2: Distribution of nurses’ knowledge on the definition of eclampsia with

respect to qualification

DEFINITION NA/N SRN/N° BSC/N° RHN/N° %

°
It’s a normal condition due to 0 0 0 0 0%
pregnancy
It’s a condition that occurs only 0 0 0 0 0%
after delivery
It’s when tonic-clonic seizures or 3 11 12 24 100
convulsion appear in a pregnant
woman with high blood pressure
and proteinuria + oedema
TOTAL 6% 21% 19% 54% 100%
From the data obtained, 54% of the reproductive health nurses had the highest score in the
definition of eclampsia

Table3: Distribution of nurses’ knowledge on the signs and symptoms of eclampsia

SIGNS AND SYMPTOMS NA SRN BSC RHN %

Blurry vision 0 0 0 5 5%
convulsion 8 12 10 20 80%
Severe headaches 1 12 10 10 10%

Reduced urine or no urine 0 0 0 0 0%

Dizziness 0 0 0 0 0%
Others 0 0 0 0 0%

TOTAL 100%
From the data obtained, 80% of the nurses were of the fact that convulsion was the major
signs and symptoms of eclampsia, and the least was blurry vision

Table 4: Distribution of nurses’ knowledge on the predisposing factors of eclampsia

PREDISPOSING FACTORS OF NA/N SRN/N° BSC/N° RHN/N° %

ECLAMPSIA °
Family history of eclampsia 0 0 0 5 12%
Pre-existing hypertension 8 0 10 10 28%
obesity 1 1 2 10 14%

primiparity 1 6 20 20 46%

Women over 40 years 0 0 0 0 0%

Multiple pregnancy 0 0 0 0 0%

TOTAL 100%
From the data obtained, 46% of the nurses were of the fact that primates was one of the
major risk factors of eclampsia, and the least 12%, came from a family history of
hypertension.

Table 5: Distribution of nurses’ knowledge regarding diagnosis of eclampsia

 DIAGNOSIS OF ECLAMPSIA NA/N SRN/N° BSC/N° RHN/N° %
°
Patients history 2 3 1 1 14%
Physical examination 3 5 4 5 17,5%
Through regular antenatal visits 1 7 6 20 34%

Urine sample collection to check for 2 11 5 10 26,5%

protein in the urine
Blood test to check your platelet 2 1 2 3 8%
counts,liver function and kidney
function
TOTAL 100%

From the data obtained, 34% of the nurses were of the fact that eclampsia can be diagnosed
through regular antenatal visits, the least predisposing factors was 8%

Table 6: Distribution of nurses’ knowledge regarding the causes of eclampsia

CAUSES OF ECLAMPSIA NA/N SRN/N° BSC/N° RHN/N° %

°
Placenta problems 2 3 10 20 36%
Insufficient blood flow to the uterus 3 5 4 5 18,5%

Poor nutrition 5 5 6 12 28%

Multiple pregnancy 0 0 0 0 0%
obesity 1 1 4 2 17,5%

TOTAL

From the data obtained, 36% of the nurses were of the fact that eclampsia can be by placenta
problems; the least cause was obesity with 8%

Table 7: Distribution of nurses’ knowledge regarding the effect of eclampsia on the mother

EFFECTS OF ECLAMPSIA ON NA/N SRN/N° BSC/N° RHN/N° %

 THE MOTHER °
Stroke 2 6 8 20 44,5%

Heart failure 3 5 4 4 15,5%

Reversible blindness 0 2 4 10 18%

Postpartum hemorrhage 0 0 0 2 4%
Placenta abruption 1 1 2 10 20%

TOTAL 100%

From the data obtained, 44, 5% of the nurses were of the fact that the major effect of eclampsia
on the mother is that of stroke, the least effect was heart failurewith 15,5%

Table 8: Distribution of nurses’ knowledge regarding the effect of eclampsia on the fetus

EFFECTS OF ECLAMPSIA ON NA/N SRN/N° BSC/N° RHN/N° %

THE FETUS °
prematurity 2 10 10 20 46,5%

Small for date babies 3 3 5 6 19,5%

Learning disabilities 0 2 4 2 16%

death 0 0 2 2 8%
Adaptation problems 0 0 0 10 10%

TOTAL 100%

From the data obtained, 46,5% of the nurses were of the fact that the major effect of eclampsia
on the fetus was that of premature delivery , the least effect was death with 10%

4.3 NURSES KNOWLEDGE REGARDING MANAGEMENT OF ECLAMPSIA

Table 9: Distribution of nurses’knowledge on the assessment of eclampsia

 NURSING ASSESSMENT DURING NA/ SRN/N° BSC/N° RHN/N° %
ECLAMPSIA N°
a) Monitor vital signs symptoms 1 10 10 20 82%

b) Monitor Fetal Heart Beat. 0 2 2 3 14%

c) Measure and record urine 0 0 0 2 4%

output,
d) Measure and record protein 0 0 0 0 0%
level
TOTAL 100%

From the data obtained, 82% of the nurses were of the fact that, assessment of eclampsia consist
of monitoring vital signs and the least of the assessment was that of measuring and recording
urine output scoring 4%

Table 10: Distribution of nurses’ knowledge on the nursing diagnosis of eclampsia

NURSING DIAGNOSIS ON NA/ SRN/N° BSC/N° RHN/N° %

ECLAMPSIA N°
Fluid Volume Deficit related to plasma 0 0 0 0 0%
protein loss, decreased colloid osmotic
pressure.
Impaired tissue perfusion related to the 0 0 0 0 0%
occurrence of vasospasm arterioles
Risk for Injury: the fetus related to 10 13 10 17 100%
inadequate placental blood perfusion
Fluid Volume Deficit related to plasma 0 0 0 0 0%
protein loss, decreased colloid osmotic
pressure.
TOTAL 100%

From the data obtained, 100% of the nurses account for risk for injury as a nursing diagnosis of
eclampsia

Table 11: Distribution of nurses’ knowledge on the intervention of eclampsia

INTERVENTION OF NURSES NA/ SRN/N° BSC/N° RHN/N° %

DURING ECLAMPSIA N°
 Provide calm, restful surroundings 2 10 10 20 84%

Monitor blood pressure of the patient at 4 6 10 5 50%

least every one hour
Administration of electrolyte and 6 6 15 18 90%
sedatives such as diazepam
Administration of magnesium sulphate 2 8 12 22 88%
intravenously
TOTAL 100%

From the data obtained, 90% of the nurses were of the fact that, they would administer
electrolytes and sedatives such as diazepam in the intervention of eclampsia and the least of it
was monitoring blood pressure at least every hour 50%

fig 5: Distribution of nurses knowledge regarding seminars on eclampsia

No training
Trainig

From fig 5, all of the nurses 100%, never had any training on eclampsia

fig 6: Distribution of nurses knowledge regarding the screening test that is routinely done
during the eclamptic period
 10%

50% Monitor BP
Urine test
blood test
40% none

From fig 6, 50% of the nurses would monitor bp for screening during eclampsia, while 10%
would carry out blood test

Fig7: distribution of nurses’ knowledge regarding the drug that is best used to control fits

24%

DIAZEPAM
MAGNESIUM SULPHATE

76%

From fig 7, 76% of the nurses would use magnesium sulphate as the best drug to control fits

fig 8: distribution of nurses knowledge regarding the treatment of eclampsia

 32%

LOXEN DRIP
REST
58% DIAZEPAM
DELIVERY OF THE BABY

6%
4%

From fig 8, 58% of the nurses would use the drip of loxen to treat eclampsia

table 12: distribution of nurses knowledge on the prevention of eclampsia

NURSES PREVENTION ON NA/ SRN/N° BSC/N° RHN/N° %

ECLAMPSIA N°
Regular antenatal visits 1 12 20 14 94%

Aspirin supplementation 0 0 0 0 0%

Weight reduction and regular aerobic 0 0 0 0 0%

exercise
Reducing Salt in the diet 1 1 1 0 6%
TOTAL 100%

From the data obtained, 94% of the nurses account for regular antenatal visit in order to prevent
eclampsia of

Table 13: Distribution of challenges faced by in the management of eclampsia.

Challenges faced by nurses in NA/ SRN/N° BSC/N° RHN/N° %

managing eclampsia N°
 Lack of magnesium sulphate 1 9 10 13 66%

Inadequate materials or equipments 0 0 0 0 0%

Lack of money on the part of the family 2 0 6 6 28%

Less knowledge on the management 1 1 1 0 6%

TOTAL 100%

From the data obtained, 66% of the nurses faced challenges through the lack of magnesium
sulphate to quickly handle an eclamptic case.

Fig 9: distribution of nurses knowledge on how often do they measure the BP of a pregnant
woman without any risk factor.

4%

every week
every month
every trimester
never

96%

From fig 9 above, 96% of the nurses would use the drip of Loxen,an antihypertensive drug to
treat eclampsia

Fig 10: distribution of nurses’ knowledge on where they would treat an eclamptic patient
after 37th week of gestation
 in the hospital
as an outpatient

100%

From fig 10 above, 100% of the nurses would treat a pregnant woman in the hospital
 DISCUSSION, CONCLUSION AND RECOMMENDATIONS

5.1 DISCUSSION
After studying the results, majority of the nurses who participated in the study were
women, with a percentage of 98%, and under age group 40-49, 40%, this explains how
women play a great role in the domain of medicine or in health care.majority of the
nurses 38% had 10 years and above in the profession, making it easier to understand their
experience, concerning the management of eclampsia.
According to the results above, majority of the nurses who participated in the study100%,
where able to defineeclampsiaas tonicclonic-seizure or convulsion which appear in a
pregnant woman with high blood pressure and proteinuria + oedema, in respect to WHO,
the reason for this high score can be from the fact that all of these nurses came from the
maternity unit, therefore, must have seen many cases of eclampsia.
80% of the nurses said the major signs and symptom is convulsion, probably because
when there is elevated blood pressure, the first sign that makes the nurse understands that
the patient has eclampsia, is when the patient is convulsing.

Table 4 shows that 36% of the nurses said the real cause of eclampsia is that of placenta
problems which may be probably because, the placenta is a foreign body that comes in
contact for the first time, in the pregnant woman, so saying placenta it’s the major cause
of eclampsia can be reasonable to an extent.

Table 5 shows that 46% of the nurses said primates are those at risk of acquiring
eclampsia, this is in accordance with (DUCKITT) who said the risk factors of eclampsia
can be seen among primipara women.

Table 6 shows that 34% of the nurses concluded that regular ANC is at the center of the
diagnosis of eclampsia, this is important because, during the antenatal visits, eclampsia
can be diagnosed and properly taken care of, this is in accordance with ( Hibbard and
rosen,) who talked of early antenatal visits as a safer means to detect eclampsia.
Table 7 shows that 44.5% of nurses said stroke was a major effect of eclampsia on the
mother, this was probably because, this condition attacks the brain and put all the
different nerves in danger, while table 8 shows that 46.5% of nurses reported premature
delivery as the major effect on the fetus, this is probably because eclampsia usually
occurs when the pregnant woman is at her 27 th week gestation, making it difficult to
follow her through up to expected date of delivery, and also because the placenta is
attached to the fetus navel, since there is less oxygen flow to the site, hence premature
delivery can be initiated.
NURSES KNOWLEDGE ON THE MANAGEMENT OF ECLAMPSIA

Table 8 CONCLUDED that 82% of the nurses, said they would assess a woman with
eclampsia through the vital signs and symptoms present, while table 9 proved that 100%
of nurses said, as a nursing diagnosis of eclampsia, they would takle on, risk for injury:
related inadequate placenta blood perfusion

Table 10 concluded that 90% of nurses would intervene during eclampsia by the
administration of electrolytes and diazepam injection to stabilize the patient, this is
probably because the nurses have no other option, other than to react before the doctor’s
prescription, since life is at stake.In the normal sense, the nurse had to wait for the
doctor’s prescription, before administering any drug on the patient, but since life is most
important, the nurse has to act fast.

Fig 5 reveals that 100% of nurses has never attended any seminar on eclampsia, probably
because most hospital underestimate the dangers that exist in this condition, and are not
aware of the complications that can occur, hence fine it hard to organize different
seminars on eclampsia.

Fig 6 shows that 50% of nurses would screen for eclampsia by monitoring the blood
pressure of a pregnant woman, this is probably because, high blood pressure is the high
cause of eclampsia, so monitoring the blood pressure of a pregnant woman would help
screen for eclampsia
Fig 7 shows that 76% of nurses said that MgSo4 is the best drug that is best used to
control fits or convulsion, probably because it has a more rapid effect than diazepam
Fig 8 reveals that 58% of nurses would administer the drip of loxen to treat eclampsia,
this reason might be probably because, loxen is an antihypertensive drug, that is used to
lower high blood pressur, since one of the major cause of eclampsia is high blood
pressure, there is the need to lower the blood pressure, in other to treat this condition.

Table 11 reveals that 94% of the nurses would prevent eclampsia through regular
antenatal visits, this is due to the fact that, most of the different complications of
pregnancy is corrected during the ANC, since the woman’s blood pressure is constantly
taken during the visits, and if found that there is an elevated blood pressure, all would be
done to stabilize it and avoid complications.

Table 12 reveals that, 66% of the nurses faced challenges in trying to manage eclampsia,
because of the lack of MgSo4, since it is scarce to fine in most hospitals, coupled with the
fact that most of the patients are unable to buy the drug, due to lack of money, 28% of
patients fine it difficult to afford this medication, which would have been put in place for
free for all pregnant women, since there is no time to waste, when a woman present with
eclampsia.

Fig 9 shows that 96% of the nurses where of the fact that, the blood pressure of a
pregnant woman, who does not present with any risk factor, should be taken every
month, during all antenatal visits, this is in abit to avoid any danger that is to happen
Finally, 100% of nurses would treat a patient with eclampsia after 37th week of gestation
only in a hospital, since it’s the best place to properly take care of any danger that has to
occur, or if there is any need for induction of labour.
 5.2 CONCLUSION

According to the results above, nurses have an adequate knowledge on what eclampsia was all
about, and the knowledge on how to manage this condition was also a little bit positive, since
most of the difficulties they faced were that of inadequate equipments and lack of medications, to
properly manage this condition. Most of the nurses knew what they had to do, although there
were some factors that made it difficult, to fully manage the condition. Therefore the managers
of hospitals should look for a way in which this condition can be properly managed by nurses

5.3. RECOMMENDATIONS

Based on this study, the following recommendations were made:

1. Pregnant women should regularly attend their antenatal visits to be diagnosed for any
dangerous sign.
2. Nurses should always check carefully the blood pressure and sugar level for any pregnant
woman coming for antenatal visit or for check up.
3. Women who are pregnant for their first time at an advanced age should take with great
care their blood pressure when they are pregnant
4. Nurses should manage with great care any woman presenting with the various signs and
symptoms of preeclampsia.
5. Nurses should advised any pregnant woman who has been diagnosed for eclampsia to
have enough rest as possible and control their diet, especially salt and spices

6. Nurses should give medications to eclamptic women as recommended and advised them
to take it as prescribed, in order to avoid danger

7. Pregnant women should not eat food that will make them get enough weight
8. Nurses should always monitor the fetal heart beat if a pregnant woman is diagnosed with
preeclampsia
9. Seminars should be organized to educate nurses more and more on pregnancy induced
hypertension, eclampsia
10. More investment in equipments and medications
11. Better structure and efficiency in hospitals

REFERENCES
Antenatal care: routine care for the healthy pregnant woman, NICE Clinical Guideline (March
2008)

Br J obstec gynecology.,(1990).women at high risk of developing preeclampsia.2.(234).

Burne., and Jerome., (2006) "Give Sperm a Fighting Chance". The Times. Article
721663.http://www.timesonline.co.uk/tol/life_and_style/health/our_experts

Douglas KA., and Redman CW., (1994)."Eclampsia in the United Kingdom".BMJ309 (6966):
1395–400. PMID 7819845.PMC 254134 http://bmj.com/cgi/pmidlookup?
view=long&pmid=7819845.

.Management of pre-eclampsia.BMJ. 332(7539):463-8.

Duckitt K., and Harrington D.,(2005). Risk factors for pre-eclampsia at antenatal
booking.Systematic review of controlled studies; BMJ. 12; 330(7491):565.

Duley L, Henderson-Smart Dj,andMeher S.,(2007).Antiplatelet agents for preventing pre-

eclampsia and its complications. Cochrane Database. (2):CD004659. [abstract]

Dekker G., (2002). "The partner's role in the etiology of preeclampsia".Journal of Reproductive
Immunology57 (1-2): 203–15. :10.1016/S0165-0378(02)00039-6. PMID12385843.

Drife JO., and Magowan (eds).,(1775). Clinical Obstetrics and Gynecology, chapter 39, pp 367-
370. ISBN 0-7020

Douglas KA., and Redman CW., (1994)."Eclampsia in the United Kingdom".BMJ309 (6966):
1395–400. PMID 7819845.PMC 254134 http://bmj.com/cgi/pmidlookup?
view=long&pmid=7819845.

Greer IA.,(2005). Pre-eclampsiamatters.BMJ. 330(7491):549-50.

Hibbard BM., and Rosen M., (1977)."The management of severe pre-eclampsia and
eclampsia".British Journal of Anesthesia49 (1): 3–9. doi:10.1093/bja/49.1.3. PMID 831744.
Hjartardottir S., Leifsson BG., Geirsson RT., and Steinthorsdottir V., (2004). "Paternity change
and the recurrence risk in familial hypertensive disorder in pregnancy”.23(2):219-
25.doi:10.1081/PRG-120037889.PMID 15369654

Johnson DD(2009). Induced labour for pre-eclampsia and gestational hypertension. Lancet

Kramer MS and Kakuma R (2003). "Energy and protein intake in pregnancy".Cochrane

Database of Systematic Reviews (4): CD000032. doi:10.1002/14651858.CD000032.
PMID 14583907.

Lind j .Vorvick ., (2009).eclampsia is the cause of maternal and fetal death.5;256(1254):453-44.

Meher S., and Duley L (2006). "Rest during pregnancy for preventing pre-eclampsia and its
complications in women with normal blood pressure".Cochrane Database of Systematic Reviews
(2): CD005939. doi:10.1002/14651858.CD005939. PMID 16625644

PadayattySJ., and Levine M. (2006). "Vitamins C and E and the prevention of pre-
eclampsia".The New England Journal of Medicine355 (10): 1065; author reply 1066.
doi:10.1056/NEJMc061414. PMID 16957157.

Robertson SA, Bromfield JJ.,andTremellen KP. ( 2003). "Seminal 'priming' for protection from
pre-eclampsia-a unifying hypothesis". Journal of Reproductive Immunology59 (2): 253–65.
Doi:10.1016/S0165-0378(03)00052-4. PMID 12896827.

Rumbold AR, Crowther CA, Haslam RR, Dekker GA., and Robinson JS. (2006). "Vitamins C
and E and the risks of pre-eclampsia and perinatal complications".The New England Journal of
Medicine354 (17): 1796–806. doi:10.1056/NEJMoa054186. PMID 16641396

Royal college of obstetricians and Gyenecologists (2006). Management of severe pre-eclampsia

and eclampsia,

ShirrenMeher .,(2004).preeclampsia,a complicated pathology.3;46.

Sibai B., Dekker G. and Kupferminc M (2005).Pre-eclampsia.Lancet4;365(9461):785-99.

Wide-Swensson, DH.,Ingemarsson, I., Lunell, NO., Forman, A; Skajaa, K., Lindberg, B;

Lindeberg, S., and Marsàl., K . (1995). "Calcium channel blockade (isradipine) in treatment of
hypertension in pregnancy: a randomized placebo-controlled study.".American journal of
obstetrics and gynecology173 (3 Pt 1): 872–8. doi:10.1016/0002-9378(95)90357-7.
PMID 7573260