Binu Thapa

KUSMS
 Contents
• Definition
• Incidence
 ECLAMPSIA
• Pre-eclampsia when complicated with
generalized tonic- clonic convulsion or coma is
called eclampsia.

• It is defined as the occurrence of one or more

convulsion in association with syndrome of
pre-eclampsia with no coincidental
neurological disease.
 INCIDENCE

• It varies widely from country to country and

even between different zones of the same
country.
• In developed country , its prevalence is far and
few but in the developing ones particularly in
the rural areas, it is still high and contributes
significantly to the maternal death.
• 1 in 500 to 1 in 30 (india)
 Cont….
• 20 cases in 1,000 hospital deliveries (Antenatal
care and severe pre-eclampsia in kathmandu
valley bl Manandhar, V Chongstuvivatwong ,
Department of OBGYN, IOM, Teaching
Hospital, Maharajgug, Kathmandu, Nepal)
• 2.9 per 1000 deliveries (Eclampsia : a hospital
based retrospective study Choudhary P Senior
Registrar, Maternity Hospital, Kathmandu )
 Clinical features:
• An eclamptic patient always shows the signs
of preeclampsia along with manifestations of
eclamptic convulsions or fits consisting four
stages:
– Premonitory phase
– Tonic phase
– Clonic phase
– Stage of coma
 Premonitory phase
• The patient becomes unconscious.
• There is twitching of the muscle of the
face, tongue and limb .
• Eye ball roll or are turned to one side
and become fixed.
• This last for about 15-30 second.
 Tonic phase
• The whole body goes into the tonic spasm-
the trunk opisthotonus, Limbs are flexed
&hands clenched .
• Respiration ceases and the tounge
protrudes between the teeth
• Cyanosis appear
• Eye ball become fixed
• This stage last for 30 second
 Clonic phase
• All the voluntary muscle undergo
alternate contraction and relaxation.
• The twitching start in the face then
involve one side of the extremities &
ultimately the whole body is involved in
the convulsion.
• Biting of the tongue may occur
 Cont…
• Breathing is Sertorius & blood stained frothy
secretion fill the mouth
• Cyanosis gradually disappear
• This stage last for 1-4 minutes
 Stage of coma
• Following the fits, the patient passes on to the
stage of coma.
• It may last for a brief period or in the other
deep coma period till another convulsion.
• On occasion, the patient appears to be in a
confused state following fits &fails to
remember the happenings.
• Rarely the coma occurs without prior
convulsion.
 Cont…
• The fits are usually multiple, recurring at varying
intervals.
• When it occur in quick succession, it is called
stage eclampticus.
• Following the convulsion , the temperature
usually rise: pulse & respiration rate increased &
so also the blood pressure.
• The urinary output is markedly diminished
proteinuria is present.
 Management
• The principle of management are:
a. Maintain airway, breathing &circulation,
b. Oxygen administration (8-10)l,
c. Ventilator support (if needed)
d. Prevention of injury
e. Arrest convulsion
f. Organize investigation
g. Delivery by 6-8 hours
h. Prevention of complication
i. Post partum care
First aid management outside the hospital

a. The patient ,either at home or in the peripheral health

center should be shifted urgently to the referral hospital,
b. Provide prompt care to the eclamptic patient,
c. The patient must be sedated before moving her to the
hospital,
d. During convulsion ; turn the patient into side position to
prevent aspiration,
e. Give oxygen to manage cyanosis, if possible
f. Don’t leave the patient alone
g. Check & record BP, pulse, respiration, FHS ,stage of fits
for maternal condition.
 General management
 Supportive care should be provided
 Detailed history is to be taken
 Monitoring: pulse, respiration, blood
pressure, hourly urine output is to be noted, if
undelivered, the uterus should be palpated at
interval to detect progress of labor & FHS
monitored.
 Fluid management
 Cont…
• Crystalloid solution (RL) is started as a first
choice.
• Total fluid should not exceed the previous 24
hours urinary output plus 1000ml (insensible
loss through lungs and skin).
• Normally, it should not exceed 2 liters in 24
hours.
 Cont….
 Catherization the bladder to monitor the
urine output.
 If urine output is <30ml / hrs, Withhold the
MgSo4 & infuse I/V fluids at one liter in 8
hours
 Never leave he women alone. A convulsion
followed by aspiration or vomit may certify
death of the woman & fetus.
 Antibiotics; ceftriaxone 1gm IV BD
 Specific management
• Anticonvulsant and sedative regimen:
the aim is to control the fits & to prevent
it’s recurrence
• Magnesium sulfate is the drug of choice.
 Regimen of MgSo4 for eclampsia

• Loading dose
• Magnesium sulphate 20% Solution, 4g IV over
5 minutes.
• Each vial contains 1gm/2ml (50%)
• So, 8ml mgso4+12 ml of distilled water.
• Follow promptly with 10g of 50% magnesium
sulphate solution
 Cont….
• 5g in each buttock as deep IM injection with
1ml of 2% lignocaine in the same syringe.
• Ensure that aseptic technique is practiced
when giving magnesium sulphate deep IM
injection.
• Tell the women that a feeling of warmth will
be felt when magnesium sulphate is given.
 Contd…

• If convulsion recur after 15 minutes give

2gm MgSO4 ( 50 % solution) IV over 5
minutes.
 Cont….
• Maintenance dose
 5g magnesium sulphate (50% solution)
with 1 mI lignocaine 2% IM every 4 hours
into alternate buttocks.
 Continue treatment with magnesium
sulpate for 24 hours after delivery or the
last convulsion, which ever occurs last.
 Before repeat administration
Ensure that:
 Respiratory rate is at least 16 beats/min.
 Patellar reflexes are present.
 Urine output is at least 30 ml/hour over 4
hours.
 Withhold or delay if above criteria not met.
 Keep antidote ready
 In case of respiratory arrest
• Assist ventilation (mask and bag,
anesthesia apparatus, intubation.
• Give calcium gluconate 1g (10ml of 10%
solution) IV slowly.
• Respiration
T E begins to antagonize the
O
Neffects of magnesium.
Use diazepam only magnesium
Use diazepam only magnesium
sulphate is not available.
 Management during fits
• A mouth gag is placed in between the teeth to
prevent tounge bite & should be removed
after the clonic phase is over,
• The airway is cleaned and turn the patient in
lateral position, oral suction is done if needed,
• Oxygen is given until cyanosis disappears,
 Nursing management
• Supportive care
• Vital monitoring
• The patient is ideally managed in dark room where
there is minimum stimulation
• Keep the patient in railing bed
• Intravenous fluid maintained
• Maintained oxygenation
• Emergency investigation should be done
• Prevent aspiration
 Cont…
• Anticonvulsant administration
• Maintain intake and output
• Never leave the patient alone
• Provide nursing care according to need such
as mouth care,
• Observe the condition of fits and sign of labor,
check FHS hourly,
 If the patient is in labor
• Delivery with vacuum extractor or caesarean
section.
• Episiotomy is performed to shorten the stage
of labor
• The patient is kept sedated up to 48 hours.
 Complications
• Mother -
1. Hazards of convulsion
injuries : tongue bite, injuries due to fall from bed
Aspiration
Exhaustion due to frequent attacks of fits
2. Pulmonary complication
Edema due to leaky blood capillaries
Pneumonia due to aspiration ,hypostatic or
infection
 Cont….
3) Cardiac : acute left ventricular failure due to
anoxia, muscular exhaustion.
4) Renal failure
5) Hepatic : necrosis
6) Cerebra: edema, infraction & haemorrhage
detachment
7) Disturbed vision
8) Post partum: shock, sepsis
 Cont…
• Fetal -
• The prenatal mortality is very high to
extent of about 30-40%. The cause are
a. prematurity
b. Intrauterine asphyxia
c. Effect of drugs use to control convulsion
d. Trauma during operative delivery
 Prevention
• Early detection
• Judicious decision
• Anti hypertensive and prophylactic
anticonvulsant drugs
• Timely delivery
• Close monitoring
Any questions???