ECLAMPSIA

MD.
Prof. Ob / Gyn
 Definition
 It is the development of convulsions in a pre-
existing pre-eclampsia.
Incidence
 About 1/1000 pregnancies.
Aetiology
 The exact cause is unknown but cerebral
ischaemia and oedema were suggested.
 Clinical Picture
 Premonitory stage: the eyes are rolled up with
twitches of the face and hands. It lasts for about ½
min.
 Tonic stage: generalised tonic contraction of the
whole body muscles with opisthotonus and cyanosis.
It lasts for about ½ min.
 Clonic stage: convulsions occur where there is
alternative contraction and relaxation of the body
muscles. The face is congested, tongue may be bitten,
blood-stained frothy saliva appears on the mouth,
breathing is stertorous, urine and stool may pass
involuntarily, temperature rises due to increased
muscular activity patient is unconcious. This lasts for
about 1 min.
 Coma: which may last for few hours. Other fits may
occur during coma, after recovery or may not recur
again.
 Types
 Antepartum eclampsia 50%.
 Intrapartum eclampsia 25%.
 Postpartum eclampsia 25% occurs within 48 hours
of delivery. It is usually the most dangerous one.
 Severity of Eclampsia
(Eden’s criteria):

1. Coma of 6 or more hours.

2. Temperature 39oC or more.
3. Pulse over 120/min.
4. Systolic blood pressure over 200 mmHg.
5. Respiratory rate over 40/min.
6. More than 10 convulsions.
Differential Diagnosis:
(1) Epilepsy.
(2) Intracranial haemorrhage.
(3) Hysteria.
(4) Meningitis.
(5) Brain tumours.
(6) Strychnine poisoning.
 Management
(A) General measures:
 Hospitalisation is mandatory.
 Efficient nursing in a single quiet semi-dark room to prevent
any auditory or visual stimuli.
 After sedation, a self-retained Foley’s catheter is applied.
The hourly output of urine is charted.
 Proteinuria, haematuria and specific gravity is noticed.
Care for respiratory system by :
 head - down tilt to help drainage of bronchial secretion,
 frequent change of patient position, keep upper respiratory
tract clear by aspiration of mucous through a plastic airway,
prophylactic antibiotic and oxygen is administered during
and after fits.
 The tongue is protected from biting by a plastic mouth
gauge.
 Management
Observation for:
a- Maternal
 - pulse,
 - temperature,
 - blood pressure,
 - respiratory rate,
 - tendon reflexes,
 - urine (see before),
 - number of fits and duration of coma,
 - uterine contraction,
b- Foetal
 FHS.
 Management
(B) Medical measures
(1) Sedation:
 Morphine 10-20 mg IM or, l
 Diazepam one ampule (10mg) IV over 4 min.then
maintain by IV infusion 40 mg in 500 ml glucose 5%
over 12-24 hours. Diazepam is used as an
anticonvulsant as well.
(2) Antihypertensives:
 Potent and rapidly acting drugs are used when
needed.
 Examples are:
 - Hydralazine IV.
 - Diazoxide IV.
 (3) Anticonvulsant therapy:
a) Magnesium sulphate:
Action:
 - inhibits neuromuscular transmission,
 - sedation,
 - peripheral vasodilatation,
 - diuresis.
 Dose: A loading dose 4 gm of 20% solution is given IV over not
less than 3 minutes, followed by 1gm/ hour. A total dose of 24
gm/ 24 hours should not be exceeded and therapy continues
during the 24 hours postpartum. The aim is to keep the plasma
level at 6-8 mEq/L. At this level tendon reflexes are still present.
They disappear at >10 mEq/L and toxic effect including
respiratory failure appears at 15 mEq/L.

Before each maintenance dose the following criteria should be

checked:
 i- knee jerk should be present,
 ii- respiratory rate not less than 16 / min.and
 iii-urine output not less than 30 ml/ hour.
 Magnesium sulphate can be given by IM injection of 50%
solution. Loading dose is 6-10 gm divided on both buttocks then
4-5 gm/ 6 hours. This regimen is not preferred due to ill control
of the blood level of MgSo4 in addition to pain and inflammation
of the injection site.
 The antidote: is 10 ml of 10% calcium gluconate given slowly IV.
 (3) Anticonvulsant therapy:
 b) Phenytoin:
 An anti-epileptic drug which can be used to prevent
 recurrence of fits not for its termination as it acts after
 about 20 min.
 Dose : 18 gm/kg body weight slowly IV.
 c) Sodium thiopentone (Intraval)
 It is a short acting general anaesthetic.
 Used in emergency as frequent convulsions.
 Dose: 25 mg increments IV until convulsions are
controlled.
 d) Muscle relaxants:
 usually used prior to procedures that might trigger off a
convulsion as endotracheal intubation.

 (4) Diuretics

 (5) Other drugs

 (C) Obstetric measures
 The policy is that there is no conservative
treatment in eclampsia and the patient should be
delivered but convulsions should be controlled
first.
 Spontaneous labour usually commences within 6
hours. If not induce labour by oxytocin as long as
there is no other indication for caesarean section
and vaginal delivery is anticipated within 8-12
hours. Otherwise, caesarean section is indicated
but never give general anaesthesia before control
of convulsions or if the patient is in coma.
 Intra-and postpartum care : as in pre-eclampsia.
PRE- EXISTING (CHRONIC) HYPERTENSION
 Causes
(i) Essential hypertension: of unknown aetiology.
(ii) Secondary to chronic renal disorder:e.g.

 - Glomerulonephritis.
 - Hydronephrosis.
 - Pyelonephritis.
 - Renal artery stenosis.
(iii) Secondary to cardiovascular disease:e.g.

 - Coarctation of the aorta.

 - Polyartheritis nodosa.
 - Systemic lupus erythematosus.
(iv) Secondary to endocrine disorders:e.g.

 - Primary aldosteronism.
 - Phaeochromocytoma.
 - Adrenocortical tumours.
 - Diabetes mellitus.
 Effect Of Pregnancy On
Chronic Hypertension
 Blood pressure falls by the second trimester in most of cases, but rises during the third trimester to a level some what above that in
early pregnancy.
 Deterioration of the underlying disease.

A- Maternal:
 superimposed pre-eclampsia/ eclampsia in 15-20% of cases.

Effect Of Chronic Hypertension

B- Foetal :
 (1) Intrauterine growth retardation.
 (2) Intrauterine foetal death.

On Pregnancy
 Treatment
 (1) General and medical treatment:
 As pre-eclampsia regarding the following:
 - Rest,
 - Sedatives,
 - Antihypertensives,
 - Diuretics,
 - Observation.
 (2) Obstetric measures:
 a.Therapeutic abortion : in severe cases not responding
to treatment.
 b. Preterm delivery if there is:
 marked deterioration of the underlying disease.
 indication for termination as in pre-eclampsia if it is
 superimposed.
 intrauterine growth retardation.
 c. Delivery at 37 completed weeks as intrauterine foetal
death may result
 from deteriorating placental functions.