Ecalmpsia

def
• Convulsions on top of severe PE.
• It could be considered as an advanced state of severe
PE.
• In high-resource countries, pre-eclampsia is currently
reported to occur in 2–8 % of pregnancies and eclampsia
to complicate 0.2–0.3 % of these cases, for an overall
incidence of 0.004– 0.02 % of births.
• In many low- and medium-resource countries, the
reported incidences of pre-eclampsia and eclampsia are
much higher.
 Risk factors
• Primigravida
• Extremes of reproductive age
• Family history of pre-eclampsia
• Gestational or pre-existing diabetes
• Chronic hypertension or renal disease
• Multiple pregnancy
• Gestational trophoblastic disease
• Hereditary or acquired thrombophilia
 Pathophysiology
 Endothelial lesion,
 Exaggerated microvascular permeability,
cerebral oedema
 Pericapillary haemorrhage are common
 Complications
• Maternal mortality occurs in about 0.07 % of eclampsia
cases, and the main causes are intracranial haemorrhage,
acute pulmonary oedema and multi-organ failure.
• Maternal morbidity includes acute pulmonary oedema,
DIC, renal insufficiency and more rarely intracranial
haemorrhage and rupture of subcapsular hepatic
haematoma
• perinatal deaths : Iatrogenic prematurity
other causes ??
 Types
• Antepartum : 50%
• Intrapartum : 25%
• Postpartum :25%
 Clinical presentation
1- premonitory stage: the eyes roll up with
twitches of the face and hands
2- tonic stage: generalized tonic contraction of
the whole body muscles with opisthotonous and
cyanosis. lasts 20 sec
3- tonic stage: alternative contractions and
relaxation of the body muscles. The face is
congested, the tongue may be bitten . Blood
stained frothy saliva appears on the mouth.
Breathing is sterotous, urine and stool may pass
involuntary, temp. rises due to increased muscle
activity.60 sec
4- coma may last few hours, other fits may occur
again during coma
 Severity of eclampsia
• Considered to be severe if one or more of the
following is present (Eden,s criteria)
1- coma of 6 h or more
2- temp 39 or more
3- pulse over 120bpm
4- RR over 40 m
5- more than 10 convulsions
 dd
• Epilepsy
• Intracranial haemorrhage.
• Cerebral venous thrombosis
• Thrombotic thrombocytopenic purpura
• Cerebral stroke
• Metabolic causes
 Imminent ecalmpsia
• Ecalmpsia is an advanced stage of PE
1- Epigastric pain : stretch of Glisson capsule of
the liver
2- Headache : cerebral hypoxia
3- Visual symptoms :blurring of vision
 management
• Control BP- CONVULSIONS
• Terminate Pregnancy
• Prevent new fits
 Management
• Anticipate and Prevent the Situation
• Ask for Help
• Avoid Lesions During the Eclamptic Seizure
• Left Lateral Safety Position, Inspect Airway and
Monitor
• Prevention of New Seizures
• Other Non-emergent Measures
• Decreasing Blood Pressure
• Recurrent Seizures
• Maintenance Dose of Magnesium Sulphate
• Fluid Balance
• Thromboprophylaxis
• Evaluation of Laboratory Results and Fetal
Evaluation
• Programming Birth
 Anticipate and Prevent the Situation
• In patients with pre-eclampsia, the prodromal
symptoms of severe frontal headache, continuous
epigastric pain and visual complaints (blind spots, fl
ashes, double vision and blurred vision) should alert to
impending eclampsia.
• Intravenous magnesium sulphate should be
started to prevent seizures and termination of
pregnancy the key elements for preventing
eclampsia.
 Ask for Help
a senior obstetrician , and an anaesthetist . The
anaesthetist will usually focus on maternal
monitoring and maintenance of the airway, while
the obstetrician will concentrate on starting
magnesium sulphate and fetal monitoring.
Avoid Lesions During the Eclamptic Seizure

Restraining tonic-clonic movements is

dangerous and confers no benefi t to patients,
so the recommended attitude during the seizure
is to remove all objects that may
cause injury and wait until it ends, which usually
takes less than 90 s.
 Left Lateral Safety Position, Inspect Airway
and Monitor
When the seizure ends, the patient should be placed in left
lateral safety position and the airway quickly inspected for
patency . In a second step, oropharyngeal secretions may be
aspirated if they are abundant, a Mayo tube inserted if the
patient remains unconscious and breathing is made diffi cult by
the tongue and oxygen by mask .
 Monitoring maternal and fetal
• Maternal heart rate and oxygen saturation
should be monitored continuously and blood
pressure evaluated every 5 min.
• Maternal ventilation also requires frequent re-
evaluation.
• continuous cardiotocography should be put in
place to evaluate fetal oxygenation.
 Prevention of New Seizures
 loading dose of magnesium sulphate
 4 g magnesium sulphate IV over 5–20 min
 Maintenance dose
 1g magnesium sulphate IV per hour
 Mechanism : NMT. VD. Diuresis
 Therapeutic level : 4-8 mEq/L
 Monitoring :Patellar Rx, RR, urine output,pulse oxymetry
 For how long
 Antidote:
 Other Non-emergent Measures
After the acute response to eclampsia described
above, the situation still requires continuous
monitoring and further management. Blood should
be drawn for haemoglobin , platelet count , liver
and renal function and coagulation studies.
Bladder catheterisation should be performed to
measure urine output , important for fluid balance
and for optimising magnesium sulphate treatment.
 Decreasing Blood Pressure
• When maternal blood pressure rises above 160 / 110
mmHg, it becomes necessary to reduce it, because of
increased risks of cerebral haemorrhage, cardiac
insufficiency, myocardial infarction and placental
abruption.
Labetalol
Nifedipine
Hydralazine
During antihypertensive treatment, blood pressure
should initially be monitored every 5 min, and the
interval is then spaced according to treatment results.
The goal is to maintain systolic blood pressure between
140 and 150 mmHg and diastolic blood pressure
between 80 and 100 mmHg. Lower diastolic blood
pressures may put cerebral and uterine perfusion at risk.
 Recurrent Seizures
intravenous bolus of 2–4 g of magnesium
sulphate can be given over the course of
5 min.
If seizures persist, the diagnosis of eclampsia
should be reconsidered and are-evaluation
carried out with the help of a neurologist.
 Intravenous diazepam is less efficient than magnesium
sulphate for preventing recurrent seizures and
reducing maternal mortality, but is a possible
alternative, given in a 5 mg bolus over the course of 5
min and repeated if necessary to a maximum of 20
mg.
• Prolonged use of diazepam should be avoided, as it is
associated with an increased risk of maternal
death and neonatal respiratory depression.
 If seizures persist, intubation and ventilation
remain as a last resource, in an intensive care unit
setting.
 Fluid Balance
The increased vascular permeability found in women with
pre-eclampsia increases the risk of acute pulmonary
oedema, cardiac insufficiency and cerebral oedema. For
these reasons, total fluid volume should not exceed 83
ml / h (2 L in 24 h) except if
there are other sources of fl uid loss, such as haemorrhage.
Colloids should not be administered except in life-saving
situations. Oliguria does not usually require additional
measures beyond fluid adjustments to the established
limits, as it will revert spontaneously 36–48 h after delivery.
 Thromboprophylaxis
Women with severe pre-eclampsia and
eclampsia are at increased risk of venous
thrombosis, so compression stockings and
prophylactic doses of low molecular
weight heparin need to be considered according
to local protocols, until the patient
is fully mobile.
 Evaluation of Laboratory Results and Fetal
Evaluation
The urgency of pregnancy termination and the method of
delivery depend on the
clinical stability of the situation; on laboratory results depicting
the severity of preeclampsia,
particularly the degree of thrombocytopenia and liver enzymes;
and on
the fetal condition. Pre-eclampsia may be associated with
chronic placental insuffi
ciency, so fetal ultrasound is required to evaluate fetal growth,
amniotic fl uid volume
and umbilical and cerebral blood fl ow.
Programming delivery
Management summary
 q
• 5 uses of MgSO4
• Antidote for MgSO4 toxicity
• 1st sign of MSO4 toxicity
• Imminent eclampsia
Thank you