“To my Hypertensive's & Eclamptics , I pledge my devotions.In their good outcome& wellbeing alone,lies my happiness.” Dr. Shrinivas Gadappa Professor & HOD Government Medical College & Hospital, Aurangabad.

Monitoring & management of Eclampsia

Dr. Shrinivas Gadappa Professor & HOD,

Government Medical College & Hospital, Aurangabad.

OBJECTIVES• Magnesium sulphate protocol• Antihypertensive• Obstetric Management• Induction & Augmentation agents• Intrapartum monitoring• Postpartum care• Summary

HYPERTENSION CLINIC

WHO SHOULD MANAGE HDP

Monitoring Targets in Pre-Eclampsia.....

HISTORY WITH HIGH RISK CONSENT• Detailed history with

high risk consent is to be taken from relatives regarding

- duration of pregnancy

- number of convulsions

- nature of medication received outside

Monitoring• Maternal• Fetal• Progress of labour• Complications• Supportive speciality• Stage 4• Puerperium

Be ready with ECLAMPSIA TOOL KIT

GENERAL EXAMINATION

• Check Pulse , BP , RR

• Use Pulseoximeter.

Examination•Once patient is stabilised

quick general , abdominal and vaginal examination is done.

•Restrict use of IV fluid

THREE steps in management

- Treat convulsion and Prevent further episode of convulsion

- Control of Hypertension

- Obstetric intervention

Antihypertensive

LABETALOL

Selective α1 receptor blockade

Nonselective ß receptor blockade

Target BP range

• SBP 140-150 mm Of Hg • DBP 95-105 mm Of Hg

MAGNESIUM SULPHATE is

Gold Standard.

Various regimens have been described for magnesium sulphate

administration in eclamptics but most commonly used one is PRITCHARD’S

REGIMEN.

INTRAVENOUS INTRAMUSCULAR

• IM dose is given in upper outer quadrant of buttock with 20 gauge 3 inch needle and 12 cc syringe.

• It is available as 50% w/v, so total loading dose is 20ml ( 10 gm), 5grams in each buttock

•MgSo4 is available as 2ml ampoule(50% w/v).

4gm (8ml) of MgS04 in 100 ml of NS over 10 min.

MgSO4 Loading dose

REGIMENS OF MgSO4 FOR MAINTENANCE

PRITCHARD’S REGIMEN ZUSPAN AND SIBAI REGIMEN

• 5 gm (10ml of 50%) given deep IM in alternate buttock every 4 hourly

• 1-2 gm/hr as IV infusion .

MgSO4 is to be continued till 24hrs of delivery or last episode of convulsion; Whichever is later.

Guidelines for magnesium sulphate administration

Monitoring for magnesium toxicity

• Uine output >30 ml /hr• DTR present• RR > 14 breaths /min.• Pulse oximetry > 96%

RECURRENCE OF CONVULSIONS Within 20 mins of loading dose

Recurrence more than twice

Wait & watchwith the supportive care

Switch over to Phenytoin 10mg/kg in 100ml NS IV over 1/2hour maintenance dose 100mg IV8hrly

After 20 mins of loading dose/while on

maintenance dose

Give 2 gm in 20%of IV MgSO4 over5mins; continue withscheduled dose .

STATUS ECLAMPTICUS : IV Thiopentone sodium given by ANAESTHETIST and intubate patient

Key Message

Key Message

Modified Obstetric Early Warning System (MEOWS)

Preeclampsia Early Recognition Tool

(PERT)

Modified Obstetric Early Warning System (MEOWS)Preeclampsia Early Recognition Tool (PERT)

Monitoring of Non severe PE

Monitoring of Severe PE

Monitoring of Post Eclamptics seizure &Toxicity of drug

Eclampsia - radiographic evaluation• should be reserved for women with

neurological deficit, recurrent seizures, or atypical presentation

• abnormal CT findings - 50%• edema, hemorrhage, infarction

• cerebral angiography has limited use• 90% of EEG evaluations may be

abnormal

INVESTIGATIONS

Indications of Central Venous Catheterization

• Central venous pressure monitoring• Volume resuscitation• Cardiac arrest• Lack of peripheral access• Infusion of hyperalimentation• Infusion of concentrated solutions• Placement of transvenous pacemaker• Cardiac catheterization, pulmonary angiography• Hemodialysis

OBSTERIC MANAGEMENTEclampsia

• Delivery is indicated regardless of gestational age

• Immediate cesarean delivery is not necessary

MATERNAL AND FOETAL OUTCOME IN ECLAMPSIA

• Study location – GMCH ABAD

• Total no of ECLAMPSIA- 335

• Study duration – 2013- 2015

Govt. Medical College & Hospital, Aurangabad (MS)

Distribution on the basis of the mode of delivery in eclampsia patients

Cut short second stage of labour with help of vacuum/ forceps as per requirement.

Second Stage

Onset- delivery Interval

• In severe pre-Eclampsia, delivery should occur within 24 hours of the onset of symptoms.

• In Eclampsia, delivery should occur within 12 hours of the onset of convulsions.

Eclampsia - management of fetus

– fetal bradycardia during seizure • ~ 5 minutes after the onset of the seizure• may be associated with rebound tachycardia• recovery phase may show late decelerations

– monitor for uterine hypertonicity• allow for fetal recovery• monitor for signs of abruption

• This system provides accurate continuous measurements of dilatation and station.

• The method is superior to digital examination and provides real time diagnosis of non-progressive and precipitous labor.

• The system is likely to reduce discomfort and infections associated to multiple vaginal examinations..

COMPUTERIZED LABOR MANAGEMENT

The Fetal Monitoring System is a computer based training system that can be

accessed over the anywhere, anytime, from within a hospital or from a home.

fetal monitoring by CTG.

H D U

In first stage of labour:–Use partograph

e-Partograph

If caesarean section is performed

ensure that:• Coagulopathy has been ruled out;• Safe general anesthesia is available.

Spinal anesthesia is associated with the risk of hypotension..

• Epidural is safer• Do not use local anesthesia or ketamine

AVOID POOR JUDGEMENT

Judgment comes from experienceExperience comes from poor

judgment

Anticipate PPH and PPH prophylaxis is to be given.

Preferably use 2 uterotonics (oxytocin + misoprostol).

Methargin is contraindicated.

PPH - BOXPPH - BOX

GOOD OUTCOME

SUCCESS

NOT YET OVER

•Postpartum care is the second half.

In an Eclamptics movie , delivery is the interval

Fourth stage of labour Intense monitoring of vitals and per vaginal bleeding every 15 min for 1 hour and then every half hourly for the next hour.

(WHO guidelines 2015)

Post Partum Care.

• Kept under close observation.

• MgSO4 infusion continued for prophylaxis.

Careful fluid balance

• Decrease dose of antihypertensive with caution

• 2 weeks therapy of AHT

• FOLLOW UP……….MUST

Fluids should be restricted to 75ml/hr. & AHT

Strict monitoring continued…..

Smoking is injurious to health

Four steps - Treat convulsion and Prevent further episode of convulsion- Control of Hypertension- Obstetric intervention- Post partum care

Possible only after monitoring

Take Home Message

God help those who help themselves

THANK YOU• Sibai BM. Hypertensive disorders in women. 2001.

• Witlin AG, Sibai BM. Magnesium sulfate therapy in preeclampsia and eclampsia. Obstet Gynecol 1998;92:883-9.

• Sibai BM. Diagnosis and management of gestational hypertension and preeclampsia. Obstet Gynecol 2003;102:181-92.

• Sibai BM. Diagnosis, prevention, and management of eclampsia. Obstet Gynecol 2005;105:402-10.

• To my Hypertensive's and to my people I pledge my devotions, in their well being alone lies my happiness

Dr. Shrinivas Gadappa Professor & HOD Government Medical College & Hospital, Aurangabad