Shamsuddin_Prevention of PE E Including Community Level Intervention in Bangladesh

8/2/2019 Shamsuddin_Prevention of PE E Including Community Level Intervention in Bangladesh

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Prof Latifa Shamsuddin

President Elect, OGSB

Prevention of Pre-eclampsia and Eclampsia

through Community Level Interventions in

Bangladesh


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Maternal HealthScenario- last 10 years

MMR:

322/100,000 live birth

Annual maternal deaths: 12,000

Delivery by skill birth attendants:18%

Facility Delivery: 15%

MDG 5: To reduce maternal deaths by 2015 to143/100,000 live births

(Source: BMMS 2001)

MMR:

194/100,000 live birth

Annual maternal deaths: 7,332

Delivery by skill birth attendants:32%

Facility Delivery: 29%(Source: BMMS: 2010 & BDHS 2011)

During the period of 2001-2010

Maternal Mortality Ratio reduced by 40%

Maternal Mortality Ratio reduced due to Eclampsia: 50%


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Eclampsia

20%

Abortion

1%

ObstructedLabor

7%

Indirect

5%

Hemorrhage

31%

Others

16%

Direct

20%

Eclampsia

24%

Indirect

17%

Hemorrhage

28%Others16%

Direct

15%

Casue of Maternal deaths

Source: BMMS-2001

Casue of Maternal deaths

Source: BMMS-2010

Causes of Maternal Deaths in Bangladesh


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Eclampsia Treatment Regimen in Bangladesh

Until 1968 Inj. Morphine / Pethedine

1972 Lytic cocktail: Inj. Pethedine, Inj. Largactil, Inj.

Phenargan with Normal saline/aqua 500 cc I/V

Diazepam therapy:

10 mg I/V slowly for 20 min; then maintain by 40 mg

diazepam in 500 ml I/V fluid in infusion form

Very high maternal mortality and morbidity (neurological,

CVS, RD Syndrome), bad fetal outcome (resp. depression)

Do not give 100 mg in 24 hours


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Eclampsia Treatment Regimen (Contd.)

Hydralizine

5 mg I/V bolus every 5 min until BP decline

Infusion 25 mg in 200 CC in Normal Saline

Labetalal- 200 mg in 200 ml Normal Saline in 20 drops/hours

1994 MgSo4

In DMCH, first trial

68% eclamptic death

2001 MgSo4 in community .

1998-2001 Participated in Magpie trial- 22 countries including

Bangladesh 2003 Follow up study was done both for mother and child up to

2 years


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Flow chart for MgSO4

Magnesium Sulphate (4g= 8ml) IV

diluted in 12 ml distilled water { 20ml of 20% solution}

Intravenous injection

over a period of 10-15minutes

Magnesium Sulphate (6g = 12ml)of 50% solution

Deep IntramuscularInjection, 3g=6 ml in each

buttock

Magnesium Sulphate (2.5 g = 5ml)of 50% solution

Deep Intramuscular injection2.5 g every 4 hourly in alternate

buttock.Continue for 24 hours after lastconvulsion or delivery (If needed)

Maintenance Dose

Loading Dose ( 4 gm + 6gm)

(Source:

EmOC Protocol, OGSB, 2009)

Inj. Nalepsin MgSo4 4g = 100 ml

Or

60-70 drops/minute


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Control of B.P.

Diastolic Pressure more than

110 mm Hg.Systolic pressure less than 80 mm Hg

or BP is not recordable

Inj. Dopamin, 1 amp (200mg) in 200ml

of NS IV @ 8-10 d/m till systolic

pressure is 120 mm Hg.

Check BP every 15 min. interval and stop

drip when Diastolic Pressure is 90 mm Hg.

Management of Severe Pre-eclampsia and Eclampsia

Inj. Hydralazine, 1 amp (20mg) in200 ml of NS IV @ of 8-10 d/m

Or Injection Labeta is used to controlacute hypertension.


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Differences of Dose between Bangladesh andInternational Standard Regimen

Regimen used in Bangladesh Loading dose = 4gm I/V + 6gm I/M = 10 gram and

maintenance dose is 2.5 x 6 = 15 gram

Total dose = 10 + 15 = 25 gram

Standard Regimen Loading dose = 4 gm I/V + 10 gm I/M = 14 gram and

maintenance dose is 5 x 6 = 30 gram

Total dose = 14 + 30 = 44 gram

Bangladeshi regimen is almost half of the standardregimen


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Madhupur

Study at the community

level on Prevention of

Severe Pre-Eclampsia

and Eclampsia

Source: BMRC. Bulletin, 2005: 31 (2): 75-82


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Objectives

To determine the effectiveness of early administrationof injection Magnesium Sulphate in PEE patients atthe community level to prevent fits before referral to

hospital

To examine whether early intervention of convulsionby Magnesium Sulphate and proper obstetric

management can reduce both maternal and perinatalmortality


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Methodology Type of Study:

Quasi-experimental Community based prospective interventional study

Study Period: July - December 2001

Study Population: Eclampsia and severe pre-eclampsia cases of study area

Sample Size: 265 cases

133 were in intervention group (patients with eclampsia or severe

eclampsia receiving loading dose of MgSo4 before referral)

132 in non-intervention group (patients with eclampsia or severe

eclampsia coming directly to hospital from same area but without

receiving loading dose of MgSo4 before referral; but they received

injection MgSo4 after admission in the hospital)


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Training of doctors


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Involvement of the communityhealth workers


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To reduce maternal mortalitycommunity awareness


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Awareness creation in the community


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Maternal Outcome of the study

2.3

17.3

1.5

6.01

8.2710.4

27.3

2.27

6.06

12.87

0

5

10

15

20

25

30

Intervention Group Non-intervention Group

Maternal Deaths Pulmonary edema Renal Failure Obstetric shock PPH

The number of patients who developed complications in intervention andnon-intervention groups show statistically significant difference ( p


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Foetal outcome of the study

Perinatal out-come of non-intervention group was poorer than interventiongroup though both groups were managed in the same way after admission

in the hospital

86.2

67.6

18.6

13.7

20.4

84

52.4

27.6

0

10

20

30

40

50

60

7080

90

Intervention

(n= 102)

Non-Intervention

( n= 105)

Alive

Healthy

AsphyxiaStilborn


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Study Conclusion

The findings of this study concluded Earlier administration of injection Magnesium Sulphate at

the community level is effective before referral to hospital

Useful result was found regarding control of convulsion by

early loading dose, recurrence of fit, maternal and fetaloutcome

Hence, the study highly recommended:

To administer early injection of MgSO4 To include the loading dose of MgSo4 before referral in

the national protocol


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Findings on Complete IM regimenTo find out the feasibility of using IM administration of MgSO4,

study was conducted in Dhaka and Chittagong Medical Colleges:

Loading dose = 10gm I/M ( 5 gm in alternate buttock) andmaintenance dose is 2.5 x 6 = 15 gram

In Chittagong Medical College Hospital ( n= 300)

There was no abscess

Patient tolerable

Recurrence of convulsion only 3% in absence of maintenance doseand no recurrent convulsion in presence of maintenance dose

In Dhaka Medical College Hospital - DMCH( n = 200)

Similar kinds of findings


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Intramuscular loading dose vs combined IV

and IM loading dose of MgSo4 in the

management of eclampsia in a tertiary levelhospital.

Study conducted by Dr. Salma Rouf, DMCH

A pilot project is conducting in DMCH where IMadministration of MgSo4 is found to be equally effective

both in preventing and controlling of recurrent fit.


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Administration of MgSo4 at the Community

Level

Pilot project at Hobiganj throughGovt., MaMoni, Mayer Hashi, OGSB& ICDDR,B.

High numbers maternal and perinatal

death FWV, SBA, HA will work in that area,

they will diagnose severe PE andeclampsia and will administer IMMgSo4 (10 gm) referral center.

Same type of work will be done inanother district like Bramhanbaria.

Referral center will manage accordingto OGSB protocol.


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Decision Algorithm: Community management

Who andWhere

What and HowMeasure BP If diastolic is >= 90 mm Hg,repeat measure after 1 hour

Urine exam for protein

FindingsDiagnosisManagement

DBP 100 --


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Challenges Though, health infrastructure in Bangladesh exists up to the

grass root level; a system of registering pregnant women hasnot been developed

Lack of confidence among the facility based service providersre administering the loading dose

Large number of floating people in both urban and ruralareas with poor socio-economic conditions

Some families changed their residence without leaving aforwarding address

Flood and river erosion affected the study. Thus it becamedifficult to contact/trace the patients


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Challenges


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Shamsuddin_Prevention of PE E Including Community Level Intervention in Bangladesh

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