PIH and Eclampsia
Dr. V. L. DeshmukhAssociate Professor
Dept. of OBGY
Govt. Medical College
AURANGABAD
Maternal Mortality
Major causes of maternal mortality are
• PIH
• Eclampsia
• APH
• PPH
• Puerperal sepsis
• Obstructed labour
• Unsafe abortions
Introduction
• Hypertensive disorders in pregnancy
• Significant maternal morbidity
• Fetal morbidity and mortality
• Includes PIH, pre-eclampsia, eclampsia, chr. Hypertension, chr. Hypertension with superadded PIH
Definition
• Multi systemic disorder
• After 20 wks
• B.P. > 140/90 mmHg
• Proteinuria
• Edema
• Excessive wt. Gain
ClassificationFinding Mild pre-eclampsia Severe pre-eclampsia
B.P. •The diastolic pressure rises 1`5-20 mmHg above the “usual’ level, OR
•The absolute level of BP is >140/90 mmHg but <160/110 mmHg
The diastolic pressure rises >20 mmhg above the ‘usual’ level; OR
The absolute level of BP is 160/110 mmhg
Proteinuria Present, but 2+ or less 3+ or persistently greater
Generalized edema (including in the face and hands)
May or may not be present
Present
Headache Absent Present
Visual distrubances Absent Present
Upper abdominal pain Absent Present
Oliguria Absent Present
Diminished fetal movement Absent Present
Eclampsia
• Characterized by convulsions and/or coma
• Women has PIH
• Types antepartum, intrapartum and postpartum.
• No lower limit of B.P. for eclampsia can even occur at 120/80 mmHg
Fulminating Eclampsia
Symptoms :• Severe headache• Drowsiness• Mental confusion• Visual distrubances• Epigastric pain• Nausea, vomiting• Decreased urinary output
Signs
• A sharp rise in B.P.
• Increased proteinuria
• Exaggerated knee jerk
Status Eclampticus
• Continuous convulsions
• Dangerous for mother and fetus
• Can lead to fetal and maternal mortality
Stage of Eclampsia
• Premonitory
• Tonic
• Clonic
• Coma
Eclampsia
• Can occur regardless of severity of hypertension
• Difficult to predict • Tonic clonic• Rapid sequence• Can occur in the absence of hyper-
reflexia, headache and visual disturbances.
D/D of Eclampsia
• Epilepsy
• Cerebral malaria
• Meningitis
• Encephalitis
• Tetanus
• Head injury
Effect on Mother
• Asphyxia• Aspiration• Pulmonary edema• Bronchopneumonia• Cardiac failure• Brain hemorrhage• Cerebral thrombosis• Cerebral edema
Effect on Mother
• ARF
• HELLP
• DIC
• Temporary blindness
• Injuries
• Tongue bite
Effect on Fetus
• Hypoxia
* IUGR
* Stillbirth
High risk for Eclampsia
• Teenagers / elderly primi.
• Essential HT
• Twins
• Women with DM, polyhydramnios, V. mole
• H/o eclampsia
• Obese women
Mortality due to Eclampsia
• Failure to monitor B.P. in ANC• Failure to monitor proteinuria• Lack of clear-cut mgt. strategy for PIH• Lack of proper equipment and drugs.• Late referral• Failure to counsel women & her relatives
about S/s of PIH & ANC• Failure to timely manage complications of
Eclampsia.
Diagnosis
• Pregnant women or PNC complaints of severe headache, blurred vision
• Unconscious
• Convulsions
• Elevated B.P.
Mgt. of PIH
• ANC• Check B.P.• Proteinuria• Body edema• Weight• Regular ANC check-up• Rise in B.P.• Refer
Mild PIH
• B.P. 140/90 mmHg but less than 160/110 mmHg.
• < 37 wks
• > 37 wks
- TERMINATE
Mild PIH
< 37 wks.• Bed rest• Wkly visit• Check B.P.• Proteinuria• Wt. Of the patient• Body edema• Exclude S/o severe PIH• DFMC• Check FHS
Mild PIH
BOOK THE PATEINT FOR DELIVERY AT BEmOC CENTER.
Mild PIH
> 37 wks.• Assess cervix• Accelerate delivery• Check B.P. 4 hrly.(2 hrly if severe
PIH)• Bed rest• Proteinuria B.D.• Monitor FHS
Mild PIH
• Give sedation
• Give antihypertensive
• Only if diastolic B.P. is > 110 mmHg
Eclampsia
Six major steps :
1. Maintain airway
2. Control fits
3. Control B.P.
4. Deliver the pt.
5. Maintain fluid balance
6. Give after care of delivery
Eclampsia
Maintain airway :1. LLP2. Gentle section3. Oxygen4. Place padded tongue blade in her mouth
to prevent aspiration and tongue biteDO NOT ATTEMPT THIS DURING
CONVULSIONS
Eclampsia
Control fits :MAGSULF THERAPY
• Dose – Inj. MgSo4 – 4 gm (20 ml of 20% sol.) slow I.V. at the rate of 1 ml / min.
NOT TO BE GIVEN AS BOLUS
• Maintenances dose 5 gm deep I.M. every 4 hrly.
Eclampsia
• If convulsions recur give additional 2 gm magsulf (10 ml of 20% sol.) I.V. over 20 min.
• Wait for 15 min.
• If still convulsions recur – give diazepam
REFER
Eclampsia
Monitoring of MgSo4 therapy
1. Output atleast 100 ml/4 hrs.
2. Knee jerk present
3. Respiratory rate 16 breath/min
POSTPONE THE NEXT DOSE IF ABOVE CRITERIA NOT MET
Eclampsia
Precautions :
Do not give
1. 50% MgSo4 without diluting it to 20%2. Rapid I.V. infusion as it may cause
respiratory failure and deathIf respiratory depression occurs (RR < 16/min)
1. Discontinue MgSo4 2. Give calcium gluconate - 1 gm I.V. (10 ml of
10% solution) over a period of 10 min.
Eclampsia
Other options available are :
1. Diazepam (10 mg I.V. slowly over 2 min.)
2. Phenytoin sodium
3. Largactil
MgSO4 IS SUPERIOR TO ALL ABOVE DRUGS IN ECLAMPSIA
Eclampsia
Controlling the B.P.
• Tab. Depine – 10 mg t.d.s.
• Tab. Labetelol – 50 mg b.d.• Other drugs available – Hydralazine
Eclampsia
Controlling fluid balance :1. Intake output chart2. Output 100 ml/4 hrs.3. 60 ml /hr fluid intake4. Extra fluid if vomiting, excessive blood loss or
diarrhoea.PROPER MAINTENANCE OF FLUID BALANCE
TO PREVENT WATER INTOXICATION, DEHYDRATION, HYPONATREMIA OR PULMONARY EDEMA.
Eclampsia
DIURETICS SHOULD NOT BE USED, IT IS DANGEROUS
Eclampsia
Delivering the baby1. If PIH deliver within 24 hrs.
2. If eclampsia deliver within 12 hrs.
3. If vg. Delivery is not anticepated or Cx is unfavourable or S/o fetal distress, REFER
Eclampsia
Delivery 1. Before labour
- Control B.P.- Control fits
REFER2. Late 1st stage / 2nd stage
- Carry out Vg. deliveryREFER
Eclampsia
Difficult deliveries :1. Labour not progressing quickly
2. Big size baby
REFER
GIVE MgSO4
Rule of Thumb
• Pt. with severe PIH comes early 1st stage of labour – REFER
• Pt. comes in late labour or 2nd stage – conduct delivery, give MgSO4 – REFER
Rule of Thumb
Eclampsia – Postpartum Care
1. Refer pt. After one hr. of delivery after ruling out PPH
2. If pt. Has fits, observe for 48 hrs. after convulsions.
3. Closely observe her consciousness, output
4. Monitor B.P. every hrly.
5. Given anti-hypertensives till B.P. comes down to 100 mmHg diastolic
Eclampsia – Postpartum Care
• Do not give excessive IV fluid• If after 72 hrs. there are no convulsions,
output is good, and B.P. is 100 mmHg diastolic – discharge the pt.
• Arrange for follow-up – 7 to 10 days after delivery.
CONTINUED FITS – REFER WITHOUT DELAY
Eclampsia – Postpartum Care
Following Eclampsia B.P. may :
1. Return to normal within 48-72 hrs.
2. Return to normal after a few wks. May remain high permanently.
Referral• Should be
transported by the quickest mode of transport
• 3 delays
Through a team approach all of the skills of the health care members involved can be combined to provide the best possible approach to meet the pregnancy’s need. The role of patient education can not be
over emphasized. Incorporating the mother as an active member in her health
care is an investment in time and effort that is cost effective both during
pregnancy and labour.
A systematic & a well begun programme with a positive thinking will definitely show
road to success to accept this challenge
Top Related