EKLAMPSIA

Presentan: dr. Rusdianto Anggota kelompok: dr. Indra Permana dr. Tri Wahyuni

PENDAHULUAN
Kasus ASLI Alasan mengankat kasus:
Kasus kedaruratan 5 besar penyebab AKI tertinggi di Indonesia

Yang menarik dari kasus:

Eklampsia post partum

Fokus pembicaraan:
Penanganan kasus eklampsia

Tujuan presentasi:
Menambah wawasan mengenai penggunaan MgSO4 dalam penanganan kasus ekampsia

DATA ADMINISTRASI PASIEN

Nama : Ny. N Status kepegawaian : swasta (IRT) Status sosial : menengah ke bawah

DATA DEMOGRAFIS
Alamat : Dusun Sekip, Rt 05/Rw 05 Kec. Sungai Kunyit, Kab. Pontianak Agama : Islam Suku : melayu Pekerjaan : ibu rumah tangga Jenis kelamin : perempuan

DATA BIOLOGIK
Umur : 18 tahun Tinggi badan : 157 cm Berat badan : 60 kg

ANAMNESIS
(21/07/2011)

Keluhan Utama : kejang Riwayat Penyakit Sekarang :

Pasien datang ke RSUD dr. Rubini dengan keluhan kejang saat melahirkan. Kejang di rumah sebanyak 3 kali selama proses melahirkan. Pecah ketuban sejak pukul 05.00 WIB.

Riwayat Penyakit Dahulu :

Tidak ditemukan riwayat menderita darah tinggi. Os tidak pernah kejang sebelumnya.

 Riwayat Perkawinan :
Menikah 1 kali

Riwayat Obstetrik :
Kehamilan saat ini merupakan kehamilan yang pertama

Riwayat Kehamilan Sekarang :

Total periksa hamil 3x ke bidan. HPHT 22 Oktober 2010. Selama kehamilan tidak ditemukan kelainan dalam kandungan pasien. Selama kunjungan antenatal tidak pernah menderita tekanan darah tinggi. Taksiran persalinan tanggal 29 Juli 2011. Kehamilan 38-39 minggu, siklus haid teratur, 7 hari.

 Riwayat persalinan sekarang :

Mulas Pengeluaran darah lendir Mengejan Keluar air banyak :+ :+ :+ :+

PEMERIKSAAN FISIK
Berat badan Tinggi badan Keadan umum Kesadaran Tanda vital

: 60 kg : 157 cm : baik : kompos mentis :

Tekanan darah : 150/110 mmHg Nadi : 98 x/menit Pernapasan : 18 x/menit Suhu : 37 0C

PEMERIKSAAN FISIK
STATUS GENERALIS
Mata : konjungtiva tidak anemis, sklera tidak ikterik, pupil isokor (3mm/3mm), refleks cahaya +/+ THT : tidak ditemukan kelainan Leher : tidak ditemukan kelainan Jantung: tidak ditemukan kelainan Paru : tidak ditemukan kelainan Ekstrimitas: pitting edema pretibial bilateral

PEMERIKSAAN FISIK
STATUS OBSTETRIK : 21/07/11(06.20WIB) Pemeriksaan luar : TFU : 3 jari px (32 cm) DJJ : 160x/menit His :2x/10 , 20-40 Kedudukan: kepala Punggung :kiri Pemeriksaan dalam Pembukaan : lengkap Presentasi : kepala Hodge : III Caput :+ Ketuban :-

PEMERIKSAAN PENUNJANG
Proteinurin : (-)

DIAGNOSIS
Inpartu Kala II pada G1P0A0 Hamil aterm dengan Eklampsia

TERAPI (IGD)
Akselserasi persalinan dengan injeksi syntosinon 5 IU drip dalam RL 20 tetes/menit Rencana partus pervaginam

FOLLOW UP :
21-07-2011, pukul 06.45WIB Sudah partus spontan dengan akselerasi persalinan, anak perempuan hidup, apgar score 3/5 langsung dirawat di perinatologi. Plasenta lahir spontan, lengkap, perineum intak Perdarahan 150cc, kontraksi uterus baik Tekanan darah Post partus 130/90 mmHg observasi tanda-tanda vital, perdarahan.

21-07-2011, pukul 07.50WIB S : kejang O : TD 170/100 mmHg A : Eklampsia P : pertahankan jalan nafas (tongue spatula) Oksigen 4L/menit Diazepam 10mg (IV lambat)

21-07-2011, pukul 08.00WIB S : kejang berhenti. Pasien tidak sadar O : Kesadaran : koma tekanan darah : 170/100 mmHg nadi : 80 x/menit, teratur, kuat angkat pernapasan : 18 x/menit, teratur suhu : 370C Proteinurin : + (kualitatif) A : Eklampsia P : pertahankan jalan napas Oksigen 4L/mt

 P : Regimen MgSO4 40%

Loading dose: MgSO4 40% 4gr (IV Lambat) dilanjutkan dengan injeksi IM Bokong kanan & kiri masing-masing 4 gr Maintenance dose: MgSO4 40% 4gr/4jam (IM) selama 24 jam setelah kejang terakhir Pasang DC Pantau TTV (tekanan darah, nadi, RR) & produksi urin

22-07-2011, pukul 07.50WIB S : keluhan (-), kejang (-) O : KU baik TD 170/100 mmHg, Nadi: 84x/mt, teratur, isi cukup, RR 16x/mt Konjungtiva tidak anemis TFU 2 jari umbilikus, kontraksi uterus baik urine: jernih; produksi urin 1500cc/24jam Lab: Hb 14,5 gr/dl, Protein urin (-) A : Post partus hari ke II dengan eklampsia P : off Dower Catheter & infus Boleh pulang

Magnesium Sulfate for the Treatment of Eclampsia

Magnesium sulphate (MgSO4) was first introduced to control convulsions in 1925 The Collaborative Eclampsia Trial (Magpie Trial) in 1995 that confirmed the efficacy of MgSO4 in the treatment of severe preeclampsia and eclampsia.
a randomized, placebocontrolled study that enrolled over 10,000 women in 33 countries MgSO reduced the risk of recurrent seizures in eclamptic women by 52% when compared to diazepam and by 67% when compared to phenytoin.
4

The Eclampsia Trial Collaborative Group. Which anticonvulsant for women with eclampsia? Evidence from the collaborative eclampsia trial. Lancet. 1995;345:14551463.

mechanism of action
mechanism of action remains unclear Several possible mechanisms of action:
acting as a vasodilator (either peripherally or in the cerebral circulation) to relieve vasoconstriction protecting the bloodbrain barrier (BBB) decrease cerebral edema formation as a central anticonvulsant

Collaborative Eclampsia Trial2 regimen for administration of magnesium sulphate

loading dose of 4 g should be given intravenously over 5 minutes, followed by an infusion of 1 g/hour maintained for 24 hours recurrent seizures should be treated with a further dose of 24 g given over 5 minutes.

The Eclampsia Trial Collaborative Group (1995) Which anticonvulsant for women with eclampsia? Evidence from the Collaborative Eclampsia Trial. Lancet 345:145563

WHO recommendations for Prevention and treatment of pre-eclampsia and eclampsia (2011) The full intravenous or intramuscular magnesium sulfate regimens are recommended for the prevention and treatment of eclampsia.
(Moderate-quality evidence. Strong recommendation.)

THE SOCIETY OF OBSTETRICIANS AND GYNAECOLOGYSTS OF CANADA (SOGC) CLINICAL PRACTICE GUIDELINE

(2008)

The initial intravenous treatment protocol was MgSO4 4g IV bolus, followed by an infusion of 1 g/hour; a recurrent seizure was treated with another 2 to 4 g IV bolus.

SOCIETY OF OBSTETRIC MEDICINE OF AUSTRALIA AND NEW ZEALAND (SOMANZ)

GUIDELINES FOR MANAGEMENT OF HYPERTENSIVE DISORDERS OFPREGNANCY 2008

magnesium sulfate (4g over 10-15 minutes) followed by an infusion (1-2g/hr). In the event of a further seizure, a further 2-4g of magnesium sulphate is given IV over 10 minutes.

National Institute for Health and Clinical Excellence (NICE) Clinical Guidelines : The management of hypertensive disorders during pregnancy 2010

loading dose of 4 g should be given intravenously over 5 minutes, followed by an infusion of 1 g/hour maintained for 24 hours recurrent seizures should be treated with a further dose of 24 g given over 5 minutes.

PEMBERIAN REGIMEN MgSO4

(ILMU KEBIDANAN SARWONO PRAWIROHARJO, 2008)

LOADING DOSE
4 gram MgSO4: intravena (40% dalam 10cc) selama 15 menit

MAINTENANCE DOSE
infus 6 gram dalam RL/6 jam; atau Injeksi 4 atau 5 gram IM

SYARAT PEMBERIAN MgSO4:

Tersedia antidotum: kalsium glukonas 10% 1gram (10% dalam 10cc) diberikan IV 3menit Refleks patella (+) kuat RR > 16 kali/menit; tidak ada tanda distress napas

PEMBERIAN REGIMEN MgSO4

(BUKU PANDUAN PRAKTIS PELAYANAN KESEHATAN MATERNAL DAN NEONATAL, 2002)

LOADING DOSE
MgSO4 4 gram IV sebagai larutan 40% selama 5 menit. Segera dilanjutkan dengan pemberian 10 gram MgSO4 50% masing-masing 5 gram bokong kanan dan kiri secara IM, ditambah 1ml lignokain 2% pada semprit yang sama. Jika kejang berulang setelah 15 menit, berikan MgSO4 2 gram (larutan 40% IV selama 5 menit

PEMBERIAN REGIMEN MgSO4

(BUKU PANDUAN PRAKTIS PELAYANAN KESEHATAN MATERNAL DAN NEONATAL, 2002)

MAINTENANCE DOSE
MgSO4 1-2 gram per jam per infus, 15 tetes/menit atau 5 gram MgSO4 IM tiap 4 jam Lanjutkan pemberian MgSO4 sampai 24 jam pasca persalinan atau kejang terakhir

WHO Recommendations for the Use of Magnesium Sulphate at the Primary Health Care Level (May 2006)

WHO Recommendations for the Use of Magnesium Sulphate at the Primary Health Care Level (May 2006)

Institute of Obstetricians and Gynaecologists, Royal College of Physicians of Ireland THE DIAGNOSIS AND MANAGEMENT OF PRE-ECLAMPSIA AND ECLAMPSIA CLINICAL PRACTICE GUIDELINE, 2011

Magnesium sulphate is given as a loading dose followed by a continuous infusion for 24 hours or until 24 hours after delivery - whichever is the later. The loading dose is 4g magnesium sulphate i.v. over 5 10 minutes.
Magnesium sulphate 4g in 50ml. This should be administered intravenously over 10 minutes as a loading or bolus dose

The maintenance dose is 1g magnesium sulphate i.v per hour.

Magnesium sulphate 20g in 500ml. This should be administered via a volumetric pump at a rate of 25ml/hour (i.e. 1g/hour of magnesium sulphate).

Alternative regimens of magnesium sulfate for treatment of pre-eclampsia and eclampsia

LOADING DOSE ALONE VS LOADING DOSE PLUS MAINTENANCE (women with eclampsia)
When loading dose alone was compared with loading dose plus maintenance regimen for women with eclampsia, one trial (401 women) showed no statistically significant differences in the critical outcomes of recurrent convulsions and maternal death, and the proxy outcome for perinatal death, stillbirth
The loading dose employed in this trial was 4 g intravenous (IV) plus 6 g intramuscular (IM), while the maintenance was 2.5 g IM every 4 hours for 24 hours.

The trial had very serious limitations with regard to its quality and the resulting data were generally imprecise.
WHO recommendations for Prevention and treatment of preeclampsia and eclampsia, 2011

LOWER DOSE REGIMENS VS STANDARD DOSE REGIMENS OVER 24 HOURS (women with eclampsia)
A small trial (50 women) compared low-dose regimen (4 g IV + 8 g IM as loading dose, then 2,5 g IM/4 hs for 24 hs) with the standard regimen (4 g IV + 8 g IM as loading dose, then 4 g IM/4 hs for 24 hs) The only case of recurrent convulsion in the trial was reported among women treated with the lowdose regimen (a highly imprecise and unreliable data for this critical outcome) No statistically significant differences were observed between the two treatment groups for admission to neonatal special care unit and any baby death
WHO recommendations for Prevention and treatment of preeclampsia and eclampsia, 2011

PREVENTION OF ECLAMPSIA: INTRAVENOUS VS STANDARD INTRAMUSCULAR MAINTENANCE REGIMEN FOR 24 HOURS

One small trial (17 women) had compared intravenous (2 g hourly for 24 hours) and intramuscular (5 g 4-hourly for 24 hours) maintenance regimens for women with preeclampsia. No case of eclampsia in either of the two arms of the trials The trial was too small to yield any reliable conclusions regarding other critical and proxy outcomes reported
WHO recommendations for Prevention and treatment of preeclampsia and eclampsia, 2011

SHORT VS 24-HOUR POSTPARTUM MAGNESIUM SUFATE REGIMENS

WOMEN WITH MILD AND SEVERE PRE-ECLAMPSIA OR IMMINENT ECLAMPSIA.

Short regimen

1st trial: stoppingmaintenance therapy after the onset of diuresis 2nd trial: individualised therapy based on clinical criteria 3rd trial: 12 hours postpartum maintenance therapy

Two of these trials, accounting for approximately two thirds of the participants, were at a low or no risk of bias while one was at a moderate risk of bias. None of the women in these trials developed any of the critical outcomes addressed: eclampsia (two trials, 394 women); magnesium sulfate toxicity (one trial, 196 women)
WHO recommendations for Prevention and treatment of preeclampsia and eclampsia, 2011