ECLAMPSIA

ECLAMPSIA
DEFINITION:
The eclampsia is derived from a Greek word, meaning like a flash of lightening. It is development of convulsions in preexisting pre-eclampsia. It may occur quite abruptly, without any warning manifestations

ECLAMPSIA Synonyms and related keywords: seizures in pregnancy, toxemia of pregnancy, coma in pregnancy, preeclampsia, cerebral vasospasm, focal ischemia, hypertensive encephalopathy INDIDENCE: In India ranges from 1 in 500 to 1 in 1000 pregnancies

AETIOLOGY: Exact cause is unknown but cerebral irritation may be the cause. It is provoked by Anoxia: spasm of the cerebral vessels following hypertension increased cerebral vascular resistance fall in cerebral oxygen consumption anoxia. Cerebral edema - may contribute to irritation. Cerebral dysrhythmia - increases following anoxia or edema.

ONSET OF FITS
Fits occur more commonly beyond the 36th week (more than 50%). On rare occasions, convulsion may occur in early months as in hydatidiform mole. Antepartum: 50% Intrapartum: 25 - 30% Postpartum: 20 - 25%, usually within 48 hours of delivery. Fits occurring beyond 7 days of delivery, reasonably rules out eclampsia

CLINICAL PICTURE:
The fits are epileptiform and consist of 4 stages 1. Premonitory stage: the patient becomes unconscious. Twitching of the muscles of the face, tongue and limbs. Eye balls roll or are turned to one side & become fixed. This stage lasts for about 30 sec.

2. Tonic stage: The whole body goes into a tonic spasm the trunk opisthotonus, limbs are flexed and hands clenched. Respiration ceases and the tongue protrudes between the teeth. Cyanosis appears. Eye balls become fixed. This stage lasts for about 30 sec.

3. Clonic stage: All the voluntary muscles undergo alternate contraction and relaxation. The twitching start in the face hen involve one side of the extremities and ultimately the whole body is involved in the convulsion. Biting of the tongue occurs. Breathing is stertorous and blood stained frothy secretions fill the mouth; cyanosis gradually disappears. This stage lasts for 1 4 minutes.

Stage of coma: Following the fit, the patient passes on to the stage of coma. It may last for a brief period or in others deep coma persists till another convulsion. On occasion, the patient appears to be in a confused state following the fit and fails to remember the happenings. Rarely, the coma occurs without prior convulsion. The fits are usually multiple, recurring at varying intervals. When it occurs in quick succession it is called status ecliptics.

 Following the convulsions, the temperature usually rises; pulse and respiration rates are increased and so also the blood pressure. The urinary output is markedly diminished; proteinuria is pronounced and the blood uric acid is raised.

 Differential diagnosis: The diseases which are associated with convulsions and/or coma are to be borne in mind while arriving at the diagnosis of eclampsia. Such diseases are; Epilepsy Hysteria Encephalitis Meningitis Puerperal cerebral thrombosis Poisoning Cerebral malaria in tropics Infra-cranial tumours.

Complications
MATERNAL
Injuries: Tongue bite, Injuries due to fall from bed, Bed sore Pulmonary complications Edema due to aspiration, hypostatic or infective. Adult respiratory syndrome Embolism

FETAL Prematurity

Intra uterine
Asphyxia - due to placental insufficiency

Hyper pyrexia Cardiac : Acute left ventricular failure.

Renal failure Hepatic necrosis, sub capsular haematoma Cerebral: oedema hemorrhage Disturbed vision: due to retinal detachment or occipital lobe ischemia.

Birth Trauma

Hematological Thrombocytopenia Disseminated intravascular coagulopathy. Post partum: Shock, sepsis, psychosis

Severity of eclampsia
Eclampsia is considered severe if one or more of the following is present, Coma of 6 or more hours. Temp 39oc or more. Pulse over 120/mt.Resp over 40/mt. Systolic B.P over 200 mm of Hg. More than 10 convulsions.

Prevention
Prevention of eclampsia rests on Early detection & effective institutional treatment with judicious termination of pregnancy during pre eclampsia. Adequate sedation, Antihypertensive therapy &/or prophylactic anticonvulsant therapy soon after delivery in pre-eclampsia. Meticulous observation for 24 48 hours.

Management
First aid treatment outside the hospital: The patient should be shifted to the referral hospitals. She must be heavily sedated before moving. To maintain sedation IM of Largactil 50mg & Phenargan 25mg or Morphine 15mg or paraldehyde 10ml. Midwife should be accompanied &equipped to prevent injury& to clear the air passages.

Hospital : PRINCIPLES
To control the hyper excitable state and to arrest convulsions. To control or to stabilize the pre-eclamptic manifestations. To prevent and to treat effectively the complications may arise. If undelivered, to deliver the baby by the quickest and safest method.

General management (MEDICAL): The patient should be placed in a railed cot in an isolated room, protected from noxious stimuli which might provoke. further fits. Only when the patient is properly sedated, a thorough but quick general, abdominal and vaginal examinations are made. Half hourly pulse, respiration rates and blood pressure to be recorded.

 If undelivered, the uterus should e palpated at regular intervals to detect the progress of labour and the fetal heart rate is to be monitored. Fluid balance: Normally, it should not exceed 2 litres in 24 hours. Additional 50ml of 50% dextrose is to be infused at intervals of 8 hours to maintain the calories Antibiotic: Ampicillin 500mg 1.M. or I.V. six hourly.

Specific Management Sedative and anticonvulsant regime a. Lytic cocktail regime; An admission: 25 mg .chlorpromazine and 100 mg pethidine in 20ml of 5% dextrose are given I.V along with 50mg chlorpromazine & 25mg pheregon given IM. Subsequently: Promethazine 25mg and chlorpromazine 50mg are given IM, alternatively 4 hourly intervals, for period upto 24 hours following in the last fit.

 I.V 500ml of dextrose drip is started at the beginning with 100mg pethidine, the drip rate is adjusted to 20 to 30/mt. Not more than 2lt of dextrose and in all 300 mg pethidine are to be given in 24 hours. b. Diazepam therapy: It is used in initial doses of 40mg I.V. A further 40mg in 500ml of 5% dextrose is infused at 30 drops/mt.

c. Phenytoin therapy: It is given by slow I.V with ECG monitoring. Initial dose is 10mg/ kg. followed by 5mg/kg 2 hours later. There after 200mg is given orally after 24 hours. It is continued until 48 hours after delivery. d.Antihypertensives& diuretics: Ex: hydralazine, labetalol, calcium channel blockers or nitro glycerine. * Diuretics ex: frusemide 20-40 mg I.V.

MANAGEMENT DURING FIT 1.Premonitory stage: A mouth gag to prevent tongue bite and should be removed after the clonic phase. 2.The air passage to be cleared off the mucus with a mucus sucker. 3.Foot end should be elevated Postural drainage 4. Oxygen is given until cyanosis disappears. Status eclampticus: Thiopentone sodium 0.5mg dissolved in 20ml of 5% dextrose is given I.V. very slowly. In unresponsive cases CS

 Prophylactic antibiotics to reduce the complication like pulmonary & puerperal infection Pulmonary edema : frusemide 40mg I.V followed by 20mg of mannitol IV. Pulse oxymeter to monitor, aspiration of the mucus Heart failure: Oxygen inhalation Parenteral lasix & digitalis

 Anuria: The treatment should be in the line as formulated in the chapter of anuria. It is often surprising that urine output returns to normal following termination of pregnancy. Hyperpyrexia: It is difficult to bring down the temperature as its is central in origin. However, cold sponging and antipyretics may be tried. Psychosis: Chlorpromazine or Eskazine (trifluoperazine) is quite effective.

Intensive care monitoring: Patient with multiple medical problems needs to be admitted in an intensive care unit where she is looked after by a team consisting of an obstetrician, a physician and an expert anaesthetist. Cardiac, renal or pulmonary complications are managed effectively. Use of blood gas analyser (to detect hypoxia and acidosis), pulse oximeter and central venous pressure monitor should be done depending on individual case. A deeply unconscious patient with raised intracranial pressure needs steroid and or diuretic therapy. CT scan or MRI may be needed for the diagnosis.