Case Study of Eclampsia

Ten percent of all pregnancies are complicated by hypertension (HTN).Eclampsia and preeclampsia account for about half of these cases worldwide.

In 1619, Varandaeus coined the term eclampsia in a treatise on gynecology.

DEFINITION: Eclampsia is defined as the clinical presentation of an unexplained seizure, convulsion, or altered mental status in the setting of the signs and symptoms of preeclampsia. It is considered a complication of severe preeclampsia.

A woman with preeclampsia develops:
--- high blood pressure (>140 mmHg systolic or >90 mmHg diastolic)
--- protein in the urine
--- swelling (edema) of the legs, hands, face or entire body.

1. PRESENTED BY:
PARTH
DHANANI (10BPW618)
B.Pharm.Hons.
BATCH E

2. BACKGROUND:
•Ten percent of all pregnancies are complicated by hypertension (HTN).Eclampsia
and preeclampsia account for about half of these cases worldwide.
• In 1619, Varandaeus coined the term eclampsia in a treatise on gynecology.
•DEFINITION: Eclampsia is defined as the clinical presentation of an
unexplained seizure, convulsion, or altered mental status in the setting of the
signs and symptoms of preeclampsia. It is considered a complication of severe
preeclampsia.
•A woman with preeclampsia develops:
--- high blood pressure (>140 mmHg systolic or >90 mmHg diastolic)
--- protein in the urine
--- swelling (edema) of the legs, hands, face or entire body.

3. In eclampsia, placenta does not form a normal system of arteries [illness( diabetes or
high blood pressure), genetic (inherited) factors and the way the mother's immune
system reacts to the growing placenta]
↓
Placenta does not anchor itself as deeply as expected within the wall of the uterus
↓
As the pregnancy progresses, a placenta creates an abnormal balance of enzymes (proteins)
called growth factors(VEGF)
(placental production and secretion of antiangiogenic factors such as protein like tyrosine
kinase 1 and activin A that antagonizes VEGF)
↓
ANGIOGENESIS IMPEDANCE
↓
Changes the way that arteries in the mother and the placenta function-
Arteries throughout the body can tighten (become narrower), ↑se BP
Become "leaky" allowing protein or fluid to seep through their walls, which causes tissues
to swell →Edema
Also react to the abnormal growth factor balance by forming clots
Abnormal cerebral blood flow in the setting of extreme hypertension. Vessels become
dilated with increased permeability and cerebral edema occurs and results in ischemia
and encephalopathy → Seizures
Many uterovascular changes occur due to the interaction between fetal and maternal
allografts and result in systemic and local vascular changes. These system changes
contribute to the brain pathology in eclampsia by inhibiting the regulation of cerebral
perfusion.

4. Problems with the cells that line the insides of certain blood vessels
Overproduction, underproduction, or malfunction of proteins needed to grow
new blood vessels in the placenta
Abnormal development of capillaries and certain types of muscles within
the placenta
Increased immune system sensitivity which causes the mother’s immune
system to attack certain molecules that are needed to regulate blood flow
into the placenta
Increased overall sensitivity to hormones that regulate blood pressure and
blood flow in different parts of the body

5. Family history of preeclampsia, prior preeclampsia and eclampsia
Poor outcome of previous pregnancy, including
→ Intrauterine growth retardation
→ Abruptio placentae
→ Fetal death
Pre-existing medical condition –
 → Obesity
→ Chronic hypertension
→ Renal disease
→ Vascular and connective tissue disorders
→ Gestational diabetes
→ Systemic lupus erythematosus

Multifetal gestations (Carrying more than one baby)
Teen pregnancy
Patient older than 35 years
Lower socioeconomic status

6. Ante partum haemorrhage
Liver complications (liver encephalopathy)
Kidney complications ( ARF)
Jaundice
Coma
Fetal death - uncommon
Maternal death - uncommon
Premature delivery ( Small baby)
Separation of placenta from uterus
Damage to the brain due to seizures

7. In addition to swelling, protein in the urine, and high blood
pressure, symptoms of eclampsia can include:
A change in reflexes (convulsions)
Rapid weight gain caused by a significant increase in bodily
fluid
Abdominal pain
Severe headaches
Reduced output of urine or no urine
Blood in the urine
dizziness
Excessive vomiting and nausea

8. Laboratory Studies:
Urinalysis to detect for proteinuria (>300 mg/24 h or > 1 g/L)
The CBC may reveal the following:
Anaemia due to microangiopathic haemolysis
Increased bilirubin >1.2 mg/dL
Thrombocytopenia (<100,000) due to HELLP syndrome
Elevated lactate dehydrogenase (LDH) levels (threshold of 180–600 U/L)
The serum creatinine level is elevated. Creatinine clearance (CrCl) may be less than 90 mL/min/1.73 m
2
.
Uric acid levels may be increased mildly
Liver function test results may reveal the following :
Aspartate aminotransferase (SGOT) level higher than 72 IU/L
Total bilirubin levels higher than 1.2 mg/d Elevated levels due to hepatocellular
injury and HELLP syndrome
LDH level higher than 600 IU/L
.
Imaging Studies:
Head CT scanning
CT scan is used to assess intracranial haemorrhage, subarachnoid haemorrhages, or cerebrovascular
accidents.
Transabdominal ultrasonography
Transabdominal ultrasonography is used to estimate gestational age.
This may also be used to rule out abruptio placentae that can complicate eclampsia.

9. GOALS OF THERAPY:
→Preventing low oxygen levels (hypoxia) in the
mother
→ Controlling maternal blood pressure
→ Preventing ongoing seizures
→ Deliver the baby by the safest method possible
The only real cure for eclampsia is the birth of the
baby.

10.  Anticonvulsants:
1. MgSO4: 4 g IV initially, followed by 1-4 g IM q4h prn
Alternatively, 1-4 g/h continuous infusion
2. Diazepam: 5-10 mg IV q10-20min; repeat in 2-4 h prn
(Valium) not to exceed 30 mg in 8 h
 Antihypertensives:
1. Hydralazine: 5 mg IV initially, then 5-10 mg IV q20-30min prn;
not to exceed 30 mg
2. Labetalol: 20-30 mg IV over 2 min followed by 40-80 mg IV at 10-min
intervals;
not to exceed 300 mg/dose
3. Nitropruside: 0.3-0.5 mcg/kg/min IV, increase in increments of 0.5
mcg/kg/min
4. Diazoxide: 1-3 mg/kg IV as a single injection, not to exceed 150 mg/dose
Supportive treatment:
Monitoring fluid intake( NS, D5%)

11. PATIENT’S DATA DOA:20/07/2010
DOD:22/07/2010
PATIENT NAME:XYZ
AGE:23 years
SEX: Female
ADDRESS: Bader district, Rajasthan
HEIGHT:5’3’’
WEIGHT:48kg

15. INVESTIGATION DAY 1 DAY 2
Hb 6.3 8.5
TC 26,200 26,000
DC 68/17/1/12/2 73/20/2/5/0
PC ↓se 82,000 1,66,000
PT ↑se Total
Control
24 sec
13.2 sec
---
RBS 120 mg/dL
(75-115mg/dL)
---
Urea ↑se 193.47
(10-20mg/dL)
---
Creatinine ↑se 8.88 (<1.5mg/dL) ---
Sodium 135.26 142.37
Potassium 4.7 4.1
S.Bilirubin ↑se 1.41 (0.3-1mg/dL) ---
SOPT ↑se 138.5 (0-35U/L) ---
S.Ammonia 39.59 ---

16. INVESTIGATION DAY 1 DAY 2
LDH ↑se 2835 (14-26%) ---
---
pH ↓se (7.38-7.44) 7.21 ---
pCO2 ↑se (35-45mmhg) 52 ---
PO2 ↑se (80-100mmhg) 67 ---
Bicarbonate ↓se
(20-30mE/L)
11 ---

17. •NormalX-RAY
•Retain products
•ARF
USG
(Abdomen)
•Bilateral ischaemia
CT
SCAN(Brain)

18. ECLAMPSIA (leading cause of death)
POST PARTAL ENCEPHALOPATHY
SEPTICAEMIA
ARF
LIVER INJURY

19. DRUG
DOSE RO
A
DURATIO
N
GENERIC
NAME
D
1
D
2
Inj. Pipzo 4.5 mg in 100ccNSi.v.12hrly Piperacillin+tazob
actam
√ √
Inj. Metrogyl 100ml i.v.8hrly Metronidazole √ √
Inj. Pantodac 40mg i.v.OD Pantoprazole √ √
Inj. Levepil 500mg in 100ccNSi.v.8hrly Levetiracetam √ √
Inj. Lasix 2amp i.v. BD Furosemide √√
Inj. FFP 250ml i.v.8hrly Fresh frozen
plasma
√√
Inj. Dopamine2@ in 50ccNS i.v.6hrly Dopamine √√
Inj. Febrinil1@ i.v.sos Paracetamol √√
Inj. Falcigo 60mg i.v.OD Artesunate √√
Inj. D25% 500ml i.v.10ml/hrDextrose √√
Inj. Sodium
bicarbonate
(0.6*wt*HCO3 def.)
0.6*48*9 =
259.2mEq
i.v.13@
straight &
13@ 6hrly
Bicarbonate √√

20. Pipzo dose claculation:
Cl cr = (140 – age yr) * Body wt. = (140-23) * 48 = 8.78
72 * S.cr 72 * 8.88
DRUGDOSE ROA DURATIO
N
GENERIC
NAME
D1D2
Inj. Duphalac 15ml i.v. 8hrly Lactulose √ √
Inj. Vit K1 1@ in
100ccNS
i.v. OD Vit K1 √ √
Inj. Norad 2@ in
50ccNS
i.v. 6hrly Nor adrenaline---√
Creatine
Clearance
Dose Dose interval
20-80 4/0.5 8
<20 4/0.5 12

21. DRUGS INTERACTIONS MANAGEMENT
lactulose ↔
Artesunate
( moderate)
Electrolyte loss and increase
the risk of torsade de pointes
ventricular arrhythmia.
Electrolyte disturbances
including hypokalemia and
hypomagnesemia.
The recommended dosage and
duration of use should not be
exceeded. Electrolye supplements
needed to be administered.
lumefantrine
↔ food
(moderate)
Coadministration with
grapefruit juice may increase
the plasma concentrations of
artemethe. The mechanism is
decreased clearance due to
inhibition of CYP450 3A4-
mediated first-pass
metabolism in the gut wall by
certain compounds present in
grapefruits.
Avoid the consumption of grapefruits
and grapefruit juice. To ensure
maximal oral absorption, artemether-
lumefantrine should be taken with
food. Inadequate food intake can
increase the risk for recrudescence of
malaria.

22. DRUGS INTERACTIONS MANAGEMENT
furosemide ↔ lactulose
(Moderate)
Potentiate the
pharmacologic effects of
diuretics. Laxatives can
cause significant losses of
fluid and electrolytes
In general, laxatives should
only be used on a short-
term, intermittent basis in
recommended dosages.
Contact physician if they
experience signs and
symptoms of fluid and
electrolyte depletion such as
dizziness, lightheadedness,
dry mouth, thirst, fatigue,
weakness, decreased
urination, postural
hypotension, and
tachycardia.

23. http://en.wikipedia.org/wiki/Ischaemic_heart_disease
http://www.rxmed.com/b.main/b1.illness/b1.1.illnesses/Ischaemic%20Heart%20disease.html
http://www.drugs.com/interactions-
check.php?drug_list
Patient’s case file at shrey hospital

24. THANK
YOU