hypertensive disorders in pregnancy:Eclampsia

hypertensive disorders

1. Eclampsia

2. Revision 1. In PIH an impending sign of eclampsia is: a. Visual symptoms b. Weight gain of 2lb per week c. Severe proteinuria of 10g d. Pedal edema

3. 2. Which of the following is the best management of an 18-year-old G1 P0 woman at 28 weeks’ gestation with a blood pressure of 160/110 mm Hg, elevated liver function tests, and a platelet count of 60,000/ uL ? A . Oral antihypertensive therapy B . Platelet transfusion C . Magnesium sulfate therapy and induction of labor D . Intravenous immunoglobulin therapy

4. 3. Which is not a feature of HELLP syndrome : a. Thrombocytopenia b. Eosinophilia c. Raised liver enzymes d. Hemolytic anemia

5. Eclampsia Preeclampsia when complicated with grandmal seizures (generalized tonic- clonic convulsions) and/or coma is called eclampsia . 10% of all pregnancy More common in primigravida 75%.

6. Pathophysiology

7. Cause Of Convulsion The cause of cerebral irritation leading to convulsion is not clear. (1) Anoxia S pasm of the cerebral vessels increased cerebral vascular resistance fall in cerebral oxygen consumption anoxia, (2) Cerebral edema — may contribute to irritation, (3) Cerebral dysrhythmia increases following anoxia or edema. There is excessive release of excitatory neurotransmitters (glutamate).

8. ONSET OF FITS Antepartum (50%) : Fits occur before the onset of labor Intrapartum (30%): Fits occur for the first time during labor Postpartum (20%):Fits occur for the first time in puerperium, usually within 48 hours of delivery.

9. Clinical Features

10. Clinical Features Premonitory stage: lasts 30 seconds The patient becomes unconscious. There is twitching of the muscles of the face, tongue, and limbs. Eyeballs roll or are turned to one side and become fixed. Tonic stage: lasts 30 seconds 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. Eyeballs become fixed

11. Clonic stage:lasts 1-4 minutes All the voluntary muscles undergo alternate contraction and relaxation. The twitchings start in the face then 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. 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.

12. The fits are usually multiple, recurring at varying intervals. When it occurs in quick succession, it is called status eclampticus .

13. investigations Hb % DC , TLC, TPC, BT/CT Urinalysis –R & M FBS Electrolytes Urinary Protein Coagulation Profile LFT RFT Serum Uric acid • Obstetric Scan Color Doppler Ophthalmoscopy BPP ECG MRI CT –Brain & Abdomen

14. Fetal Complications • Prematurity. • Placental infraction , Abruptio placentae. • Fetal hypoxia • IUGR (Intra uterine growth retardation), sepsis • Death

15. Differential diagnosis Eclampsia. Epilepsy Hysteria Meningitis and Encephalitis. Tetanus . Tetany. Brain tumors. Uremic convulsions

16. Management

17. General measures Supportive care : ( i ) to prevent serious maternal injury from fall ( ii) prevent aspiration, iii ) to maintain airway and ( iv) to ensure oxygenation. Detailed history is to be taken from the relatives, relevant to the diagnosis of eclampsia, duration of pregnancy, number of fits and nature of medication administered outside.

18. Examination of the patent Maternal and Fetal monitoring Fluid balance: Antibiotics

19. Definitive Measures 1.Anticonvulsant and sedative regimes Magnesium sulfate is the drug of choice . Membrane stabilizer and neuroprotector Reduces motor endplate sensitivity to acetylcholine Blocks neuronal calcium influx also Induces cerebral vasodilatation, dilates uterine arteries, increases production of endothelial prostacyclin Inhibits platelet activation

20. MANAGEMENT

21. MANAGEMENT PRITCHARD’S REGIMEN: 1 vial of MgSO4 = 2 ml = 1 gm of MgSO4 Loading dose: Total of 14 gms (14 vials) 4 vials (4 gms ): 20 % MgSO4 20 ml syringe containing 4 vials (8 ml) MgSO4 + 12 ml Distilled water IV over 4 – 5 min 5 vials (5 gms ): 50 % MgSO4 10 ml Syringe IM in one buttocks 5 vials (5 gms ): 50 % MgSO4 10 ml Syringe IM in one buttocks

22. Maintenance dose: 5 gm of 50% MgSO4 IM 4 hourly in alternate buttocks( after assessent ) Magnesium sulfate is continued for 24 hours after the last seizure or delivery whichever is later For recurrence of fits , further 2 gm IV bolus is given over 5 min in the above regimens.

23. Monitoring Hourly for Magnesium Sulfate toxicity: Suspend or postpone use of Magnesium sulfate, if any of the following is present: Respiratory rate < 16/min (Respiratory depression) Absent patellar reflex (Muscle paresis) Urine output < 30 ml/hour in preceding 4 hours (Impaired renal function)

24. MANAGEMENT SEIZURE PROPHYLLAXIS: The therapeutic level of serum magnesium:4–7 mEQ /L MgSO4 toxicity: Deep tendon reflex: 1 st to disappear (10 – 12 meq /lit) Respiratory depression: ≥ 12 meq /lit MgSO4 toxicity: Best marker: Respiratory depression Antidote: Calcium gluconate 10 ml of 10% Calcium gluconate over 10 min Absolute contraindication: Myasthenia gravis Impaired renal function

25. QUESTONS

26. 1.A female of 36 WOG presents with epigastric pan blurring of vison and headache. Her blood pressure s 180/120 hg. Urine analysis reveals 3+ protein. a)What is the most likely diagnosis ? b) List three maternal signs that would help guide our management . c) What are three possible maternal complications of this disease if its remains untreated ? d) What investigations would you perform ? e ) How should this woman by managed?

27. A 30years primigravida at 30 Weeks of gestation admitted with BP of 160/130 mmHg .After two hours she has convulsoons . 1.What s the diagnosis? 2.The first measure to be done : a. Care of airway+ MgSO4 b. Sedation of patent c. Urgent delivery d. Wait and Watch

28. 3. Earliest sign of Mg toxicity? a) Depression of deep tendon reflex b) Respiratory depression c) Cardiac arrest d) Anuria

29. 4. How will you manage the MgSO4 toxicity? Delivery of the baby Calcium gluconate Give sedatives