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MANAGEMENT OF MANAGEMENT OF ECLAMPSIAECLAMPSIA
DR. OKAGUADR. OKAGUA
LEVELS OF PREVENTIONLEVELS OF PREVENTION
Pre-conception carePre-conception care
Prediction of those at riskPrediction of those at risk
Preventive measures for those at riskPreventive measures for those at risk
Early diagnosis/appropriate management Early diagnosis/appropriate management of pre-eclampsia of pre-eclampsia
PRE-CONCEPTION CAREPRE-CONCEPTION CARE
Advice early antenatal careAdvice early antenatal care
Pre-pregnancy hypertension controlPre-pregnancy hypertension control
Pre-pregnancy diabetic controlPre-pregnancy diabetic control
Good nutrition for those at riskGood nutrition for those at risk
PREDICTION PREDICTION Family/Personal HistoryFamily/Personal History→ DM, HT, PE→ DM, HT, PE
Age/ParityAge/Parity
Multiple pregnancy Multiple pregnancy
Roll-over testRoll-over test
Uterine artery Doppler waveformsUterine artery Doppler waveforms
Angiotensin infusion testAngiotensin infusion test
Urine Kallikrein to Creatinine ratioUrine Kallikrein to Creatinine ratio
Plasma FibronectinPlasma Fibronectin
Serum inhibinSerum inhibin
Serum UrateSerum Urate
PREDICTION (cont.)PREDICTION (cont.)
Urinary calciumUrinary calcium
Serum AFP/hCGSerum AFP/hCG
HaematocritHaematocrit
Antithrombin IIIAntithrombin III
Plasminogen activator inhibitors (1&2)Plasminogen activator inhibitors (1&2)
INTERVENTIONS TO INTERVENTIONS TO PREVENT PEPREVENT PE
CalciumCalcium
AspirinAspirin
MagnesiumMagnesium
Fish oilsFish oils
Anti-hypertensive drugsAnti-hypertensive drugs
EARLY DIAGNOSIS OF PEEARLY DIAGNOSIS OF PE
Good antenatal careGood antenatal careEarly bookingEarly bookingRoutine BP, Urine Protein, Weight checksRoutine BP, Urine Protein, Weight checks
Early recognition of Pre-eclampsia & Early recognition of Pre-eclampsia & appropriate management of severe Pre-appropriate management of severe Pre-eclampsiaeclampsia
FEATURES OF IMPENDING FEATURES OF IMPENDING ECLAMPSIAECLAMPSIA
Epigastric pain Epigastric pain → right hypogastric → right hypogastric tenderness tenderness Headache → Papilloedema on FundoscopyHeadache → Papilloedema on FundoscopyVisual symptomsVisual symptomsNausea/vomitingNausea/vomitingHyperreflexia, excessive clonus, twitching Hyperreflexia, excessive clonus, twitching and/or tremorand/or tremor
Benefit from prophylactic Benefit from prophylactic anticonvulsants especially in presence of anticonvulsants especially in presence of diastolic BP ≥ 110mmHg and Proteinuria ≥ 2+diastolic BP ≥ 110mmHg and Proteinuria ≥ 2+
DIAGNOSTICDIAGNOSTICCLINICAL CRITERIACLINICAL CRITERIA
Usually occurs between 20wks gestation and 10 Usually occurs between 20wks gestation and 10 days post-partumdays post-partum
Any fit which does not appear to be of epileptic Any fit which does not appear to be of epileptic origin, metabolic or other known causes should origin, metabolic or other known causes should be classified as eclamptic convulsionbe classified as eclamptic convulsion
The convulsions should have features of grand The convulsions should have features of grand mal convulsions including aura, tonic and clonic mal convulsions including aura, tonic and clonic movements, involuntary activity and a post-ictal movements, involuntary activity and a post-ictal statestate
BRITISH ECLAMPSIA SURVEY BRITISH ECLAMPSIA SURVEY TEAM (BEST)TEAM (BEST)
Defined eclampsia using the above clinical Defined eclampsia using the above clinical criteria with at least 2 of the followingcriteria with at least 2 of the following HypertensionHypertension Proteinuria Proteinuria ThrombocytopeniaThrombocytopenia Liver enzyme elevationLiver enzyme elevation
PRINCIPLES OF PRINCIPLES OF MANAGEMENTMANAGEMENT
Ensure ventilation and correction of Ensure ventilation and correction of hypoxia/ fluid/electrolyte derangementhypoxia/ fluid/electrolyte derangement
Control/prevent convulsionsControl/prevent convulsions
Control blood pressureControl blood pressure
Expeditious delivery of the fetus & Expeditious delivery of the fetus & placenta (for antepartum/ intrapartum placenta (for antepartum/ intrapartum eclampsia)eclampsia)
ANTI-CONVULSANTS ANTI-CONVULSANTS
Magnesium Sulphate: Magnesium Sulphate: better seizure better seizure control, no sedation, no significant neonatal control, no sedation, no significant neonatal effect, cheap?effect, cheap?
DiazepamDiazepam
Lytic Cocktail Lytic Cocktail
PhenytoinPhenytoin
ParaldehydeParaldehyde
Sodium AminobarbitoneSodium Aminobarbitone
BrometholBromethol
MAGNESIUM SULPHATE MAGNESIUM SULPHATE ADMINISTRATIONADMINISTRATION
Intravenous or intramuscular regimenIntravenous or intramuscular regimenIntramuscular regimen used in this Intramuscular regimen used in this centrecentre
→→ Loading dose of 14gLoading dose of 14g →→ Maintenance dose of 5g 4hrly for Maintenance dose of 5g 4hrly for
24hrs 24hrs after after last fit, provided,last fit, provided,
Respiratory rate > 16/minRespiratory rate > 16/minKnee jerk presentKnee jerk presentUrine output > 100mls in last 4 hrsUrine output > 100mls in last 4 hrs
BLOOD PRESSURE CONTROLBLOOD PRESSURE CONTROL
HydrallazineHydrallazine
Nifedipine (sublingual)Nifedipine (sublingual)
LabetalolLabetalol
Sodium nitroprussideSodium nitroprusside
NitroglycerineNitroglycerine
Monitor BP ¼ hrly then ½ hrly when stableMonitor BP ¼ hrly then ½ hrly when stable
GENERAL CAREGENERAL CARE
Resuscitate with cautious correction of Resuscitate with cautious correction of fluid & electrolyte imbalancefluid & electrolyte imbalance
Maintain strict imput/output chartMaintain strict imput/output chart
Maintain airwayMaintain airway
Nurse semi-proneNurse semi-prone
Give oxygenGive oxygen
Patient must be stable before attempts Patient must be stable before attempts at delivery at delivery
DELIVERYDELIVERYMode of delivery will depend on maternal Mode of delivery will depend on maternal status and fetal viabilitystatus and fetal viability
Vaginal delivery preferred were feasibleVaginal delivery preferred were feasible
Continuous FHR monitoringContinuous FHR monitoring
Avoid prolonged laborAvoid prolonged labor
Assisted second stageAssisted second stage
Active management of 3Active management of 3rdrd stage (No stage (No ergometrine)ergometrine)
replace blood loss, volume for volumereplace blood loss, volume for volume
INDICATIONS FOR CESAREAN INDICATIONS FOR CESAREAN SECTIONSECTION
All deeply unconscious patients (unless All deeply unconscious patients (unless delivery is imminent)delivery is imminent)All unco-operative patients due to All unco-operative patients due to restlessnessrestlessnessIf vaginal delivery is unlikely in 6-8hrs from If vaginal delivery is unlikely in 6-8hrs from the 1the 1stst eclamptic seizure eclamptic seizureThere is obstetric indication for C/S There is obstetric indication for C/S including fetal distressincluding fetal distress
POST-NATAL CAREPOST-NATAL CARENurse in intensive care unit for 24-48hrsNurse in intensive care unit for 24-48hrsStop anticonvulsants after 24hrs fit freeStop anticonvulsants after 24hrs fit freeOliguric patients unresponsive to fluid challenge will Oliguric patients unresponsive to fluid challenge will benefit from low dose Dopamine benefit from low dose Dopamine Continue IV antihypertensives & change to oral Continue IV antihypertensives & change to oral when oral intake commenced then tail offwhen oral intake commenced then tail offCounsel about risk of recurrence; advice on Counsel about risk of recurrence; advice on contraception and early booking before dischargecontraception and early booking before dischargeThose with persistent hypertension on discharge Those with persistent hypertension on discharge should be seen weekly and referred to the should be seen weekly and referred to the physicians after 6 weeks for full work-up physicians after 6 weeks for full work-up Long term follow-up for neurological assessmentLong term follow-up for neurological assessment..
COMPLICATIONSCOMPLICATIONSMATERNALMATERNAL
Severe bleeding from abruptio placenta withSevere bleeding from abruptio placenta with its resultant coagulopathyits resultant coagulopathyPulmonary oedemaPulmonary oedemaAspiration pneumoniaAspiration pneumoniaAcute renal failureAcute renal failureCerebrovascular haemorrhageCerebrovascular haemorrhageLiver ruptureLiver ruptureRetinal detachmentRetinal detachmentIncreased operative deliveryIncreased operative deliveryMaternal deathMaternal death
COMPLICATIONSCOMPLICATIONS
FETALFETAL
PrematurityPrematurity
Birth asphyxiaBirth asphyxia
↑↑ MTCT of HIV 1 due to depletion of MTCT of HIV 1 due to depletion of vitamin Avitamin A
Fetal wastageFetal wastage
CONCLUSIONCONCLUSIONEvidence from developed and developing Evidence from developed and developing countries suggest that of the 3 major causes countries suggest that of the 3 major causes of maternal mortality, death from hypertensive of maternal mortality, death from hypertensive disorders of pregnancy are the most difficult to disorders of pregnancy are the most difficult to prevent (Duley, 1992)prevent (Duley, 1992)
However with effective implementation of the However with effective implementation of the above prevention strategies and appropriate above prevention strategies and appropriate treatment based on the best available treatment based on the best available evidence, we can continue the march towards evidence, we can continue the march towards a zero maternal mortality for the benefit of our a zero maternal mortality for the benefit of our mothers, our babies and the nation.mothers, our babies and the nation.
THANK YOUTHANK YOU