INTRODUCTION

Hypertension is the most common medical problem

encountered during pregnancy.

Hypertensive disorders in pregnancy may cause maternal &

fetal morbidity & leading cause of maternal mortality.

Hypertensive disorders are :

1. Pre-eclampsia

2. Eclampsia

3. Gestational Hypertension

4. Chronic Hypertension

DEFINITION

Varadaeus coined the term eclampsia, is derived from a

Greek word, meaning is “ like a flash of lightening”.

The International Society for the study of Hypertension

in pregnancy (ISSHP), defines as the “Occurrence of

generalized convulsions associated with signs of pre-

eclampsia during pregnancy, labour or within 7 days of

delivery and not caused by epilepsy or other convulsive

disorders.

Contd……………………….

Pre- eclampsia when complicated with generalized tonic-

clonic convulsions and/or coma is called eclampsia.

PATHOPHYSIOLOGY

Placental hypo perfusion

Constriction of small arteries

Reduced blood flow to multiple organs

Increased vascular permeability

Shift of extracellular fluid from the blood to the interstitial space

Contd…………………………

Reduced blood flow and edema

Hypertension, Renal ,Pulmonary and Hepatic dysfunction

and cerebral edema with cerebral dysfunction and

convulsion.

CLINICAL FEATURES

It consist of four stages, that are:-

PREMONITORY STAGE :-

The patient becomes unconscious.

There is twitching of muscles of face, tongue and limbs.

Eye balls roll or are turned to one side and becomes

fixed.

This stage lasts for about 30 second.

Contd………………………..

TONIC STAGE :-

The whole body goes into a spasm called trunk

opisthotonus.

Limbs are flexed and hands clenched.

Respiration ceases and tongue protrudes between the

teeth.

Cyanosis appears.

Contd……………………………………

Eye balls become fixed.

This stage lasts for about 30 seconds.

CLONIC STAGE :-

All the voluntary muscles undergo alternate contraction

and relaxation.

The twitching starts in face then involve one side of

extremities and ultimately the whole body is involved

Contd……………………

in the convulsion.

Biting of tongue occurs.

Breathing is stertorous and blood stained frothy

secretions fill the mouth.

Cyanosis gradually disappears.

This stage lasts for 1 – 4 minutes.

Contd……………………………

STAGE OF COMA :-

Following the fit, the patient passes on 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

Contd………………………………….

confused state following the fit and fail to remember the

happenings.

The fits are usually multiple, recurring at varying

intervals.

When it occurs continuously it is called status

eclampticus.

Following the convulsion, temperature rises, pulse and

Contd…………………………..

respiration rate are increased and blood pressure also

increases.

The urinary output is markedly diminished, proteinuria

is in pronounced and blood uric acid is raised.

OTHER CLINICAL FEATURES

Headache

Visual disturbance

Epigastric pain

Oedema

High blood pressure

Fluid retension

Fundal height less than approximate date

MANAGEMENT

Aim of management.

Prediction & prevention.

First aid treatment outside the hospital.

General management (medical & nursing).

Specific management.

Obstetric management.

1. AIM OF MANAGEMENT :-

Arrest convulsion

Maintenance of patent airway, breathing and

circulation.

Oxygen administration at the rate 8-10 L/minute.

Terminate pregnancy.

Ventilatory support.

Prevention of complication.

Contd…………………………………..

Prevention of life threatening situation.

Postpartum care.

Medicine and regular follow up.

Contd……………………………

2. PREDICTION AND PREVENTION :-

In majority of cases, eclampsia is preceded by pre-

eclampsia.

Thus prevention of eclampsia rest on early detection

and effective institutional treatment with judicious

treatment of pregnancy with eclampsia.

Contd……………………..

Use of anti-hypertensive drugs, anti- convulsent therapy

and timely delivery are important steps.

Close monitoring during labour and 24 hours of

postpartum, are also important in prevention of

eclampsia.

Unfortunately 30 -85% of cases of eclampsia remained

unpreventable.

Contd……………………………..

Use of magnesium sulphate lowers the risk of eclampsia.

3. FIRST AID TREATMENT OUTSIDE THE

HOSPITAL :-

The patient, either at home or in the health center

should be shifted urgently to the tertiary referral care

hospitals, because there is no place of continuing the

treatment in such place.

Contd………………………………….

Transport of an eclamptic to a teritiary care centre is very

important.

Such patient needs neonatal and obstetric intensive care

management.

IMPORATANT STEPS IN TRANSPORT ARE :-

a. All maternal records and detailed summary should be

sent with patient.

Contd…………………………….

b. Drugs should be established and convulsions should be

arrested.

c. Drugs should be give like: magnesium sulphate,

labetalol, diuretics, diazepam.

d. One medical personnel and a trained midwife should

accompany with the patient in a well equipped

ambulance to prevent injury and complications.

Contd……………………….

4. GENERAL MANAGEMENT :-

SUPPORTIVE CARE :-

Aims to prevent serious maternal injury from fall, to

prevent aspiration, to maintain airway and to ensure

oxygenation.

Patient is kept in railed cot and a tongue depressor is

inserted between teeth.

Contd……………………

• She is kept in lateral position to avoid aspiration.

• Vomitus and oral secretion are removed by frequent

suctioning, oxygenation is maintained through face mask

to prevent respiratory acidosis.

• ABG analysis is needed when oxygen saturation falls

below 92%.

• Sodium bicarbonate is given when PH is below 7.10.

Contd……………..

HISTORY :-

Detailed history is to be taken from relatives, relevant to

diagnosis of eclampsia, duration of pregnancy, number

of fits and nature of medications administered outside.

EXAMINATION:-

Once the patient is stabilized, abdominal and vaginal

examination are made. A self retaining catheter is

introduced and urine if tested for protein.

Contd……………………..

MONITORING :-

Half hourly pulse, respiration rate are recorded.

Hourly urine output is to be noted.

If undelivered the uterus should be palpated at regular

intervals to detect the progress of labour and fetal heart

rate is to be monitored (bradycardia occurs).

Contd………………………

FLUID BALANCE :-

Ringer’s lactate solution.

A excess of dextrose or crystalline solutions not be used

as it will aggravate the tissue are overload leading to

pulmonary edema, circulatory overload and ARDS.

ANTIBIOTIC:-

Ceftriaxone 1gm IV, BD.

Contd………………………..

5. SPECIFIC MANAGEMENT:-

Anti- convlsant and Sedative therapy:-

Magnesium sulfate is the drug of choice.

Other regimen are:-

a) Phenytoin

b) Diazepam

c) Lytic cocktail(MENON 1961) using

chlorpromazine, pethadine, promethazine.

Contd…………………………

Anti – hypertensive and diuretics :-

Drugs commonly used are:-

a) Hydralazine

b) Labetalol

c) Calcium channel blocker or nitroglycerine.

Diuretics in case of pulmonary edema. Frusimide is

given in dose of 20-40 mg IV .

Management during fits:-

Contd………………………..

Status Eclampticus:-

Thiopentone sodium 0.5gm dissolved in 20ml of 5%

dextrose is given very slowly.

Treatment of complication:-

Prophylactic antibiotics.

For pulmonary edema and ARDS, frusemide 40mg IV

followed by 20gm of mannitol IV.

Contd………………………..

For heart failure, dopamine infusion if given.

For psychosis, chlorpromazine or trifluoperazine is quite

effective.

6. OBSTETRIC MANAGEMENT:-

Fits controlled

1) Baby mature

2) Baby premature(<37 weeks)

3) Baby dead

Contd……………………..

Fits not controlled:-

Termination of pregnancy.

Low rupture of the membranes is to be done to

accelerate the labour.

BIBLIOGRAPHY

DC DUTTA’S TEXTBOOK OF OBSTETRICS,

PAGE NO: 230- 236.

ESSENTIAL OBSTETRICS AND GYNACOLOGY, E.

MALCOLM SYMONDS & IAN. M. SYMONDS, PAGE

NO: 107-110.

ECLAMPSIA – SLIDE SHARE PRESENTATION BY

V. SHARMA,4TH YEAR NSG, BANGLORE.