Shamsuddin_Prevention of PE E Including Community Level Intervention in Bangladesh
Transcript of Shamsuddin_Prevention of PE E Including Community Level Intervention in Bangladesh
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Prof Latifa Shamsuddin
President Elect, OGSB
Prevention of Pre-eclampsia and Eclampsia
through Community Level Interventions in
Bangladesh
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Maternal HealthScenario- last 10 years
MMR:
322/100,000 live birth
Annual maternal deaths: 12,000
Delivery by skill birth attendants:18%
Facility Delivery: 15%
MDG 5: To reduce maternal deaths by 2015 to143/100,000 live births
(Source: BMMS 2001)
MMR:
194/100,000 live birth
Annual maternal deaths: 7,332
Delivery by skill birth attendants:32%
Facility Delivery: 29%(Source: BMMS: 2010 & BDHS 2011)
During the period of 2001-2010
Maternal Mortality Ratio reduced by 40%
Maternal Mortality Ratio reduced due to Eclampsia: 50%
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Eclampsia
20%
Abortion
1%
ObstructedLabor
7%
Indirect
5%
Hemorrhage
31%
Others
16%
Direct
20%
Eclampsia
24%
Indirect
17%
Hemorrhage
28%Others16%
Direct
15%
Casue of Maternal deaths
Source: BMMS-2001
Casue of Maternal deaths
Source: BMMS-2010
Causes of Maternal Deaths in Bangladesh
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Eclampsia Treatment Regimen in Bangladesh
Until 1968 Inj. Morphine / Pethedine
1972 Lytic cocktail: Inj. Pethedine, Inj. Largactil, Inj.
Phenargan with Normal saline/aqua 500 cc I/V
Diazepam therapy:
10 mg I/V slowly for 20 min; then maintain by 40 mg
diazepam in 500 ml I/V fluid in infusion form
Very high maternal mortality and morbidity (neurological,
CVS, RD Syndrome), bad fetal outcome (resp. depression)
Do not give 100 mg in 24 hours
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Eclampsia Treatment Regimen (Contd.)
Hydralizine
5 mg I/V bolus every 5 min until BP decline
Infusion 25 mg in 200 CC in Normal Saline
Labetalal- 200 mg in 200 ml Normal Saline in 20 drops/hours
1994 MgSo4
In DMCH, first trial
68% eclamptic death
2001 MgSo4 in community .
1998-2001 Participated in Magpie trial- 22 countries including
Bangladesh 2003 Follow up study was done both for mother and child up to
2 years
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Flow chart for MgSO4
Magnesium Sulphate (4g= 8ml) IV
diluted in 12 ml distilled water { 20ml of 20% solution}
Intravenous injection
over a period of 10-15minutes
Magnesium Sulphate (6g = 12ml)of 50% solution
Deep IntramuscularInjection, 3g=6 ml in each
buttock
Magnesium Sulphate (2.5 g = 5ml)of 50% solution
Deep Intramuscular injection2.5 g every 4 hourly in alternate
buttock.Continue for 24 hours after lastconvulsion or delivery (If needed)
Maintenance Dose
Loading Dose ( 4 gm + 6gm)
(Source:
EmOC Protocol, OGSB, 2009)
Inj. Nalepsin MgSo4 4g = 100 ml
Or
60-70 drops/minute
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Control of B.P.
Diastolic Pressure more than
110 mm Hg.Systolic pressure less than 80 mm Hg
or BP is not recordable
Inj. Dopamin, 1 amp (200mg) in 200ml
of NS IV @ 8-10 d/m till systolic
pressure is 120 mm Hg.
Check BP every 15 min. interval and stop
drip when Diastolic Pressure is 90 mm Hg.
Management of Severe Pre-eclampsia and Eclampsia
Inj. Hydralazine, 1 amp (20mg) in200 ml of NS IV @ of 8-10 d/m
Or Injection Labeta is used to controlacute hypertension.
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Differences of Dose between Bangladesh andInternational Standard Regimen
Regimen used in Bangladesh Loading dose = 4gm I/V + 6gm I/M = 10 gram and
maintenance dose is 2.5 x 6 = 15 gram
Total dose = 10 + 15 = 25 gram
Standard Regimen Loading dose = 4 gm I/V + 10 gm I/M = 14 gram and
maintenance dose is 5 x 6 = 30 gram
Total dose = 14 + 30 = 44 gram
Bangladeshi regimen is almost half of the standardregimen
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Madhupur
Study at the community
level on Prevention of
Severe Pre-Eclampsia
and Eclampsia
Source: BMRC. Bulletin, 2005: 31 (2): 75-82
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Objectives
To determine the effectiveness of early administrationof injection Magnesium Sulphate in PEE patients atthe community level to prevent fits before referral to
hospital
To examine whether early intervention of convulsionby Magnesium Sulphate and proper obstetric
management can reduce both maternal and perinatalmortality
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Methodology Type of Study:
Quasi-experimental Community based prospective interventional study
Study Period: July - December 2001
Study Population: Eclampsia and severe pre-eclampsia cases of study area
Sample Size: 265 cases
133 were in intervention group (patients with eclampsia or severe
eclampsia receiving loading dose of MgSo4 before referral)
132 in non-intervention group (patients with eclampsia or severe
eclampsia coming directly to hospital from same area but without
receiving loading dose of MgSo4 before referral; but they received
injection MgSo4 after admission in the hospital)
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Training of doctors
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Involvement of the communityhealth workers
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To reduce maternal mortalitycommunity awareness
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Awareness creation in the community
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Maternal Outcome of the study
2.3
17.3
1.5
6.01
8.2710.4
27.3
2.27
6.06
12.87
0
5
10
15
20
25
30
Intervention Group Non-intervention Group
Maternal Deaths Pulmonary edema Renal Failure Obstetric shock PPH
The number of patients who developed complications in intervention andnon-intervention groups show statistically significant difference ( p
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Foetal outcome of the study
Perinatal out-come of non-intervention group was poorer than interventiongroup though both groups were managed in the same way after admission
in the hospital
86.2
67.6
18.6
13.7
20.4
84
52.4
27.6
0
10
20
30
40
50
60
7080
90
Intervention
(n= 102)
Non-Intervention
( n= 105)
Alive
Healthy
AsphyxiaStilborn
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Study Conclusion
The findings of this study concluded Earlier administration of injection Magnesium Sulphate at
the community level is effective before referral to hospital
Useful result was found regarding control of convulsion by
early loading dose, recurrence of fit, maternal and fetaloutcome
Hence, the study highly recommended:
To administer early injection of MgSO4 To include the loading dose of MgSo4 before referral in
the national protocol
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Findings on Complete IM regimenTo find out the feasibility of using IM administration of MgSO4,
study was conducted in Dhaka and Chittagong Medical Colleges:
Loading dose = 10gm I/M ( 5 gm in alternate buttock) andmaintenance dose is 2.5 x 6 = 15 gram
In Chittagong Medical College Hospital ( n= 300)
There was no abscess
Patient tolerable
Recurrence of convulsion only 3% in absence of maintenance doseand no recurrent convulsion in presence of maintenance dose
In Dhaka Medical College Hospital - DMCH( n = 200)
Similar kinds of findings
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Intramuscular loading dose vs combined IV
and IM loading dose of MgSo4 in the
management of eclampsia in a tertiary levelhospital.
Study conducted by Dr. Salma Rouf, DMCH
A pilot project is conducting in DMCH where IMadministration of MgSo4 is found to be equally effective
both in preventing and controlling of recurrent fit.
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Administration of MgSo4 at the Community
Level
Pilot project at Hobiganj throughGovt., MaMoni, Mayer Hashi, OGSB& ICDDR,B.
High numbers maternal and perinatal
death FWV, SBA, HA will work in that area,
they will diagnose severe PE andeclampsia and will administer IMMgSo4 (10 gm) referral center.
Same type of work will be done inanother district like Bramhanbaria.
Referral center will manage accordingto OGSB protocol.
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Decision Algorithm: Community management
Who andWhere
What and HowMeasure BP If diastolic is >= 90 mm Hg,repeat measure after 1 hour
Urine exam for protein
FindingsDiagnosisManagement
DBP 100 --
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Challenges Though, health infrastructure in Bangladesh exists up to the
grass root level; a system of registering pregnant women hasnot been developed
Lack of confidence among the facility based service providersre administering the loading dose
Large number of floating people in both urban and ruralareas with poor socio-economic conditions
Some families changed their residence without leaving aforwarding address
Flood and river erosion affected the study. Thus it becamedifficult to contact/trace the patients
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Challenges
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