Eclampsia

Eclampsia is a potentially fatal complication of pregnancy and childbirth characterized by extreme hypertension, edema of the extremities, proteinuria, and convulsions or coma. The fits or convulsions are epileptic in nature, consisting of four premonitory transitional stages. It is a medical emergency. It happens during the prenatal, intranasal, and postpartum periods (after delivery 24-48 hours).

Incidence

The hospital incidence ranges from one in 500 to one in thirty. It is more common in primigravida and occurs during the 36th and 37th weeks of pregnancy.

Warning signs of eclampsia

1. No improvement in pre-eclampsia
2. Visual disturbance- double vision
   - Flashes of lights in the eyes
   - Rolling of the eyes
3. Twitching of the eyelids and face
4. Severe frontal headache
5. Epigastric pain and vomit

Complication

Maternal

1. Bedsores and tongue bites caused by a fall from bed
2. Aspiration
3. Exhaustion as a result of numerous attacks
4. Edema of the lungs
5. Pneumonia
6. Hyperpyrexia
7. Edema and cerebral hemorrhage
8. Necrosis of the liver
9. Postpartum depression
10. Psychosis
11. Embolism of the lungs
12. Complications with the eyes
13. Fetal discomfort, premature baby

Fetal

1. IUGR (Intrauterine growth retardation)
2. IUD(Intrauterine death)

Management

Treatment outside the hospital

• Give the eclamptic patient timely attention.
• Before being transported to the hospital, the patient must be deeply sedated.
• During a convulsion, turn the patient to the left lateral side to avoid aspiration.
• To avoid tongue biting, insert the spatula between the teeth.
• Provide oxygen to manage cyanosis.
• Do not leave the patient alone and make arrangements for a hospital transfer.
• Monitor and record blood pressure, pulse, and breathing.
• Frequent monitoring of fetal heart sounds is recommended.

General management in hospital for eclampsia

• Admit the patient to the hospital for immediate care and management.
• The patient should ideally be handled in a dark, isolated environment with minimal stimulus.
• Maintain a well-ventilated and well-lit environment for the patient.
• To avoid a fall injury, keep the patient inside the rail bed.
• Complete blood count, clotting time, serum electrolytes, platelet count, grouping and cross match, hemoglobin, liver, and renal function tests should all be performed as part of an emergency inquiry.
• Maintain oxygenation- Oxygen must be kept on hand in case of an emergency.
• To avoid aspiration, place the patient in a left lateral position to allow secretions to drain. Oral suctioning should be done on a regular basis. After each convulsion episode and SOS, chest auscultation must be performed. A chest X-ray will be performed to confirm the suspicion of aspiration.
• Anticonvulsant medications should only be prescribed by a doctor.
• When maternal acidosis is present, it must be treated.
• Insert the Foley catheter and track intake and output. Every 4 hours, check the urine albumin.
• Never leave a patient alone in his or her room or bed.
• Provide nursing care to patients based on their needs.
• Take note of the onset, duration, severity, and symptoms of fits.
• Keep an eye out for signs of labor starting.
• Keep an eye on the mother's overall vital signs and the fetal heart sounds.
• Check for edema and weight on a daily basis.
• Antibiotics should be administered to avoid subsequent infection.
• Antihypertensive medications are prescribed by a doctor.
• In the event of a fit, maintain the mouth gag in between the teeth to prevent a tongue bite. Clean the airway, then turn to the left lateral side and perform oral suctioning.

In the case of labor:

• Forceps and vacuum delivery should be used. To shorten the second stage of labor, an episiotomy should be performed. Membrane rupture is similar to pre-eclampsia.
• Keep suction, oxygen, an incubator, a resuscitation tray, and an emergency trolley on hand.
• If the mother's condition worsens, a cesarean section should be performed once the fits have been controlled.

Magnesium Sulphate for the management of pre-eclampsia and eclampsia

• Give a loading dose
  4gm IV 20 percent magnesium sulfate over 5 minutes Follow immediately with 10gm of 50% magnesium sulfate solution, 4gm deep IM in each buttock, and 1ml of 2% lignocaine in the same syringe. While performing deep IM, use the aseptic method. If the convulsion occurs again after 15 minutes, give 2gm magnesium sulfate (50%) solution IV over 5 minutes.
• Maintenance dose
  Every 4 hours, inject 5gm MgSO4 with 1ml lignocaine 2% IM into the opposite buttock. Continue MgSO4 medication for 24 hours following the birth or the final convulsion, whichever comes first.

Note:

1. Make sure your respiratory rate is at least 16 beats per minute before repeating the MgSO4.
2. Patellar reflexes are present.
3. Urinary production is at least 30ml per hour for at least four hours.
4. Drug withholding or postponement (MgSO4)
5. The respiratory rate is fewer than 16 breaths per minute.
6. Patellar reflexes are absent.
7. Over the previous four hours, urinary production was less than 30ml per hour.

References

• HealthLine. 2005. 2017 http://www.healthline.com/health/eclampsia
• MedicineNet. 1996. 2017 http://www.medicinenet.com/pregnancy_preeclampsia_and_eclampsia/article.htm
• Medline Plus. 05 January 2017 https://medlineplus.gov/ency/article/000899.htm
• Tuitui R. 2002, A textbook of Midwifery A (Antenatal), 3rd edition, Vidyarthi Pustak Bhandari (Publisher and Distributor), Bhotahity, Kathmandu
• Tuitui R. 2002, A textbook of Midwifery C (Antenatal), 3rd edition, Vidyarthi Pustak Bhandari (Publisher and Distributor), Bhotahity, Kathmandu
• Medscape. 1994. 2017 http://emedicine.medscape.com/article/253960-overview
• NHS Choice. http://www.nhs.uk/conditions/Pre-eclampsia/Pages/Introduction.aspx