Eclampsia

Question 1

Definition of eclampsia

Answer 1

RCOG define eclampsia as a condition which causes women to experience convulsions similar to an elliptic fit in pregnancy, labour or postnatal. Usually follows presentation of pre-eclampsia but not always.

Question 2

Incidence rate

Answer 2

Eclampsia is rare and affects 2.7 in 10,000 pregnancies according to Baston and Hall. Less common in the UK due to good antenatal care and monitoring throughout pregnancy.

Question 3

Death rate?

Answer 3

6/225 women who have eclampsia die

Question 4

Risk factors

Answer 4

Primip
>35 or <20 years old
Multiple pregnancy
Infection
Diabetes
Obesity
Hypertension

Question 5

Cause?

Answer 5

Unknown but thought to be due to abnormal implantation of the placenta. Shown with IUGR/ SGA.

Question 6

Physiology of implantation

Answer 6

Trophoblast implants and spiral arteries form to allow for perfusion from placenta to baby > in eclampsia the serial arteries become fibrous and narrowed> this leads to production of proinflammatory proteins> these enter maternal blood stream causing inflammation in endothelial cells and vasoconstriction > poor perfusion

Question 7

Kidneys?

Answer 7

Poor perfusion to kidneys damages the glomerulus > this slows the filtration rate causing proteinuria and oligouria > also leads to retained salts and therefore hypertension.

Question 8

Liver?

Answer 8

Reduced blood flow > hypoxia > damage to tissues> causes swelling > elevated ALTs and liver capsule stretches causing epigastric pain

Question 9

Retinas?

Answer 9

Reduced blood flow to retinas> hypoxia> Scotoma> are of vision becomes worse. Women experience blurred vision and flashing lights.

Question 10

Endothelial cells

Answer 10

Damage> clot formation which uses platelets damage to red blood cells > haemolysis > DIC (low platelets) > vessels become more permeable and leaky causing oedema.

Question 11

Oedema?

Answer 11

Oedema is likely to occur globally and therefore cerebral oedema will cause headaches, confusion and seizures.

Question 12

What can Eclampsia evolve to?

Answer 12

HELLP. Haemolysis. Elevated Liver Enzymes. Low platelets. 10-20% of eclamptic women. If unrecognised/ untreated > eclamptic fit.

Question 13

Signs of tonic-clonic seizures?

Answer 13

eye-rolling, twitching, skin cyanosed, jerking movements, facial swelling, unresponsive.

Question 14

Aim of eclampsia management?

Answer 14

Stabilise condition. Control seizures and blood pressure. Deliver baby? eliminate fluids and oxygenate.

Question 15

Initial Management

Answer 15

Ensure safe zone. Into left lateral to ensure patent airway and reduce aortocaval compression. Check for obstructions.
Commence 02 15l/min non rebreathe mask.
Continuous obs with dynamap, at least every 10 minutes.
CTG
Venous access (2x 16 G cannulas)
Catheterise with consent (foley indwelling with urometer) Aim for UO of previous hour + 30 mls.
Fluid restriction to avoid pulmonary oedema.
Medical Review

Question 16

What bloods for eclampsia?

Answer 16

FBC (Hb - haemorrhage? PLT -DIC & HELLP?
Us&Es - Kidney function (increased creatinine if poor)
LFTs- Liver function (increased ALTs if damaged)
Group and Save to crossmatch for transfusion and transfer to theatre.
Clotting bloods- DIC & HELLP

Question 17

Mag sulphate?

Answer 17

4g bolus IV over 15 minutes.
2- 4g further bolus if still convulsing over 5-15 mins
1g hourly maintenance dose

Question 18

Signs of magnesium sulphate toxicity

Answer 18

Absent patella reflexes
UO <20ml/ hour
Resps< 14
SATS< 95%
STOP INFUSION IF SIGNS OF TOXICITY

Question 19

How to treat the hypertension?

Answer 19

Magnesium sulphate can reduce blood pressure so monitor closely.
Labetalol orally 200mg (not for asthmatics) OR Nifedipine 20mg orally
IV labetalol 20mg over 2 minutes can double with 10-minute intervals but not exceed 50mg hourly.
IV hydralazine (5 mg every 20 mins until 20 mg) for asthmatics.

Question 20

After care

Answer 20

Strict fluid restriction so close monitoring of UO.
Repeat bloods at 6-24 hours and monitor Magnesium levels.
? Hypo pathway for baby due to potential compromise and IUGR/ Maternal drugs and cord gases.
PN care TWOC, VTE adjusted.
Document, DATIX, debrief.