Eclampsia + uterine rupture Flashcards
What is eclampsia?
- Defined as the occurrence of one or more convulsions in a pre-eclamptic woman in the absence of any other neurological or metabolic causes.
- OBSTETRIC EMERGENCY - most occur in postnatal period, but can also occur in antepartum and intrapartum settings.
Moderate RF for pre-eclampsia?
All patients with pre-eclampsia are at risk of developing eclampsia. Mod RF for pre-eclampsia:
1) Nuliparity
2) Maternal age >40
3) Maternal BMI >35
4) FH of pre-eclamspa
5) Pregnancy interval >10yrs
6) Multiple pregnancy
High RF for pre-eclampsia?
All women with pre-eclampsia are at risk of developing eclampsia, high RF for pre-eclampsia:
1) Chronic HTN
2) HTN, pre-eclampsia/eclampsia in previous pregnancy
3) Chronic kidney disease
4) Autoimmune disease (SLE, APS)
5) Diabetes Mellitus
Clinical features for Eclampsia?
- New onset tonic-clonic type seizure in the presence of pre-eclampsia (new onset HT and protein area beyond 20 weeks gestation).
- Seizure lasts 60-75 seconds followed by a variable post-ictal phase.
- Maternal conclusions may cause (FOETAL DISTRESS AND BRADYCARDIA)
- Aside from seizures, Sx similar to pre-eclampsia - often includes signs and symptoms of end-organ dysfunction.
1) Hyperreflexia
2) Generalised oedema
3) N+V
4) Headache
5) Visual disturbance
6) Altered mental state
7) RUQ ab pain +/- jaundice
Complications of Eclampsia?
MATERNAL: 1) HELLP 2) DIC 3) AKI 4) Adult respiratory distress syndrome 5) Cerebrovascular haemorrhage 6) CVS damage permanently 7) Death FOETAL: 1) IUGR 2) Prematurity 3) Infant respiratory distress 4) Placental abruption 5) Intrauterine foetal death
Ddx of Eclampsia?
Important to ddx between eclamptic seizures and those caused by other disorders, in pregnancy. Eclampsia women usually have features of severe pre-eclampsia prior to accompanying seizures. Ddx: 1) Hypoglycaemia 2) Epilepsy 3) Cerebrovascular haemorrhage 4) Head trauma 5) Meningitis 6) Medication-induced 7) Septic shock 8) Brain-tumour 9) Ischaemic stroke 10) Cerebral aneurysm
Investigations of Eclampsia?
- Investigations in suspected eclampsia used to exclude other reversible causes (e.g. hypoglycaemia) and assess for any complications (DIC or HELLP).
1) FBC - reduced Hb and platelets
2) U+Es - raised urea, creatinine, urate, decreased urine output
3) LFTs - raised ALT, ALP, bilirubin
4) Clotting factors
5) Blood glucose - ABDOMINAL ULTRASOUND to estimate gestational age, rule out placental abruption which can complicate eclampsia.
- CTG monitoring - evidence of foetal distress/bradycardia (not routine).
- MRI/CT to rule out any other cause of seizures
5 main principles in the management of Eclampsia?
1) Resuscitation - ABCDE assessment and intervention, patient lying in left lateral position with secures airway and oxygen therapy.
2) Cessation of seizures - eclamptic seizures teated with Magnesium Sulphate (assess for hypermagnesaemia - resp depression and hyperreflexia + CTG monitoring)
3) Blood pressure control - Labatelol and hydralazine used, target MAP <120mmHg (can affect foetus so continuous CTG during and 30 mins after IV anti-HTN)
4) Prompt delivery of baby and placenta - only definitive Tx, but mother must be stable before delivery - seizures, HTN and hypoxia controlled/corrected - C-section ideal
5) Monitoring - fluid balance monitoring to prevent pulmonary oedema and detect AKI, monitor platelets, liver enzymes and creatinine levels.
Cessation of seizures management:
- With Magnesium Sulphate Prophylaxis - 4g in 100ml, 0.9% NaCl 1st seizure - 4g in 100ml, 0.9% NaCl Maintenance - 1g hourly for 24 hours Recurrent seizures - 2g bolus
Post-Natal care and follow up?
Can be divided into inpatient and outpatient care:
INPATIENT:
- Regular symptom review
- Bloods 72 hours post part - FBC, LFTs, U+Es
- Pre-conceptual counselling
- Step-down to community - well controlled BP, adequate urine output, discontinued Magnesium sulphate, asymptomatic.
OUTPATIENT:
- Consider CT head
- BP measurement (daily for 2 weeks postpartum)
- Follow-up at 6 weeks - Check BP, proteinuria, creatinine. Repeat FBC, LFT, creatinine if not previously returned to normal.
What is a uterine rupture?
- Refers to full-thickness disruption of the uterine muscle and overlying serosa - typically occurs in labour and can extend to affect the bladder and broad ligament.
- Two main types - incomplete: where the peritoneum overlying the uterus is intact - in this case the uterine contents remain within the uterus, complete: the peritoneum is also torn, and the uterine contents can escape into the peritoneal cavity.
- Rare but significant maternal and foetal morbidity/mortality.
Risk factors for uterine rupture?
1) Previous C-section (greatest risk factor)(classical incisions carry greatest risk)
2) Previous uterine surgery
3) Obstruction of labour
4) Multiple Pregnancy
5) Multiparity
Clinical features of uterine rupture?
- NON-SPECIFIC - makes diagnosis and prompt management difficult.
1) SUDDEN SEVERE ABDOMINAL PAIN (persists between contractions) - shoulder tip pain from diaphragmatic irritation.
2) Vaginal bleeding
O/E: - Regression of presenting parts
- Palpation of abdomen - scar tenderness and parts of baby palpable
- Significant haemorrhage - signs of hypovolaemic shock - tachycardia and hypotension.
- Foetus - foetal distressing and absent heart sounds
Ddx of uterine rupture?
1) Placental abruption
2) Placental praevia
3) Vasa pravia
Investigations of uterine rupture?
- For women at risk - intrapartum monitoring and CTG.
- Changes in FHR patterns (recurrent or late decelerations) and prolonged bradycardia are early indicators for uterine rupture.
- Pathological CTG usually prompts emergency C-section + uterine rupture is noted infra-operatively.
- Maternal haematuria on catheterisation
- Suspicion of rupture in pre-labour setting - Ultrasound can be used - abnormal foetal lie or presentation, haemoperitoneum and absent uterine wall.
