Eclampsia

Question 1

What is Eclampsia?

Answer 1

• it is defined as one or more convulsions in association with pre eclampsia
• it is estimated that 38% of seizures occur before proteinuria and hypertension have been documented
• 44% of seizures occur postpartum, 38% antepartum and 18% intrapartum
• the seizure is thought to be du to intense vasospasm of the cerebral arteries, oedema secondary to ischaemic damage of vascular endothelium and/or intravascular clot formation

Question 2

What are the three defined phases of an eclampsia fit?

Answer 2

• prodromal —> in which the imminent fit is heralded by possible reports of visual disturbances, muscular twitching, facial congestion, foaming at the mouth and/or deepening loss of consciousness
• tonic-clonic —> where initially generalised muscular contractions are present and respiration is absent, this is followed by repeated strong jerky irregular muscular activity
• abatement —> which occurs within 60-90 seconds of onset during which time respiration is re-established and there is gradual return to consciousness, but perhaps with a confused agitated state

Question 3

How should eclampsia be managed?

Answer 3

• CALL FOR HELP (SOAPS)
• SUPPORT
  —> protect from injury during the tonic-clonic phase
  —> maintain airway, breathing and circulation
  —> move the mother into left lateral
  —> administer high flow facial oxygen with a reservoir bag
  —> do not attempt to restrain during her seizure, immediately following ensure the woman is maintained in the left lateral position with an open airway
  —> IV access and bloods (FBC, group and save, blood glucose, U+E’s, LFTS, clotting)
• CONTROL SEIZURES
  —> give magnesium sulphate loading dose (4g IV over 5 mins)
  —> magnesium sulphate maintenance dose (1g/hour IV for at least 24 hours after last seizure)
  —> recurrent seizures (magnesium sulphate 2g bolus over 5 minutes) (consider over causes of seizures such as intracranial haemorrhage and organise urgent CT or MRI)
  —> consider anti-hypertensives
• fluid balance (urinary catheter)
• maternal observations
• achieve stability of maternal condition prior to making plans for birth but assess fetal wellbeing, CTG monitoring
• patellar reflexes in view of risk of magnesium toxicity
• DOCUMENT

Question 4

Why use magnesium sulphate?

Answer 4

• the results of the collaborative eclampsia trial demonstrated that women treated with magnesium sulphate have fewer recurrent seizures compared with women treated with diazepam or phenytoin
• it appears to act primarily by reducing cerebral vasospasm
• the subsequent MAGPIE trial demonstrated that magnesium sulphate can also prevent eclampsia

Question 5

What about magnesium toxicity?

Answer 5

• magnesium sulphate is excreted by the kidneys
• magnesium toxicity is unlikely with this regimen and, if the woman has a normal urine output, the measurement of levels is not necessary
• however, if the woman is oliguric (produces less than 100ml urine over 4 hours) or has renal impairment, magnesium levels are more likely to become toxic and it is therefore advisable to administer the loading dose only
• if the woman develops oliguria while receiving the maintenance dose this should be stopped blood should be taken to measure the serum magnesium level
• at toxic level there is a loss of deep tenon reflexes followed by respiratory depression, respiratory arrest and ultimately cardiac arrest

Question 6

What are some of the predisposing factors for preeclampsia?

Answer 6

• primiparous
• previous PET
• chronic hypertension
• family history of pre eclampsia
• pre-existing diabetes
• multiple pregnancy
• interval of 10 years or more between pregnancies
• obesity
• extremes of maternal age
• autoimmune disease
• renal disease
• IVF

Question 7

What are some of the signs and symptoms of preeclampsia?

Answer 7

• brisk reflexes
• papilloedema
• severe and persistent occipital or frontal headaches
• visual disturbances
• altered mental state
• oliguria
• oedema
• pulmonary oedema
• difficulty breathing
• upper epigastric pain
• vomiting