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Management of eclampsia. Phase 1: Prodrome (20-30 seconds)
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Management of eclampsia
Eclamspia is the most severe form of hypertensive disorders of pregnancy. It is expressed by seizures, which are accompanied by loss of consciousness and convulsions, very similar to epileptic. Each attack of eclampsia lasts 1-2 minutes. After a fit, a woman can either come to consciousness, or fall into a coma. There is also non-convulsive eclampsia (coma), which refers to extremely severe HP, and is very rare. It is not absolutely necessary that eclampsia occurs as a result of a successive transition of one stage of HP to another, from mild to more severe. In some cases, seizures or coma may be the first recognizable sign that a pregnant woman has had preeclampsia.
Clinically, eclampsia presented by consecutive phases of development of convulsive syndrome.
Phase 1: Prodrome (20-30 seconds)
• Twitching of the face, the eye lids
• Facial congestion
• Mouth foaming
• Altered Level of Consciousness
— Phase 2: Tonic convulsions(30-40 seconds)
• Muscle rigidity
• Tension of the whole body
• Cessation of breathing,
• Cyanosis of the face.
— Phase 3: Clonic convulsions (about 45-60 seconds)
• Rhythmic muscle contractions and relaxation
• Generalized Tonic Clonic Seizure
• Loss of respiratory activity
— Phase 4: Comatose
• Respiratory effort, but otherwise comatose
• After the convulsion subsides, the patient goes into coma for a certain period of time; then she slowly regains consciousness and is amnesic as to the event.
— Phase 5is - Postictal phase - also distinguished in some countries:
• Patient confused and agitated
Sometimes the attack of convulsions recurs while the patient is in coma. The number of such attacks varies from one or two to ten and over. Eclampsia usually causes maternal and fetal death. Convulsions may attack after delivery too: one third of seizures occur in the postpartum period, most within 24 hours of delivery, and almost all within 48 hours.
Algorithm of medical care in eclampsia attack (treatment in case of seizure begins on the spot). The basic principles of airway, breathing, and circulation (ABC) should always be followed.
1. Place the patient on a flat surface in the position on the left side to reduce the risk of aspiration of stomach contents, vomiting and blood.
2. Quickly clear the visible airways.
3. Open the mouth and push the lower jaw forward.
4. Evacuate the contents of the oral cavity.
5. It is necessary to protect the patient from damage, but not keep it active
6. With the saved spontaneous breathing, enter the oropharyngeal airway and start inhalation of oxygen by applying the facial mask to the nose through the system of moistening the oxygen mixture.
7. With the development of respiratory apnea, immediately begin forced ventilation through the nasal face mask with 100% oxygen in the positive pressure mode at the end of the exhalation. If the convulsions are repeated or the patient remains in a coma, introduce muscle relaxants and begin artificial ventilation (IVL) in a normal ventilation mode.
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8. Simultaneously make catheterization of the peripheral vein and begin the injection of anticonvulsants (Magnesium Sulfate - bolus 4 g for 5 minutes IV, then maintenance therapy (1-2 g / h. ) with careful control of blood pressure and heart rate). If convulsions continue introduce another 2 g of magnesium sulfate (8 ml of 25% solution) for 3-5 minutes. Treat recurrent seizures with an additional bolus of 2 g or an increase in the infusion rate to 1. 5 or 2 g per hour (15 or 22 drops/min).
9. Instead of an additional bolus of Mg Sulfate, use Diazepam IV slowly (10 mg) or Thiopental Sodium (450-500 mg). If the convulsive seizure lasts more than 30 minutes, this condition is regarded as an eclampsic status;
10. If dBP remains (> 110 mm Hg, antihypertensive therapy is performed. The goal of hypertension treatment is to maintain BP around 140/90 mm Hg. Avoid drastic reduction in blood pressure as a result of antihypertensive therapy
11. The bladder is catheterized (leaving a permanent catheter - hourly recording of urine excretion and proteinuria analysis);
12. After arresting of seizures, correction of metabolic disturbances, water-electrolyte and acid-base balance and protein metabolism is carried out.
13. Accurate control of ABP is mandatory.
14. Continuous monitoring of blood pressure, determination of hourly diuresis, assessment of clinical symptoms with mandatory registration in the history of labor - hourly.
15. Continuous CTG monitoring of the fetus.
16. Delivery is carried out after the onset of stabilization.
NB! Artificial ventilation is not the main way to treat eclampsia, but the elimination of hypoxia (the most important pathogenetic factor in the development of multi-organ failure) is a prerequisite for other activities.
Fluid management
· Aggressive volume resuscitation may lead to pulmonary edema
· Patients should be fluid restricted when possible, at least until the period of postpartum diuresis
· Central venous pressure (CVP) or pulmonary artery pressure monitoring may be indicated in critical cases
· A CVP of 5 mm Hg in women with no heart disease indicates sufficient intravascular volume, and maintenance fluids alone are sufficient
· Total fluids should generally be limited to 80 mL/hr or 1 mL/kg/hr
Postpartum management
· Many patients will have a brief (up to 6 hours) period of oliguria following delivery
· Magnesium sulfate seizure prophylaxis is continued for 24 hours postpartum
· Elevated BP may be controlled with nifedipine or labetalol postpartum
· Liver function tests and platelet counts must document decreasing values prior to hospital discharge
· Anti-hypertensive medication should be continued after delivery as dictated by the blood pressure. It may be necessary to maintain treatment for up to 3 months, although most women can have treatment stopped before this. If a patient is discharged with BP medication, reassessment and a BP check should be performed, at the latest, 1 week after discharge
· Unless a woman has undiagnosed chronic hypertension, in most cases of preeclampsia, the BP returns to baseline by 12 weeks’ postpartum
· Patients should be carefully monitored for recurrent preeclampsia, which may develop up to 4 weeks postpartum, and for eclampsia that has occurred up to 6 weeks after delivery
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