PLAN TEACHING PROGRAME ON: -

EMERGENCY MANAGEMENT OF
ECLAMPSIA

By: Angelina Samuel Lal

M.Sc. Nursing Final Year
 INTRODUCTI
ON
The term eclampsia is derived form a Greek word,
meaning ‘like a flash of lightening’. Hypertension is
most common medical problem encountered during
pregnancy may cause maternal and fetal morbidity
and leading cause of maternal mortality.
Hypertensive disorders are:
 Pre-eclampsia
 Eclampsia
 Gestational hypertension
 Chronic hypertension
 DEFINITIO
N
 Eclampsia is defined as ‘a new onset of grand
malseizure (generalized tonic-clonic convulsions)
and/or coma in pregnancy & post-partum period is
called eclampsia.
 Pre-eclampsia when complicated with generalized
tonic-clonic seizures and/or coma is called eclampsia.
INCIDENCE RATE
 Eclampsia occurs in 10% of all
pregnancy.
 India ranges from 1 in 500 to 1 in 30.
 Pre-eclampsia occurs more commonly
in 75% cases of primigravida.
 Five times more common in twins
than in singleton pregnancies.
 It occurs between 36th week and term
in more than 50% cases.
 ORGAN DYSFUNCTION IN
ECLAMPSIA
01 02 03
CARDIOVESCUL HEMATOLOGIC RENAL
AR
o Generalized vasospasm
AL
o Decrease plasma volume o Decrease GFR
o o Hemoconcentration
Increased peripheral vascular resistance o Decrease renal plasma flow
o o Coagulation disorder
Decrease CVP (central venous pressure) o Increase serum uric acid
o o Increase blood viscosity
Decrease pulmonary wedge pressure.

04 05
CENTRAL NERVOUS HEPATIC
SYSTEM o Liver cell damage
o Cerebral edema
o Subcapsular hematoma
o Cerebral hemorrhage
o Periportal necrosis
 CAUSES
 Exact etiology is unknown.
 More common in previous hypertensive disorder.
 Failure of placentation.
 Abnormal lipid metabolism
 Decrease calcium in diet

OTHER CAUSES ARE: ‘ACDEPR’

 A- Alcohol
 C- Coarct action of aorta
 D- Drugs
 E- Endocrine disease
 P- Pregnancy induced hypertension
 R- Renal disease
 RISK
FACTORS
 Pre-existing disease
 Age
 Primigravida
 Past history
 Placenta enlarges
 Genetic
 Nutrition
 Infection
 Immunology
 Endocrinology
SYMPTOMS
 Seizures
 Coma
 Headache
 Fatigue
 Change in vision
 Hyperactive reflexes
 Double vision
 Aching muscles
 Increased blood pressure
 Proteinuria
 Generalized edema
 Reduced urination
 Abnormal renal and kidney function
 Epigastric pain
 PHASES OF ECLAMPSIA
PHASE-1 PHASE-2
(tonic stage)
(Premonitory stage)
 Starts in jaw, moves to the muscles of face and
 The patient becomes unconscious. eyelids and then spread throughout the body.
 Body becomes rigid, leading to  The whole body goes into a tonic spasm.
generalized muscles contraction.  Cyanosis appears, eyeballs are fixed.

• Last For 15-20 SECONDS. • Last about 60 SECONDS.

PHASE-3 PHASE-4
(clonic stage) (stage of coma)
 In another deep coma persists till another convulsion.
 Biting of the tongue occurs.
 The fits are usually multiple, recurrent at varying interval.
 All voluntary muscles undergo  Patient appears to be in a confused state.
alternate contraction and relaxation.
For 1-4 MINUTES.
• Period of A COMA.
• Last
Unconsciousness
PATHOGENESI
S
Since eclampsia is a severe form of pre-eclampsia.

The exact cause of seizure is unknown.

Cerebral vasospasm can be severe.

To cause focal ischemia.

Its leads to seizures

And pathological alterations in cerebral blood flow.

And its cause tissue edema.

Induced vasospasm may result in headache, visual

disturbance, hypertensive encephalopathy.

Resulting in seizures.
 ONSET OF FITS
Fits occurs more commonly in 3rd trimester (more than 50%), on rare
condition fits may occur in early months as in hydatidiform mole.

ANTIPARTUM INTRAPARTUM
(50%): (30%):
Fits occur before the onset Fits occur for first time
of labor. during labor.

POSTPARTUM LATE
(20%): POSTPARTUM:
Fits occur for the first time in Fits occur beyond 48 hours but less
puerperium, usually within 48 than 4 weeks after delivery is accepted
hours of delivery. as late postpartum eclampsia.
 COMPLICATIONS
Maternal complications: - Neonatal & fetal complications: -
 Tongue biting  Death
 Head trauma  Prematurity
 Aspiration  Placental infraction
 Permanent CNS damage  Abruptio placentae
 Intra cranial haemorrhage  Fetal hypoxia, aspiration, etc
 Renal failure  IUGR (intra uterine growth retardation)
 Death  Sepsis
 Injuries due to falling from bed
 Disturbed vision
 Psychosis
 Shock
 Cardiomyopathy
 Hematoma
 Pneumonia
 Acute ventricular failure, etc
 DIAGNOSIS
Diagnosis can be made by cardinal signs as given below:

1. Blood Pressure: 2. Proteinuria: 3. Convulsions:

Diastolic pressure: A rise of 10 Protein in urine is an index of
to 20 mmHg above mother’s severity of pre-eclampsia. It is
normal diastolic pressure or identified in mid-stream urine.
increase above 90 mmHg on two
occasions identified at least 6
hours apart at rest.
Systolic pressure: An increase
of systolic pressure 140 to 170 4. Occult oedema:
mmHg It occurs due to retention of fluid. It
marked as increased weight. It’s
found in feet, ankles, pretibial
region, hands, vulva, sacrum & face.
 EMERGENCY MANAGEMENT OF
ECLAMPSIA:

General management Obstetric

Aim of
(medical & nursing) Management
management

1 2 3 4 5

Specific
First aid treatment Management
outside the hospital
 1
AIM OF
MANAGEMENT
 Arrest convulsion.
 Maintenance of patient airway, breathing &
circulation.
 Oxygen administration at the rate of 8-10 L/Min.
 Terminate pregnancy.
 Ventilatory support
 Prevention of complication.
 Hemodynamical stable.
 Prevention of life-threatening situation.
 Postpartum care.
 Medicine & regular follow-up.
 2
FIRST AID TREATMENT
OUTSIDE THE HOSPITAL
 The patient, either at home or in the health centre
should be shifted urgently to the tertiary referral care
hospitals.
 Transport of an eclamptic patient to a tertiary care
centre is very important.
 Such patient needs neonatal & obstetric intensive
care management.
 3

GENERAL
MANAGEMENT
(MEDICAL & NURSING)
 NURSING MANAGEMENT
SUPPORTIVE
 To prevent CARE:
serious maternal injury from fall

 Prevent aspiration

 To maintain airway

 To ensure oxygenation

 ABG analysis is needed

 Sodium bicarbonate is given when pH is below 7.10

 Keep her in side lateral position

 CONT…..
DETAILED HISTORY:

It is to be taken from relatives, relevant to

diagnosis of eclampsia, duration of pregnancy,
numbers of fits, & nature of medications
administered outside.
 CONT…..
EXAMINATION:

Once the patient is stabilized a thorough out

quick general, abdominal & vaginal
examination are made. A self-retaining catheter
is introduced & urine is tested for protein.
 CONT…..
MONITORING:

 Half hourly pulse, reparation rate and blood

pressure are recorded.
 Hourly urine output is to be noted.
 The progress of labour & fetal heart rate is
to be monitored.
 CONT…..
FLUID BALANCE:

 Ringer’s solution started as first choice.

 Total fluid should not exceed the previous 24
hours urinary output plus 1000ml.
 CONT…..
ANTIBIOTIC:

To prevent infection, ceftriaxone 1gm IV BD.

 MEDICAL MANAGEMENT
 Call for extra help.
 Control of seizures MgSO4 (IV/IM regimens)
 To put patient left lateral recumbent position.
 Maintain oral airway
 O2 inhalation.
 Commence IV lines; 1-2 wide bore cannulas.
 Foley catheter with urometer.
 To monitor O2 saturation.
 To monitor fetal vital status and magnesium toxicity.
 Control of hypertension: Labetalol, hydralazine.
 Suction.
 Diuretics: pulmonary oedema.
 Investigation of blood like, CBC, AST, ALT, LDH,
Creatinine, uric acid, urine analysis- protein.
 4
SPECIFIC MANAGEMENT
1. ANTICONVULSANT REGIME:
2. OTHER REGIMEN:
3. ANTIHYPERTENSIVE & DIURETICS:
4. MANAGEMENT OF FITS:
5. STATUS ECLAMPTICUS:
6. TREATMENT OF COMPLICATION:
 CONT…..
1. ANTICONVULSANT REGIME:
The aim to control the fits & prevent it’s recurrence.
Magnesium sulphate is drug of choice, it acts as a membrane
stabilizer & neuroprotector.
For IV administration, concentration of MgSO4 should not exceed
20%.
One part of 50% MgSO4 injection is diluted with 1.5 parts of
water for injection to make it 20%.
It is then given IV slowly.
Repeat injections are given only if knee jerk is present, respiration
rate more than 12/min, urine output exceeds 30ml/hour.
MgSO4 is continued for 24 hours after the last seizer or delivery.
 CONT…..
1. ANTICONVULSANT REGIME:

Regimen Loading dose Maintenance dose

I/M 4g (20% solution) IV 5g (50%) IM 4 hourly

(Pritchard) over 3-5 minute in alternative buttock
followed by 10g (50%),
deep IM (5g in each
buttock)

I/V (Zuspan 4-6g IV slow over 15- 1-2g/h IV infusion

or sibai) 20 minute
 CONT…..
2. OTHER REGIMEN:

 Phenytoin
 Diazepam
 Lytic cocktail, menon 1961
(chlorpromazine,
pethidine, promethazine)
 CONT…..
3. ANTIHYPERTENSIVE & DIURETICS:

 If the blood pressure remains more than

160/110 mmHg, hypertensive drugs should
be administered.
 Drugs commonly used are: Hydralazine,
labetalol, calcium channel blocker or
nitroglycerine.
 Labetalol 20mg IV is given. Repeat dose
given after 10 minutes.
 Hydralazine 5 to 10 mg IV is given.
 CONT…..
4. MANAGEMENT OF FITS:
 In premonitory stage: a mouth gag is
placed in between teeth to prevent tongue
bite.
 The air passage is to be cleared off the
mucus with mucus sucker, the patient’s
head is to be turned to the one side, raising
the foot end of bed facilitates postural
drainage of the upper respiratory tract.
 Oxygen is given unit cyanosis disappears.
 CONT…..
5. STATUS ECLAMPTICUS:

 Thiopentone sodium 0.5gm dissolved in

20ml of 5% dextrose is given IV very
slowly.
 In unresponsive cases, caesarean section in
ideal surrounding may be a lifesaving
attempt.
 CONT…..
6. TREATMENT OF COMPLICATION:
 Prophylactic use of antibiotics markedly reduces the
complication like pulmonary & puerperal infection.
 Pulmonary oedema & ARDS: Frusemide 40 mg IV
followed by 20gm of mannitol IV, pulse oximeter is
very useful in such patient. Aspiration of mucus from
trachea-bronchial tree by a suction apparatus is done.
 Heart failure: Oxygen inhalation, parenteral Lasix
and digitalis are used.
 Anuria: The dopamine infusion is given.
 Hyperpyrexia: cold sponging & antipyretics are
given.
 Psychosis: chlorpromazine or Trifluoperazine is quite
effective.
 5 OBSTETRIC MANAGEMENT
1) DURING PREGNANCY:
 In majority cases with antepartum eclampsia, labour starts soon after convulsion.
 But when labour fails to start, the management depends on: whether the fits are controlled or not, the maturity of fetus. 
A) FITS ARE CONTROLLED: There may be 3 condition like: baby mature, baby premature & baby dead.
(i) Baby mature: Delivery should be done.
• If cervix is favourable & there is no contraindication of vaginal delivery, surgical induction by low rupture of the
membrane is done.
• When cervix is unfavourable cervical ripening with PGE2 gel could be achieved before ARM.
• If cervix is unfavourable &/or there is obstetric contraindication for vaginal delivery, caesarean section is done.
(ii) Baby premature (before 37 weeks): Delivery is recommended in set of NICU.
• The underling disease process of preeclampsia & eclampsia persist until women delivers.
• The disease process may flare up.
• Moreover, there is risk of convulsion & IUFD.
• Steroid therapy is given when pregnancy may improve perinatal outcome.
• But this must be carefully balanced with maternal wellbeing.
(iii) Baby dead:
• The pre-eclampsia process gradually subsides & eventually expulsion of baby occur, other wise medical of induction is
started.
B) FITS ARE NOT CONTROLLED:
• If fits are not controlled with anticonvulsant within a reasonable period (6-8 hours),
• Termination of pregnancy should be done.
2) DURING LABOUR: In absence of any contraindication to vaginal delivery as soon as labour is established, low rupture of
membrane is done to accelerate labour.
 FOLLOW-UP &
Patient PROGNOSIS:
should be followed up in the
postnatal clinic by 6 weeks’ time. Persistence
of hypertension, proteinuria and abnormal
blood biochemistry necessitates further
investigation and consultation with a
physician. Further pregnancy should be
deferred till they are controlled.
CONCLUSION
SEclampsia is a common complicated
still associated with high level of
maternal and perinatal mortality as well
as morbidity. ANC coverage should be
strengthened to detect preeclampsia,
and prevent eclampsia. Management in
the hospital should be optimized to
prevent recurrent convulsion and
complication after admission.
ANY QUESTIONS….?
 REFERENCES
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childrearing family. Sixth edition. Philadelphia; Lippincott Williams & Wilkins: 2010.
 Cunningham, Leveno, Bloom,William’s obstetrics, 23rdedition,United states of America;
Mcgraw Hill companies: 2010.
 Nettina S.M, Mills E.J. Lippincott Manual of Nursing Practice. 8th Edition.
Philadelphia: Lippincott Williams and Wilkins; 2006
 Multiple Pregnancy and Birth: Twins, Triplets, and High-order Multiples: A Guide for
Patients. Patient information series. American Society for Reproductive Medicine 2012.
THANK
YOU!