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Eclampsia, its Diagnosis and Management

Nov 11 | 1:30 PM

Of the lesser known complications of pregnancy is Eclampsia. Young primigravidas, illiteracy, lack of adequate ante-natal care and low economic conditions are few major social factors responsible for the high incidence of eclampsia in India. It is one of the leading causes of maternal morbidity and mortality. However if detected early, it can be prevented. Join us to know more about how to diagnosis and manage this disease with Dr. Padmaja Mavani.

[Music] so good evening everyone i am dr samadhi i welcome you all on behalf of team netflix today we have with us a very passionate personality dr padmaja mavani associate professor obstetrics and gynecology said gsmc and km hospital mumbai over to you ma'am yeah thank you so much will you put on the presentation please yes ma'am okay so good evening everybody and thank you dr samadhiya uh we're going to be talking today about this evening about eclampsia its diagnosis and management now i am going to begin with a story so this is a story of a 24 year old primary gravida who came to us uh 17 weeks gestation was referred from community health center with an episode of generalized tony clinic conversions at home without her any precipitating episode like trauma or anything the patient had regained consciousness and was taken to a nearby health center where she was found to have blood pressure of 180 by 120. she was given injection magnesium sulphate in the loading dose and she was referred to a tertiary care center for further management she had an antenatal registration at 14 weeks in her own clinic with normal blood pressure recorded on booking visit and early antenatal ultrasonography suggestive of single life intrauterine gestation she otherwise had no past medical history and no history of warning symptoms prior to conversion episode now this lady doesn't fit anywhere in our definition of eclampsia because she was just about 17 weeks pregnant so we have n numbers of such patients who really don't fit into the otherwise known definition of eclampsia and those diagnostic challenges to us so we will be looking at diagnosis and management of these cases and some other cases with uh comorbidities or end organ uh complications etcetera where our conventional managements fail so uh if you can see the pipe chart here among all the causes of maternal mortality 13 that's a significant chunk is taken by eclampsia now eclampsia or say it would be once the generalized tony clonic conversion passes uh she would either have aspiration or she would have end organ damage and most of the patients as we will see later on in the number of cases percentages would arrive to a clinic or would be detected with hypertension and convulsion would be preventable so this is a preventable mortality so our objectives for today's session are diagnosis of eclampsia investigations treatment of convergence hypertension treatment delivery options and management of complications eclampsia may not always be preceded by 20 weeks gestation or hypertension etc and it could poses a diagnostic dilemma so in absence of hypertension with proteinuria eclampsia has been demonstrated to occur in about 38 percent of cases reported in the united kingdom so this is more than one-fourth of cases did not have hypertension with protein urea now similarly hypertension was absent in 16 of cases reviewed in the united states in cases of eclampsia so 16 percent again a percent again is a very large number so how to diagnose and how to reach a proper conclusion so that proper treatment can be administered so what are the risk factors for eclampsia family history of preeclampsia previous preeclampsia and eclampsia are known risk factors poor outcome of previous pregnancy including fetal growth restriction abrasion placenta or fetal death are also known but if we say about 10 percent of primees will have eclampsia that means they will will not have presented any time with poor obstetric outcome or fatal go through growth restriction or abruptio placenta or fetal death multify gestation hydrated deform mole hyper hydroxy and primary gravity are all the risk factors now coming to previous medical conditions chronic hypertension renal disease thrombophilias protein c proteins deficiency anti-thrombin deficiency vascular and connective tissue disorders systemic lupus erythematosus gestational diabetes and diabetes mellitus again coming back to primary gravity which are a large chunk of these patients will not have history of any of these things our patients are young uh sometimes very young prime gravity bordering on 1920 most of them anemic most of them unregistered but they don't give us all this history they don't have investigations with them and we have to suspect and diagnose eclampsia in these patients eclampsia is a multi-organ affection so there are significant cardiovascular concerns like generalized vasospasm increased peripheral vascular resistance and increased left ventricular stroke output pulmonary capillary wedge pressure may vary from low to elevated in these cases and even if we put a central venous line cvp may not always correlate with pulmonary capillary pressure in patients with severe preeclampsia or eclampsia and here is where we will be faced with great dilemma whether to infuse these patients who have renal shutdown or to not infuse whether to give them monetal whether to give them magnesium sulfate whether to give them uh fruit semi obese diabetic ecliptic women may have pre-existing cardiac disease and cardiac strain and they may pose therapeutic challenges to us there are hematologic concerns like problems associated with preeclampsia and eclampsia in hematology area can include decreased plasma volume increased blood viscosity and hemoconcentration and coagulopathy at the same time when we say on one side there is hemoconcentration on the other side if they have help syndrome and they have hemolysis then they may present with anemia renal concerns eclampsia associated renal abnormalities can include decreases in glomerular filtration rate renal plasma flow uric acid clearance as well as protein urea so the old standard for treatment of eclampsia magnesium sulfate may not be a suitable anticonvulsant for patients with either accutabulon necrosis or severe oliguria or do not know where we exactly are then hepatic concerns hepatic derangements associated with eclampsia can include periportal necrosis repetocellular damage and subcapsular hematoma now sub capsular hematoma will require imaging that is much later on but patient may not we really may not be able to palpate hepatic tenderness also because they will be fully gravid and we cannot really palpate their liver with 36 weeks period of gestation uterus they may not be jaundiced their bilirubin may be just above normal so how to know whether they are in liver cell failure we will get eventually sgot sgpt ldh etc etc but what sort of treatment to establish and how to manage these patients creates a concern central also you know there is a dilemma sometimes whether she is um just um [Music] she is only hypertensive with our um what you call viral hepatitis or she is hypertensive bordering on to eclampsia sometimes they may present with hypertension and they may not present with convulsions but liver derangement so we have to make a decision as to as to whether we have to deliver her or whether we have to wait for her viral hepatitis to resolve then central nervous system concerns eclampsia can result in central nervous system abnormalities such as cerebral over perfusion due to loss of autoregulation resulting in cerebral edema and sometimes cerebral hemorrhage cerebral hemorrhage will leave them with lasting [Music] problems uh with stroke related uh later on disabilities etc etc and they will become very high risk for further management in this pregnancy as well as in future pregnancies now what is this relation of seizure to delivery almost 70 percent of patients or more than 70 percent of them will have seizures before delivery of which 25 percent may be antipatem 50 percent may be intrapartum now when we say intrapartum that means patients have come to us either with severe hypertension or mild hypertension we have induced them for whatever reason or they have gone into spontaneous labor for whatever reason and then they converse so this is exactly where a vigilant monitoring can avoid conversion related morbidity and mortality of the mother and the baby then 25 percent will be post partum now these postpartum are the tricky patients because if they are they have delivered and if we have send them with vp monitoring at home or something and if they converge at home if they do not monitor their blood pressure diligently at home or if even if they try to monitor blood pressure diligently and they are unable to monitor it properly or understand the significance of it then they have a problem now premonitory signs and symptoms headache is there in eighty three percent of patients hyperactive reflexes in eighty percent of patients marked protein urea would be there in fifty two percent of patient generalized edema and forty nine percent visual disturbances in forty four percent and epigastric pain in nineteen percent of these patients convergence uh we may see patients during conversion in a receiving room or they may have been brought after conversion has taken place either in another hospital or at home if in another hospital they might have been given some sort of anti-convulsant but if she has conversed at home and she has sort of come out of that conversion she has not been given anything so she may be in a postal state that is a state of confusion or she may be comatose she may have headache which is usually a frontal headache she unfortunately if she has had a fall there would be consequences of fall or there would be a tongue bite or something if she hasn't had followed tongue bite good enough very few of them might have actually aspirated because convulsion can occur anytime and they might be on full stomach and they may vomit and they may convulse and they may aspirate on that visual disturbances would be there in forty percent of patients such as blood vision or photophobia right upper quadrant pain with nausea in about twenty percent of patients and amnesia or other mental status changes in about 20 to 30 percent of patients now there would be absence of pre-monetary symptoms in some patients like lack of edem 39 percent absence of protein urine 21 and normal reflexes in 20 now here is where i would like to caution everybody if you're doing protein urea with dipsticks it is all right but if you are doing with conventional method like sulphur salicylic acid believe me in different areas of warts dilution of sulfur salicylic acid which is prepared by the junior most nurses or even servants sometimes can be wrong and you know suddenly outside you are getting patient having two plus protein area and inside she comes into the ward and the protein you have become stressed it cannot reverse like that but still these are the findings that may be noted on paper and they may be extremely confusing 25 percent of patients have symptoms consistent with mild preeclampsia actually so whatever we expect she will have severe hypertension she will she will have pre-monetary symptoms so these are not there in these patients and then they throw a fit physical findings generalized edema may may not be there as we see so already vital signs there would be tachycardia tachypnea uh because of convulsion and post technical state there would be rals if she has aspirated there would be hypertension there would be mental status changes allegory or protein urea would be their right upper quadrant pain we might find small fundal height uh for the estimated gestational age because of fetal growth restriction occasionally if the patient has been unfortunate if she has abrupted there would be bleeding pervasiveness and abstinent fetal hearts or fetal heart decelerations might be there but if mind you if decelerations are during conversion then we are supposed to wait dissertations are immediately post convulsion we are supposed to wait and no action has to be taken because those decelerations mostly will recover ophthalmic findings generally when a call is sent for ophthalmic person to evaluate they would come and write no evidence of papillima now actually nobody bothers to dilate the pupils also at that time and we are not expecting papillion in these patients what we are expecting these patients is what is the grade of hypertensive retinopathy papillaedema occurs only in cases of idiopathic intracranial hypertension and cerebral venous thrombosis very rarely papillaedema will be seen in patients with eclampsia the commonest findings and why the these findings are there is first of all there is retinal vasospasm and the resistance to blood flow these are the positive factors for pathogenesis of the visual symptoms so the there would be serious retinal detachments cotton wool spots retinal hemorrhages elsing spots or decreased ratio of retinal arterioles to veins so hypertensive changes would be their vagiso spasm would be there there would be corollary ischemia coral ischemia would cause subretinal leak of fluid and this sub return leak of fluid would cause serious retinal detachment all of these are reverse retinal attachment is reversible the cortical blindness that occurs in these patients is reversible then the differential diagnosis see with convulsion we can have any neurological condition as a differential diagnosis but convulsion in a pregnant woman who has had hypertension who has had little bit of edema who has had mild or moderate protein urea mostly mostly would be eclampsia rather than unless she has had history of epilepsy and this is not the first time she would somebody would be having epileptic conversion so either she has to have epilepsy in the past or she has to have a fall or something of that sort to give us other differential diagnosis but for sake of completion the differential diagnosis would be either cerebellar or subarachnoid hemorrhage cerebral venous thrombosis encephalopathy or either hypertensive encephalitis or meningitis head trauma undiagnosed brain tumors seizures and epilepsy septic shock systemic lupus erythematosus thrombotic thrombocytopenic purpura cerebral vasculitis drug overdose so on and so forth now it is it may be uh logical at the same time may be illogical to discuss investigations just now because when a patient of eclampsia comes into the receiving room we don't start with investigations we start with treatment so stabilization is the first but for the sake of you know sequence diagnosis investigations and then treatment i am going in this order but it is important to understand that supportive treatment is established first anticonvulsant is given first catheterization etc etc everything is done first before we reach the stage of investigations so what does complete blood count show us it may shows anemia due to microangiopathic hemolysis or hemoconcentration due to third spacing of fluid both are possible peripheral smear may show schistocytes burst cells or echinocytes thrombocytopenia a platelet count less than one lac or help syndrome may be seen in 20 to 25 patient percent patients with eclampsia we have to rule out associated disseminated intravascular coagulation dic is rare unless there is an associated abruption liver function tests liver function test results may reveal the following about 20 to 25 percent patients with eclampsia raised is go t and sgpt more than pregnancy related levels it is acceptable to have about one and a half to two times rise in liver function test sometimes uh in patients with uh preeclampsia but not beyond that total bilirubin levels higher than 1.2 milligrams per cent ldh levels which are higher than 600 intra international units per liter alkaline phosphatase is not of any value because there is a placental source of alkaline phosphatase and we cannot really depend upon alkaline phosphatase renal function tests we normally don't do albumin creatinine ratio in these patients we do albumin only we do urinary proteins rather than albumin so but it is seen that if measured early in second trimester and albumin creatinine ratio of 35.5 milligrams per millimole or high a millimole or higher may predict preeclampsia even before symptoms rise the serum creatinine level is also elevated in preeclampsia because of decreased intravascular volume and reduced glomerular filtration rate they are there is dehydration of salts in these patients so their creatinine may be higher creatinine clearance may be less than 90 milliliters per minute per uh 1.73 meter squared ah body surface area now we require to hydrate them when we require to hydrate them we have to know that pulmonary edema doesn't occur so that is why ah central venous line is important in these patients so central venous line the person will put only knowing that their dic profile is normal so for dic profile uh we require to wait for some time now do we have time to wait for all this so is there any value of bedside coagula coagulation tests this is a question each one of us has to ask ourselves because we have left far behind the clinical competence of doing bedside coagula coagulation tests etcetera and we depend more and more on the laboratory ct scanning or mri in patients with trauma patients who are refracted to magnesium sulphate therapy or have a typical presentation since just 24 hours after delivery absence of severe hypertension etc there is a place for ct scan or mri abnormal mr imaging findings that is gray matter white matter junction on t2 weighted images showing increased signals as well as cortical edema and hemorrhage this implies the syndrome of posterior reversible encephalopathy indicative of central vesogenic edema it has been increasingly recognized as component of eclampsia but generally we do not require to do mri or ct scan in these patients unless we see that there is a neurodeficit somewhere which indicates that there is some other problem other than only convulsion because of cerebral vasospasm and cerebral edema so when there is neurodeficit or when we suspect an intracranial tumor or something then we might do a ct or mri otherwise patient gets convulsion she is on magnesium sulfate she delivers she becomes all right and then city mri is not required or in patients who are postpartum and they converse we may require cns imaging so abdominal imaging sonography is not a sensitive finding a sensitive imaging study for detection of placental abruption but it is highly specific positive sonographic findings are associated with increased maternal morbidity and require more aggressive obstetric management and it is associated with worse perinatal outcome but a negative sonography for abruption does not mean that absorption is not there this can be because of the varied appearance of the retroplacental clot which may be homogeneous with the uterine musculature sometimes it may be found as or reported as a uterine focal contraction or something of that sort ct mri though they may be accurate we don't do ct or mri for absorption this is a picture which shows um where the arrow is actually it shows the ah subcapsular hematoma this is one of the rare things we have seen this patient about 28 weeks pregnant coming with severe pih and severe right hypochondrial pain and i first diagnosed as sub diaphragmatic hematoma so diaphragmatic hematoma we were wondering whether it is a um trauma or whether it is something else where we require to our intervention has to be ah you know it was very difficult to know she was a case of ivf pregnancy and we required to terminate her pregnancy we required to take decision and we had done this mri to show and we had found this particular picture and this picture had shown a large subcapsular hematoma eventually patient delivered a 900 grams baby they had given an uh an informed refusal signature and unfortunately the baby succumbed hematoma resolved on its own now treatment which i said is actually instituted immediately when the patient comes to the receiving room so supportive care securing an intravenous line with a large bore catheter securing the uh urinary catheter in place taking care that urinary catheter does not get pulled because hematuria because of trauma may be confused with bic related hematuria and this creates a lot of problems sometimes a clot may sit there at the opening of the catheter inside the bladder that clot prevents drainage and we think patient is in an area so catheter should not be pulled initiate cardiac monitoring and administer oxygen every place may not have the luxury of cardiac monitoring or a multiparamonitor but at least administration of oxygen is important and transporting patients in the collateral decubitus this is the most most important thing so as to prevent aspiration then close monitoring airways support adequate oxygenation and anti-conversion therapy and blood pressure control are the main stage magnesium sulfate recommendations suggest that magnesium sulfate be utilized for three things one is seizure prophylaxis in severe preeclampsia and controlling seizures in eclampsia second is forfeited neuro protection before anticipated early breakdown delivery then third is for short term prolongation of pregnancy uh less than 48 hours before 48 hours to allow for administration of antennae corticosteroids and pregnant women who are at the risk of preterm delivery so this is all aimed at the well-being of the fetus in some sense so the regimens which are there for magnesium sulfate in our unit we always give z span regimen why we give this span regimen let me tell you later but conventionally for years together we all have been given pre-charge regime richard regiment is 4 grams iv slow 20 but now we require 20 percent solution and a 50 solution which is very important for iron this thing injections it is better to have a concentrated uh magnesium sulfate that is 50 percent so 20 solution 4 grams iv slowly uh is given over period of 15 minutes followed by 10 grams divided intramuscular in both buttocks and maintenance doses 5 grams deep im alternate buttock every four hours the span's regimen is 4 grams iv 20 percent solution in 100 ml caramel celery in over 20 minutes and 1 gram iv per hour in 100 ml rl rns c by regimen is 6 grams and 2 grams iv per hour dhaka regimen is nearly half the dose i am sorry about the spelling errors there but dhaka regimen is 4 grams id plus 2 grams in each buttock and the maintenance dose is also 2 grams 2.5 grams so why we give this band reaching one is to prevent the gluteal abscesses to have a consistent because if the patient has thrombocytopenia we are not going to be able to give them uh intramuscular dosage so why give intramuscular at all when we have a secure line we can immediately stop the once we have given a loading dose we cannot withdraw it from the body whereas the iv solution we can immediately stop if we see patient going into magnesium toxicity that is our logic of giving them intravenous regimens so the recommendations for treatment of preeclampsia eclampsia and continuous iv infusion as we said magnesium sulfate four gram to six grams depending upon the body weight of the mother if the mother is more than 70 kilos then she should have 6 grams less than 7 60 kilos she should have 4 grams in between is 5 grams loading those diluted in 100 ml of fluid administered intravenously over 15 minutes followed by continuous intravenous infusion of one to two grams per hour depending upon the body weight discontinued 24 hours after delivery or the last seizure or intermittent intramuscular injections magnesium sulphate four grams at twenty percent solution intravenously at a rate not exceeding one gram per minute followed by immediately five grams fifty percent solution into upper quadrant a per outer quadrant of each butter then five grams alternate buttock every 4 hours with 20 gauge 3 inch long needle to be used and discontinued 24 hours after the last seizure if suppose she gets recurrent convergence if conversion persist after 15 minutes or gets recurrent convergence up to 2 grams more iv as 20 solution at a rate not exceeding 1 gram per minute if a woman is more than 70 kilos then additional 2 grams may be given slowly next imdose or the iv infusion is continued if respiratory rate is 16 minutes 16 per minute urine output is at least 25 ml per hour and particular reflexes are present if urine output is less than 100 ml in four hours and there are no other signs of magnesium toxicity the next im dose is reduced to half or the infusion to 0.5 grams per hour and magnesium level to be monitored now the problem with magnesium level to be monitored is magnesium level is not available in every hospital so one patient may not have money for that and two it may not the report may not be available to us so we have to depend only on these clinical parameters now serum magnesium level is measured every four to six hours if serum creatinine is more than one milligram percent now this is a small chart uh which shows level of serum magnesium in millimoles milli equivalence per liter or milligrams per liter and the effect so now let us go by milli equivalence and milligrams per liter which is per deciliter which is commonly available so between four to seven milli equivalents or five to nine milligrams per deciliter is a therapeutic range so when we read the reports actually those reports are not necessarily meant for pregnant patients so we require to understand that for pregnant patient who is on magnesium therapy the level which is therapeutic is five to nine so it is not your and my magnesium level it is a therapeutic magnesium level where we have been given five grams of magnesium then at more than seven and more than nine of milligrams percent loss of particular reflexes occurs then at more than 10 milligrams per liter respiratory paralysis occurs and more than 25 ml equivalents per liter or more than 30 milli grams percent cardiac arrest occurs if particular reflexes are depressed and respiration is normal further doses are withheld until the reflex is returned so only output we can give serum magnesium for test and we can halve the dose and we can continue but when the patellar reflexes go we should not be giving them magnesium we should stop the magnesium now here is where iv magnesium comes in very handy if there is concern about respiratory differential depression magnesium is stopped and oxygen by mask is given and calcium gluconate is given 10 milliliters of 10 solution over 10 minutes this is a live gun chart which has been published in maternal and child health journal of 2011 by amin m a and a kid d akichi so this chart is a composite chart magnesium sulfate pitocin and duadeline these are the three charts which are very critical in labor room and magnesium sulfate chart must not go wrong so what is important in magnesium sulphate charts is that the identification of the patient then on the upper uh left side you can see various blood pressure levels so blood pressure systolic and blood pressure that's diastolic has to be monitored then the drugs that are given hydrolyzing labitolol nephritipine all that has to be written then the uh subsequent monitoring like uh uh patient's title parameters etc all this monitoring has to be written you did not in military everything is to be written per hour so this is what magnesium sulfate uh chart means leukon chart means which is very crucial in managing these patients then blood pressure control severe hypertension of more than 160 systolic and more than 110 diastolic must be addressed after magnesium infusions the we should maintain the blood pressure around 140 systolic and about 90 diastole crushing the bp to normal levels may create actually placental ischemia and fitted distortions so uh the drugs available to us are hydrolyzing levital oil or nephrine nephrine is not so much given now labitelol is available everywhere and a wonderful drug so initial dosage of 20 milligrams iv if not responded within 20 minutes then a bolus of 20 next can be given then sodium nitro procedure nitroglycerin is given very rarely but that is with medical or intensivist monitoring and diuretics only for pulmonary edema prior to delivery or if the patient is in renal shut down with the nephrologists advice and with a cvp line in place drastic decrease in blood pressure can cause fetal compromise as i said then planning for delivery is very important those of antenatal steroids may be administered in anticipation of immersion delivery beta methods on 12 milligrams two doses uh 24 hours apart or dexamethasone six four doses six milligrams every 12 hours delivery is the treatment of eclampsia after the patient has stabilized the mode of delivery should be on obstetric indications and vaginal delivery is preferable from maternal standpoint in the absence of fetal malpresentation or fatal distress oxytocin or prostaglandins must be used to initiate the induction of labor now depending upon whether the fetal or maternal compromise is there see if the severely preterm baby is there then the bishop is definitely going to be very poor at the these times there would be prolonged labor there may be two or three survey primes and then oxytocin etcetera etcetera foley induction all this only will increase the maternal morbidity so once the patient has stabilized we have to take sometimes a decision of doing a c-section for maternal indication and in cases of abruption where you know the balance may tip any moment that time we have to take a call and may be required to do a c-section when the baby is alive so intrapartum complications like abruption and non-reassuring fitted heart patterns we have to make the decision and when emergency and delivery is indicated the absence of coagulopathy this is very important has to be ah confirmed now this will reassure the anaesthetist also and anesthetist can make the decision between uh what sort of anesthesia mostly they would give us original general anesthesia in a patient who has had conversion so energy or labor analgesia not all places use labor analgesia in patients with because they see these patients with great trepidation they don't use labor analgesia in these patients and anesthetists also would be a little very of giving labor analgesia with epidural to these patients but they work wonderfully well now maternal morbidity and mortality in these patients maternal complications like intracranial bleeds disseminated intravascular coagulation acute tubular or rarely acute cortical necrosis pulmonary edema cardiopulmonary arrest these are all the disasters the mother can have eclampsia is called a near miss the most significant is permanent cns damage secondary to recurrent seizures or intracranial bleeding and the maternal mortality rate is nearly 30 percent or more in these cases fetal and neonatal mortality varies between 13 to 30 percent and it is related to prematurity and its complications then abruptio placentae interior and growth restriction and intrapartum asphyxia this is the three delays model where the delay may be in patients on patient side where she has not short care delay may be in a referral side that is the second level delay may be the third level where we have not instituted the right treatment and that is it should never happen delay in third side third level should never ever happen so actually eclampsia requires a multidisciplinary approach with anesthesiologist nephrologists hematologist and neonatologist working together with an obstetrician now what do we do when creatinine is high and output is low and we require to give them anti-convergent and magnesium sulphate is to be given and what do we do so now quite some time um quite many times labor active has been given to these patients uh when magnesium sulfate has been ah we have been compiled to stop magnesium circuit it does not inhibit or induce hepatic enzymes most of it is eliminated and eliminated unchanged by kidneys thus because it is minimally protein bound and lacks metabolism by liver the risk of hepatotoxicity is low but a few reports of acute renal injury are there but these are very few doses which we require so leverage has been used in micu settings in these patients phenytoin sodium the cochrane review of 2010 says that it is known to cause liver and kidney injury and the use of phenytoin sodium should be banned in patients this is a an article which is highly recommended ah for all obstetricians uh where we deal with patients of pregnancy and renal disease these guidelines very clearly say about what is to be done with these patients how preventive value of aspirin is there how preventive value of aspirin even in kidney donors is there and how patients of ckd are to be managed throughout pregnancy so that eclampsia can be prevented because once eclampsia is there in these patients it is a disaster this is my very favorite chart i have which i use everywhere where it shows the gross underestimation of our estimate our visual estimate of blood loss and blood loss can be very tricky in these patients so we have to know how much a certain mop or a gauze will carry blood and that gives us a good idea as to how much replacement of blood loss has to be done and how much patient may have lost whether she is in dic and then whether we require to compensate her with factors etcetera etcetera so a large 40 to 45 centimeter swab ah contains about 350 ml and one kilo of soaked swabs contain about 1000 ml and 50 centimeter diameter floor spill contains about 500 ml so there itself ah about 1500 blood loss is there and these patients are anemic or they are in hemoconcentration and we have had false value of hemoglobin and we require to compensate them for blood loss now uh one platelet uh six to ten units of platelets are used one gives rise gives platelets to the tune of 5000 per microlite 5000 platelets per microliters so now this uh when we give one um if suppose the patient has got 50 000 platelet count when she has 50 000 platelet count we require to have for normal delivery it is said our hematologists at least say for normal delivery about 60 000 platelet count is okay now normal delivery is also accompanied by epg autumn so we consider sixty to seventy thousand so if our account is fifty thousand i require to give a four platelets if i am going to do a c section i require a minimum eighty thousand platelet count so i require to give us six to eight platelets to bring her platelet down to up to eighty to ninety thousand now if there is a single donor platelet then i will give me thirty thousand rice so i have to weigh and balance how much of platelets i am going to give i have to make those many platelets or those many plasmas available normally if i have given her 4 units of blood then i require to give her 4 units of ffp and if i am going to take a patient who is in early dic for cesarean section i require to give a 10 to 15 ml per kg of ffp so that patient is fit for surgery now an entity called as inter current eclampsia inter current eclampsia is no more considered as a [Music] treatable condition inter current eclampsia is patient has delivered minimum 10 days after delivery so we consider now that eclampsia is a threat to life and it should not be treated as inter current eclampsia and patient must be delivered when she has had convulsion manitol for cerebral edema this is from um uk uh paper brigham and women's hospital and it says manitoba treatment which automatically draws liquid from fluid from the brain tissue and back into the blood vessels reducing cerebral edema and lowers intracranial pressure this is a standard treatment in brigands and women's hospital so cerebral edema is treated either with hyperventilation or with manitol and we must remember to reduce central venous pressure i mean intracranial pressure by manitol if the patient is not responding investigations for future pregnancies like uterine artery doppler which has a great value in diagnosing uh at if it is done at around 13 14 weeks uh knowing the high resistance uterine artery values will ah indicate patients who are going to have ph in future ophthalmic artery doppler it mimics uterine artery pictures and it is very crucial and it is much easier first trimester i mean arterial pressure has a very important value in the predicting pih and then antiphospholipid syndrome so normally we don't do antiphospholipid antibodies etcetera etcetera in all patients but this is for future pregnancies once we have had a bad outcome so obstetric features of syndrome are either bad obstetric history or recurrent um what you call recurrent abortions then unexplained second or third trimester fetal deaths severe preeclampsia at least 34 weeks gestation unexplained growth retardation all these cases require antiphospholipid antibody syndrome evaluation so we do anticardiolipin antibodies igg or igm two values uh at least 12 weeks apart lupus anticoagulant again two values at least 12 weeks apart and anti-beta two glycoprotein one antibodies two values twelve weeks apart so this gives us good idea as to whether we should be [Music] giving this patient heparin aspirin in the next pregnancy so coming back to our patient was 17 weeks gestation with one episode of generalized tonic chronic convulsion with hypertension proteinuria with anemia and low positive titres of acla um she had an intracranial uh mri suggestive of breast syndrome and the diagnosis was eclampsia with antiphospholipid antibody syndrome and thrombophilia so we had a patient who was a 17 week so we can get such patients and we should have a high index of suspicion and we should be saving as many lives as possible with high suspicion and institution of proper treatment so thank you very much and i would like if there are any questions let me see in the chat box oh thank you ma'am uh dr ram has written a question on choice of antihypertensive preeclampsia labitolol or choice is always lavatory rather than nephilippine the multiple reasons is nephilipin can cause tachycardia and it can cause cardiac um excessive cardiac work stroke volume will be increased cardiac rate will be increased so labitole will control all these features so we would always go with labytalon ma'am uh we have question from doctor uh sudha muthu is asking can kindly clarify sudden increase in weight gain sudden increase in weight gain dr mutto is almost always because of fluid retention now this fluid retention is it could be either gestational edema or it could be ph related edema so [Music] in absence of protein urea we consider that as gestational proteinuria and hypertension we consider it as uh gestational edema so these patients have to be very clearly ex be explained that they should regularly monitor their blood pressure you know patients are really because of fear because of uh once having been told they feel reassured that their blood pressure is normal and they are load to check their blood pressure but this is where the trap lies and they should be checking their blood pressure for this training patients now everywhere electronic fetal electronic bp machines are available so it is a good idea to invest in an electronic bp machine for these patients and to check their blood pressure and record it diligently mom there is question from dr shreya singh she's asking what is the maximum dose of labity lol that can be given and dr shreya maximum dose of labitole generally we go up to 80 milligrams if i am giving iv labitolol so i cannot go beyond that so every 20 minutes increments i can give 20 milligrams is given first and beyond that i have to resort to nitro procide or nitroglycerin patch or something of that sort um i'm dr amrit ninja bharara is saying ma'am nice presentation and uh dr sheesh bala singh wonderful session thank you ma'am and dr pk krishna priya singh excellent informative session thank you ma'am and also we have one question uh dr amar shinde is asking mam there are dosage of magnesium and eclampsia magnesium sulfate in eclampsia see if we are giving we have to know the weight of the patient wait our standard textbook of williams says 60 kilogram body weight the guidelines say 70 kilos so let us go by 60 to 70 kilo okay so below 70 kilos and above 70 kilos almost all otherwise healthy women will have weight more than 70 kilos so when we are giving the and now we have to decide whether we want to give intramuscular regimen or intravenous regimen let us consider we are giving intravenous regimen so intravenous regimen with 70 kilos would be about 5 grams iv stack which is 20 percent solution over a period of 15 minutes in either normal saline or ringer lactate followed by one gram to 2 grams so if it is 70 then we would give 2 grams that is c by is regimen or we normally in my unit we give only 1 gram iv per hour later on we give with a dial flow so dial flow uh controls the flow of the drip rate and it doesn't allow the drip to move very rapidly unless somebody as mischief rotates the dial so dial flow is an important thing for these patients and then it is given one gram overly till the patient delivers and 24 hours after that if the patient converges in between again then a gram or two can be given iv slowly not more than a gram per minute ma'am dr rohan modi is asking now ge has introduced lumela test for pre-eclampsia it measures glycolated fibronectin so he's asking how useful is it ma'am see this has been known and people have been residents also and fibronectin has a role but uh see i am in an institutional practice so i am not really going to be asking patients to do these tests but otherwise fibronectin is a useful test but it doesn't take away the importance of regularly checking blood pressure what is important is if you are going to give aspirin to these patients you might not be giving apparent to these patients only on basis of this test but you might give aspirin and aspirin will help these patients because and the renal society also has recommended aspirin in these patients uh ma'am dr nishant is asking ma'am can you please tell us drug of choice in high creatinine with those dr nishan the thing is hi if the creatinine is high first of all we have to check whether it is dehydration so to know whether she is dehydrated we have to see urine output we have to put in a catheter we have to do a central venous pressure if she is dehydrated correct hydration then take the creatinine again if still her creatinine is high then that means she is in acute uh kidney injury if she is an acute kidney injury as i said we might give her a half dose of magnesium sulfite or we might give her levator acid so libertarian somehow we have succeeded till now with some small doses of levator system but i wouldn't recommend because there are no guidelines on liver system what i mentioned libertarian is that people have been using these things then there is phenytoin sodium but there is very strong cochrane data review uh which says that phenytoin sodium is of no use but if magnesium sulfate is not to be given then then we have to give them something so finite and sodium can be given mom uh there's a question daisy pump somebody rule of digest so daisy pam in eclampsia now diazepam is a very tricky thing diazepam causes severe depression in mother as well as the baby and then the fetal monitoring also will go heavier the maternal responses would be tricky see magnesium sulfate why it is gold standard is because once magnesium sulfate is given mother is wide awake and mother's sensorium is normal so ah magnificent sulphate has a lot of value but diazepam though it has been recommended daisy palm or even our pentothal etc in the last resort as uh given to patients who are in status eclampticus etc etc but they are otherwise not recommended a diazepam should not even be given in the early this thing because diazepam will cause these patients to if she is about to vomit she will not be able to prevent aspiration now somebody has given magnesium uh z span regimen was covered on a postnatal day for patients i didn't understand that magnesium sulfate is from personnel if suppose somebody this i understand if suppose somebody converges on postnatal day 4 then magnesium has to be given and it has to be continued for 48 hours okay because now there is no nothing after delivery 24 hours so 48 hours it can be continued okay the question is best anti-convulsion ga versus sa um ga versus essay is the anaesthetist to decide you know anesthetist would decide whether to be given ga or spinal anesthesia but anesthetist would always want to control uh [Music] parameters in cases who are you know woozy and who are not fully conscious but otherwise if the platelet count is normal and blood pressure is controlled and status would still go out and give a regional analgesia and anaesthesia for cases of cesarean section is there any literature which suggests that even if ah zero span regimen is chosen if the patient had eclampsia then the loading dose will be same as recharge regimen then at least 14 grams but if the patient is having ah severe pi then span loading those will be four grams only ah for any all these doses are for severe ph magnesium sulfate is given for severe pi so these are the doses for severe ph and eclampsia both normally we do not give dns or dextrose we give ringer lactate kindly gives us clarifies certain increase in base skin when we have to give injection diazepam diazepam is not to be given then [Music] there's a question from dr cyril how to prevent eclampsia in a pre-eclampsia woman what is entire criteria to diagnose and pick up preeclampsia okay if patient has preeclampsia even if she gets pre-eclampsia at 28 weeks it is prudent to give her metamethazone prepare the fetal lungs and deliver her around when she the baby has gone significant gathered significant weight and when the mother is regularly monitored if the mother is going to be dependable and she is going to monitor her blood pressure diligently then she can be left at home otherwise she has to be admitted at whatever weeks because nowadays even at 28 weeks fitted survival is excellent so i wouldn't say that you don't deliver at 28 weeks etc okay if the mother is diabetic then the question of fetal lungs is there but then these patients require in-house monitoring okay so um severe we should not allow the mother to go to severe pre-eclampsia stage or eclampsia stage now once we deliver because delivery is the treatment in these patients delivering will be preventing eclampsia otherwise if she becomes severely preeclamptic we have to give her magnesium sulfate and deliver period mom doctor amar is saying wonderful presentation ma'am it's very helpful thank you mom um dr amar shinde is asking drug of choice for gestational hypertension a drug of choice for gestational hypertension is labitalol we begin with 100 milligram bd can go to 200 milligram twice a day and to 200 milligram thrice a day after that if the blood pressure is still high then we have to balance as i said between the gestational age and the blood pressure and give her bitter methazone and deliver her i think they are almost covered the questions so thank you all very much thank you ma'am for a wonderful session and looking forward for you to the next session thank you so much thank you ma'am

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Dr. Darius Justus & 951 others

SPEAKERS

dr. Padmaja Mavani

Dr. Padmaja Mavani

Associate Professor Obstetrics & Gynecology, Seth GSMC & KEM Hospital, Mumbai

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dr. Padmaja Mavani

Dr. Padmaja Mavani

Associate Professor Obstetrics & Gynecology, ...

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