CASE PRESENTATION

25 years old women with Eclampsia

Mutiara Riahna Sitepu

dr. Helmina, Sp.OG

Patient Identity

NAME Ms. R
GENDER Woman
AGE 25 years old
ADDRESS Utan panjang II Barat
RELIGION Moslem
WORK -
EDUCATION High school
MARITAL STATUS Single
DATE OF ENTRY 30th June 2019
 Anamnesis

Main Seizures since 1 hour

complain: before entering the hospital

Additional Headache (+)

complains : Nausea (+)
 History of the disease
Patients came to the emergency room delivered by the family with generalized
seizures since 1 hour ago. Back home the patient had seizures once for
approximately 2 minutes then regained consciousness and the patient vomited
1 x containing food. Before the seizures, patient are conscious and complains
that her vision suddenly turns black. When arriving to the emergency room,
patient complains having headache and nausea, suddenly the patient had
another seizures throughout the body and the eyes roll upward. Then the
anamnesis is carried out to the patient's family to determine whether the patient
is pregnant or not, the family answers that the patient is not pregnant because
she is not married. After reaffirming about the pregnancy the patient's family
continues to answer that the patient is not pregnant.
Then the initial management of seizures was carried out and the patient was
given Diazepam 5 mg
 History of the disease

Soon after the seizures stopped in 1 minute and the patient regained
consciousness, crying and complaining of dizziness. Few moments later,
the patient’s family acknowledges that the patient is 8 months pregnant
and is indeed not married. After knowing this, the management of
eclampsia was immediately carried out and planned for Emergency/Cito
caesarian delivery
 Past health history

Hypertension (+) Seizures (-)

Treated with Amlodipin 10mg
( Used when the patient deem it
necessary e:g Headache etc )

Family History
Hypertension (+)
Seizures (-)
Grandmother (+)
Father (+)
Mother (+)
Sister (+)
 Menstrual history
Menarche : 12 years old

Cycle : 28 days

Periods : 7 days

The first day of last menstruation : October 2nd 2018

Estimated day of birth : July 9th 2019

Physical findings

General condition
General appearance Severe illness
Conscious stage / GCS Delirium, E2M5V3

Vital sign

Blood pressure 190/150mmHg

Pulse rate 105x/m

Respiration rate 20x/m

Temperature 36,7°C
Physical findings
• Head : Normocephal
• Eye : Anemic conjunctiva -/-, Icteric sclera -/-
• ENT : Normal shape, discharge (-)
• Neck : Lymph nodes enlargement (-)
• Chest : Symmetric, chest retraction (-)
• Lung : VBS +/+, rales -/-, wheezing -/-
• Heart : S1/S2 regular, murmur (-), gallop (-)
• Abdomen : Enlarged symmetrically, Normal bowel sound (+)
• Extremity : Pretibial oedema (+/+), Warm, CRT <2”
 Obstetric status
• Leopold I : Uterine fundus as high as the xiphoideus process, on the
fundus of the uterus palpable round, soft fetal parts, the
impression of the buttocks
• Leopold II : On the right is the hard part of the fetus, the left side is felt by
small parts of the fetus. Fetal heart rate : 133x/m
• Leopold III : The lower part of the fetus is round, hard, the impression of a
head
• Leopold IV : Head havent entered the door of pelvis (Convergent)
 Laboratory findings
Examination Result Examination Result
Hb 13.1 g/dl Creatinine 0.8
White blood cell 18.69/ul (H)
count Natrium 146

Hematocrit 42% Kalium 5.1

Platelet count 385u/ul Chlorida 106
RBC 5,43/ul (H)
Blood glucose 125
MCV/VER 76fL
HBsAg (-) Negative
MCH/HER 24pg
MCHC/KHER 32 Protein (urine) 3+

Bleeding time 1.30 min SGOT 12

Clotting time 4.00 min SGPT 9
 Resume
Patients came with seizures since 1 hour ago. Back home the patient had seizures once
for approximately 2 minutes then regained consciousness . When arriving to the
emergency room, patient complains having headache and nausea, suddenly the patient
had another seizures throughout the body and the eyes roll upward. Then the
anamnesis is carried out to the patient's family to determine whether the patient is
pregnant or not, the family answers that the patient is not pregnant.Then the initial
management of seizures was carried out and the patient was given Diazepam 5 mg.
After the patient regain consciousness, the patient’s family acknowledges that the
patient is 8 months pregnant and is indeed not married

Physical examination :
Laboratory :
BP : 190/150mmHg
White blood cell count :18.690
HR : 105x/m
Protein in urine : 3+
RR : 20x/m
T : 36,7°C
 Diagnosis

G1P0A0 39weeks pregnant with

Antepartum Eclampsia
 Emergency Room Treatment
Phamacology
Non-Phamacology
•O2 5 lpm
• GCS, blood pressure
•IVFD Ringer’s lactate
• and pulse monitoring
•Diazepam 1x5mg IV
• Put on DC
•Ranitidin 1amp IV
• Plan for HCU
•Ondancentron 1amp IV
• Plan for cesarean delivery
•Loading MgSO4 40% 10 cc (4 gr) IV
• Inform the family about the
in 10 - 20 minutes (not given
patient condition
due to lack of urine output )
Post operation treatment

• IVFD RL 1500cc/24hours + Sistosinon 2 ampoule

• IVFD RL 20 dpm + drip MgSO4 40% (6 gr) / 8hours
• Pethidine 100mg/24hours
• Nitrogliserin 5mcg/minutes target of titration  BP 130-140
/80-90mmHg
• Ceftriaxone 2x1gr amp IV
• Dopamet 3 x 500 mg tab
• Amlodipin 1x10mg tab
 Follow up - HCU
Date S O A P
1/7/20 -Pain on BP: 155/110 mmHg Pulse: 120x/min P1A0 post SC et • IVFD RL 1500cc/24hours
19 surgical RR: 20x/min T: 36,7 C causa Eclampsia + Sintosinon 2ampoule
Wound GCS : 15 • Pethidine 100mg/24hours
- Dizziness Head : Normocephal • Perdipine 6.3cc/hour
Eye : AC-/-, IS -/- (dose reduced gradually)
Chest : Symmetric, chest retraction (-) • Ceftriaxone 2x1gr
Lung : VBS +/+, rales -/-, wheezing -/- • Amlodipin 1x10mg
Heart : S1/S2 regular, murmur (-), gallop (-) • Dopamet 3x500mg
Abdomen : Distension (-), Normal bowel sound (+) • Lasix extra 1 ampoule
Extremity : Warm, CRT <2”
DC (+) urine output 70cc/h
2/7/20 - Pain on BP: 140/92 mmHg Pulse: 92x/min P1A0 post SC et • IVFD RL 1500cc/24hours
19 surgical RR: 20x/min T: 36,7 C causa Eclampsia • Ceftriaxone 2x1gr
wound GCS : 15 • Ketorolac 3x30mg
General examination: within normal limits • Amlodipin 1x10mg
Localized examination: • Dopamet 3x500mg
Excision location covered by dressing, blood (-), pus ( • DC can be removed
-) • Can move to Anisa
DC (+) urine output 90cc/h tomorrow if blood
pressure is stable
 Follow up - Anisa
Date S O A P
3/7/20 - Slighted BP: 150/90 mmHg Pulse: 88x/min P1A0 post SC et • Discharged tomorrow
19 pain on RR: 20x/min T: 36,6 C causa Eclampsia • Medicine to take home
surgical GCS : 15 to:
wound General examination: within normal limits • Amlodipin 1 x 5mg
Localized examination: • Cefixime 2 x 200mg
Excision location covered by dressing, blood (-), pus ( • Mefenamic acid
-) 3 x 500 mg
Literature Review
 Introduction
Hypertensive disorders of pregnancy affect about 10%
of all pregnant women around the world
This group of diseases and conditions includes pre-eclampsia
and eclampsia, gestational hypertension and chronic hypertension

In Asia and Africa, nearly one tenth Hypertensive disorders of

of all maternal deaths are associated pregnancy are an important cause
with hypertensive disorders of of severe acute morbidity, long-
pregnancy term disability and death among
mothers and babies
 Definition
Eclampsia is defined as the clinical presentation
of an unexplained seizure, convulsion, or altered
mental status in the setting of the sign and
symptoms of preeclampsia.
It is considered a complication of severe
Preeclampsia

Or
The presence of new onset grandmal seizure in
woman with preeclampsia
Classification
 Risk factor
Chronic
Previous
hypertension or
Primiparity preeclamptic
chronic renal
pregnancy
disease or both

History of Multifetal
Obesity
thrombophilia pregnancy

Advanced
Type I diabetes Systemic lupus
maternal age
mellitus or type II erythematosus
(older than 40
diabetes mellitus
years)
Etiology & Pathophysiology
Theory of placental vascularization abnormalities
01
Theory of placental ischemia, free radicals, and
02 endothelial dysfunction

Theory of immunological intolerance between

03 mother and fetus

04 Theory of genetic cardiovascular adaptation

Theory of inflammatory
05
Pathophysiology
 Diagnosis Eclampsia
Physical examination
Anamnesis
- Loss of conciousness
Pregnant women with
generalized seizures - Blood pressure
≥140/>90

Laboratory
Proteinuria
 Treatment
Management of eclampsia :
- Call for help
- Avoid tonguebite – insert airway / mouth gag
- Avoid injury
- Maintain oxygenation (O2, pulse oxymetry)
- Minimize aspiration (lateral decubitus position, oral suction)
- Initiate Magnesium Sulfate
- Control blood pressure
- Delivery
Treatment
 • BP and pulse every 5 • Review management • 10% Calcium

Antidote
Monitor

Stop infusion
minutes until stable then with consultant if: Gluconate 10 mL IV
every 30 minutes
• Respiratory rate and
• - Urine output < 80 mL over 5 minutes
patellar reflexes hourly in 4 hours
• Temperature 2nd hourly - Deep tendon
• Continuous CTG reflexes are absent or
monitoring if > 24 weeks - Respiratory rate < 12
(interpret with caution if < breaths/minute
28 weeks)
• Measure urine output
hourly via IDC
• Strict fluid balance
monitoring
• Check serum magnesium
if toxicity is suspected on
clinical grounds
Treatment
 Treatment
Medication Onset of action Dose

Labetolol 5-10min 20mg IV, then 40-8-mg

every 10 min up to maxim
um dose of 220mg IV

Hydralazine 10-20min 5mg IV every 20 min up tp

maximum dose of 20mg
IV
Nifedipine 10-20min 10 mg PO every 20
min up to maximum dose
of 50mg
Nicardipine 10-15min Initial infusion 5mg/h,
increase by 2,5mg/h
maximum 15mg/h
Complication
 Prevention
Primer
1. It is necessary to screen the risk of
Secondary
preeclampsia for every pregnant
woman from the beginning of her 1. The use of low-dose aspirin (75 mg /
pregnancy day) is recommended for prevention
preeclampsia in women with high risk.
2. Low-dose apirin as a precaution for
preeclampsia should be used before
20 weeks' gestation
3. Calcium supplementation of at least
1 g / day is recommended especially in
women with low calcium intake
THANKYOU