Eclamptic convulsions are life-threatening emergencies and require the proper treatment to decrease maternal morbidity and mortality. Delivery is the only definitive treatment for eclampsia. The patient should be advised and educated on the course of the disease and any residual problems. She should also be educated on the importance of adequate prenatal care in subsequent pregnancies. Several organizations have developed screening, treatment, and prevention guidelines for preeclampsia and eclampsia. [22, 23, 24] The American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine (SMFM) continue to support the short-term (usually < 48 hours) use of magnesium sulfate in obstetric care for conditions and treatment durations that include the following [24] :
An experienced obstetrician or maternal-fetal medicine specialist should be consulted. Patients with eclampsia require immediate obstetric consultation and admission to a labor and delivery unit capable of providing intensive care until delivery of the neonate. In the event of premature delivery or fetal compromise, a pediatrician or neonatologist should be consulted. When initially evaluating a patient with eclampsia, become familiar with the level of care that the medical center can offer the patient, as eclampsia clearly poses a risk of considerable maternal and neonatal morbidity and mortality. Patients with eclampsia may benefit from management at a tertiary care center, a high-risk obstetric facility that provides neonatal and maternal intensive care. Emergency medical services personnel should (1) secure an intravenous (IV) line with a large-bore catheter, (2) initiate cardiac monitoring and administer oxygen, and (3) transport the patient in the left lateral decubitus position. Supportive care for eclamptic convulsions includes the following:
Place the patient in the left lateral position. This positioning decreases the risk of aspiration and will help to improve uterine blood flow by relieving obstruction of the vena cava by the gravid uterus. Protect the patient against injury during the seizure by padding and raising guardrails, using a padded tongue blade between the teeth, and suctioning the oral secretions as needed. After the seizure has ended, a 16- to 18-gauge IV line should be established for drawing specimens and administering fluids and medications. (Fluid management is critical in patients with eclampsia.) IV fluids should be limited to isotonic solutions to replace urine output plus about 700 mL/d to replace insensible losses. Pharmacotherapy goals are to reduce morbidity, prevent complications, and correct eclampsia. The drug of choice to treat and prevent eclampsia is magnesium sulfate. [24, 25] Familiarity with second-line medications phenytoin and diazepam/lorazepam is required for cases in which magnesium sulfate may be contraindicated (eg, myasthenia gravis) or ineffective. Control of hypertension is essential to prevent further morbidity or possible mortality. The most commonly used antihypertensive agents are hydralazine, labetalol, and nifedipine. IV magnesium sulfate is the initial drug administered to terminate seizures. Seizures usually terminate after the loading dose of magnesium. A loading dose of 4-6 g (15-20 min) and a maintenance dose of 1-2 g per hour as a continuous IV solution should be administered. For recurrent seizures or when magnesium is contraindicated, one may use lorazepam (Ativan; 2-4 mg IV over 2-5 minutes) or diazepam (Valium; 5-10 mg IV slowly) can be used to terminate the seizure. While benzodiazepines can be used to treat the seizures due to eclampsia magnesium remains the preferred choice. There exist over 50 years of data and experience using magnesium for this purpose with excellent safety and efficacy. Once the seizures terminate, 85% of patients note improved BP control. [23, 26] Note: Magnesium toxicity can cause coma, and, if mental status changes with these infusion rates, this should be considered. [2] Benzodiazepines or phenytoin can be used for seizures that are not responsive to magnesium sulfate. Avoid the use of multiple agents to abate eclamptic seizures, unless necessary. Severe hypertension (>160 mm Hg systolic or > 110 mm Hg diastolic) must be addressed after magnesium infusions. Hydralazine or labetalol can be administered IV for BP control. The goal is to maintain systolic BP between 140 and 160 mm Hg and diastolic BP between 90 and 110 mm Hg. An IV bolus of hydralazine (5-10 mg over 2 minutes) or labetalol (initial dose 20 mg) is recommended. Alternatively, oral nifedipine capsules (10 mg) may be administered. Other potent antihypertensive medications, such as sodium nitroprusside or nitroglycerin, can be used but are rarely required. [2] Diuretics are used only in the setting of pulmonary edema prior to delivery. Care must be taken not to decrease the BP too drastically; an excessive decrease can cause inadequate uteroplacental perfusion and fetal compromise. [25] A dose of antenatal steroids may be administered in anticipation of emergent delivery when gestational age is less than 32 weeks. Betamethasone (12 mg IM q24h × 2 doses) or dexamethasone (6 mg IM q12h × 4 doses) is recommended. About 10% of women with eclampsia will have an additional seizure after receiving magnesium sulfate. Another 2 g bolus of magnesium may be given in these cases. For the rare patient who continues to have seizure activity while receiving adequate magnesium therapy, seizures may be treated with sodium amobarbital, 250 mg IV over 3-5 minutes. [27] Alternatively, lorazepam or diazepam may be administered (as described above) for status epilepticus. However, these drugs can be associated with prolonged neonatal neurologic depression. BP should be assessed with the goal of maintaining the diastolic BP at less than 110 mm Hg with administration of antihypertensive medications as needed (eg, hydralazine, labetalol, nifedipine). Keep nothing by mouth (including medications) until the patient is medically stabilized or delivered, because she is at risk for aspiration when postictal and may have recurrent seizures. Anjum et al reported that following a loading dose of magnesium sulfate, a reduced duration of maintenance doses (12 hours vs 24 hours) for women with eclampsia may be effective for preventing recurrent seizures. [28] Depending on the clinical course, regularly check the patient’s neurologic status for signs of increased intracranial pressure or bleeding (eg, funduscopic examination, cranial nerves) Monitor fluid intake and urine output, maternal respiratory rate, and oxygenation, as indicated, and continuously monitor fetal status. Pulmonary arterial pressure monitoring is rarely indicated but may be helpful in patients who have evidence of pulmonary edema or oliguria/anuria. Once the seizure is controlled and the patient has regained consciousness, the patient’s general medical condition should be assessed to identify any other causes for seizures. Induction of labor may be initiated when the patient is stable. Fetal heart rate and uterine contractions should be continuously monitored. Fetal bradycardia is common following the eclamptic seizure and has been reported to last from 30 seconds to 9 minutes. The interval from the onset of the seizure to the fall in the fetal heart rate is typically 5 minutes or less. Transitory fetal tachycardia may occur following the bradycardia. Typically, emergent cesarean delivery is not indicated for this postseizure transient bradycardia; it spontaneously resolves. After the initial bradycardia, during the recovery phase, the fetal heart rate tracing may reveal a loss of short- and long-term variability and the presence of late decelerations. These abnormalities are most likely due to the decrease in uterine blood flow caused by the intense vasospasm and uterine hyperactivity during the convulsion. If the fetal heart tracing does not improve following a seizure, further evaluation should be undertaken. Growth-restricted and preterm fetuses may take longer to recover following a seizure. Placental abruption may be present if uterine hyperactivity remains and fetal bradycardia persists. Delivery is the treatment for eclampsia after the patient has been stabilized. No attempt should be made to deliver the infant either vaginally or by cesarean delivery until the acute phase of the seizure or coma has passed. The mode of delivery should be based on obstetric indications but should be chosen with an awareness that vaginal delivery is preferable from a maternal standpoint. Adequate maternal pain relief for labor and delivery is vital and may be provided with either systemic opioids or epidural anesthesia. In the absence of fetal malpresentation or fetal distress, oxytocin or prostaglandins may be initiated to induce labor. Cesarean delivery may be considered in patients with an unfavorable cervix and a gestational age of 30 weeks or less, as induction under these circumstances may result in a prolonged intrapartum course and is frequently unsuccessful in avoiding cesarean delivery, given the high rate of intrapartum complications. When emergent cesarean delivery is indicated, substantiating the absence of coagulopathy before the procedure is important. (See Surgical Therapy.) [29] Intrapartum complications include the following:
Irrespective of gestational age, a prolonged induction with clinically significant worsening of maternal cardiovascular, hematologic, renal, hepatic, and/or neural status is generally an indication for cesarean delivery when the anticipated delivery time is remote. |
Which is the nurses priority action when caring for an obstetrical client experiencing eclampsia
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