Management of Postpartum Collapse - CONVULSIONS

Convulsions may be due to eclampsia, epilepsy, malaria, head injury, cerebral abscess, meningitis, encephalitis, etc.

Whatever the cause, initial steps are the same.

• Stop the fits
• Maintain airway
• Prevent aspiration
• Prevent injuries

Immediate care :

• Position the patient - head low, turn to a side
• airway - plastic or metal
• Suck the mouth and pharynx
• Place cushions around the patient or tie the limbs loosely with soft cloth  

Immediate drug treatment

• Diazepam 10 mg I.V. slowly (2 min.)
• Insert an I.V. cannula & splint the arm

Quick history from a bystander

 

History of epilepsy, malaria, fever, head injury, POA, hypertension, antenatal clinic records

 

Examination
General ------------------------- Oedema ----------------? Eclampsia
                                                 External injuries ----- ? Head injury

CVS ----------------------------- Hypertension----------? eclampsia Pulse, heart

RS ------------------------------- Crepitations& rhonchi

CNS ----------------------------- Pupils (if unequal)---- ? Cerebral abscess 
                                                 Neck rigidity --------- ? Meningitis
                                                                                    ? Encephalitis
                                                 Planter reflex
                                                 Level of consciousness

 

 Abdomen ----------------------- Confirm pregnancy                                                   
                                                  If less than 16 weeks ---? Epilepsy
                                                  Hepatosplenomegaly --- ? Malaria

Impending eclampsia

This means fits have not started but may start at any time.

Symptoms and signs

 

Severe headache

Visual changes ------------------ Blurring of vision

                                                  Seeing flashes of light or spots

                                                  photophobia

Restlessness

Epigastric pain, nausea, vomiting

Severe hypertension - diastolic BP of120 mmHg or more

Exaggerated knee jerk

 

If eclampsia or impending eclampsia is diagnosed,

• Prevent or control fits
• Control hypertension
• Maintain airway
• Transfer

Further drug treatment

 

a)  Antihypertensive

 

If diastolic BP > 100 mmHg

 

Puncture a capsule of nifedipine 10 mg and squeeze the contents into the area under the tongue
                                                          
                                                             Or

Administer hydrallazine 10 mg I.V. slowly repeat even} 30 minutes till diastolic BP is 90-100 mmHg.

However, sometimes the BP may not come down with this and you may have to transfer the patient with diastolic BP above 100mmHg.

b) Anticonvulsants

• Mgso4g iv     infusion 15mm+
• Maintenance dose 1g/hour
• Ensure UOP >30ml/m
• Chart     BP, RR,  PR   1/4hourly

• Start 20 mg diazepam in 500 cc of 5% dextrose and run it fast until the patient is deeply sedated. E.g. Responds to deep pain but very sleepy.
• Ensure that respiratory rate is not less than 15 per min.
• Keep 10 mg diazepam in a syringe to be given if fits recur.
• Transfer to a specialist unit.

However, sometimes the fits may not stop with this treatment and you may have to transfer the patient before fits are completely controlled.

 

c)  Additional measures

Indwelling urinary catheter  - Keep opened during transfer also.
                                                Check for proteinuria.

Before Transfer  -  

• Make sure that the patient is well sedated i.e. responds to pain but very sleepy.
• Try to bring down the diastolic BP to 100 mmHg.
• Ensure that respiratory rate is above 15 per min.
• Ensure that the Airway is in place and secretions are sucked out.
• Telephone the specialist unit prior to transfer.

During transfer -

• To accompany the patient, a nurse may be better than a midwife if you have adequate staff  because it may be necessary to repeat I.V. diazepam during transfer.
• Keep the patient turned to a side during the journey.