Anti-convulsant therapy in eclampsia.JR Maheshwari, SV Desai, MD Hansotia, VR Walvekar
Seventy four patients presented with eclampsia at N.W.M. Hospital. Bombay. Among the patients with eclampsia, 64.9% were primis, 29.7% were gravida II-IV and 5.4% were grand multis. As many as 40.5% patients were less than 20 years of age, while 2.7% were over 30 years of age. 48.7% had antepartum convulsions, 40.5% had intrapartum convulsions, while 8 patients convulsed in the postpartum period. Besides standard management of eclamptic patients, 3 protocols of anticonvulsant therapy were utilised. 27% were managed with diphenyl hydantoin sodium, 43% with magnesium sulphate, and 30% by combination of diazepam and pentazocine. The maternal and perinatal outcome was evaluated. Control of convulsions was superior with magnesium sulphate while perinatal outcome was best with diphenyl hydantoin.
Keywords: Adult, Anticonvulsants, therapeutic use,Comparative Study, Diazepam, therapeutic use,Drug Therapy, Combination, Eclampsia, drug therapy,mortality,Female, Human, Infant Mortality, Magnesium Sulfate, therapeutic use,Maternal Mortality, Pentazocine, therapeutic use,Phenytoin, therapeutic use,Pregnancy,
Various protocols have been devised for anticonvulsant therapy in eclampsia. Control of convulsion with concomitant attention to maternal and fetal wellbeing are the major consideration of the obstetrician.
Till the exact etiology of P.I.H. is completely elucidated treatment of this disorder will remain largely empirical. The extent to which wide ranges of drug regimes used influence maternal and perinatal outcome is not clear. The current study, therefore, analyses maternal and perinatal outcome in different protocols in eclampsia.
Seventy four patients presented at the N.W.M. Hospital, Bombay with eclampsia over a period of 4 years. The patients were randomly allocated to three anticonvulsant regimes as follows:
1. Magnesium sulphate as per recommendation of Pritchard et al. The antihypertensive used however was nifedipine 10 mg sublingually stat and repeated as required when diastolic BP rose over 110 mm Hg on the B.P. monitoring.
2. Inj. Biphenyl hydantoin sodium (Eptoin) 200 mg IV at 0 hours.
A drip with 200 mg of eptoin in 500 ml glucose was simultaneously started and given over 2 hours. This drip to be continued for 24 hours after the last convulsion. Then through oral route 100 mg of eptoin given 8 hourly. The antihypertensive used was same as regime I.V. nifedipine.
3. Inj. diazepam 10 mg IV at 0 hours
Inj. diazepam 10 mg IM 6 hourly Alternating
Inj. pentazocine 30 mg. 3 hourly
IM 6 hourly
Inj. largactil 25 mg. IM When required to control hypertension
and/or (i.e. diastolic BP more than 110
In. clonidine 1 amp. IM mm of Hg)
Seventy four patients presented with eclampsia. Forty patients (54.05%) were emergency admissions. Thirty six (48.7%) had antepartum convulsions, 30 (40.5%) had intrapartum convulsion while 8 (10.8%) were cases of postpartum eclampsia. Thirty four (43.2%) patients were less than 20 year old, 38 (51.4%) between 21-30 year while 4 (5.41%) were more than 30 year old. Forty eight (64.9%) patients were primis, 22 (29.7%) were gravida II-IV while 4 (5.4%) were grandmulti.
Twenty six (35.1%) patients had gestational age of 29-36 weeks. Thirty eight (51.4%) patients were between 37-40 weeks while 4 (5.4%) patients were beyond 40 weeks. Eight patients presented with postpartum eclampsia. Two patients had convulsion prior to 28 weeks of gestation.
Thirty two (43.2%) patients were given magnesium sulphate, 20 (27.02%) were given eptoin while 22 (29.73%) were subjected to pentazocine/diazepam regime.
[Table - 1]shows the number of convulsions thrown by the patients prior to commencing therapy. After therapy was instituted, control of convulsions was best with magnesium sulphate. As many as 30% patients on epsolin had more than 3 convulsions after instituting therapy.
As seen in[Table - 2], there were 2 mortalities in each group. The maternal morbidity was similar in the groups treated with epsolin and magnesium sulphate (50%). The groups treated with pentazocine/diazepam had the least morbidity (36.36%). 18.75% patients on magnesium sulphate and 18.2% patients on pentazocine/diazepam had the additional complication of D.I.C./accidental haemorrhage as compared to only 10% in the group given epsolin therapy. However, ARF/oliguria was maximal with epsolin, (20%) and pentazocine/diazepam therapy, (18.2%) as compared with 6.25% with magnesium sulphate therapy. Magnesium sulphate is however known to inhibit uterine activity and as many as 21.8% patients with this therapy had uterine inertia.
The perinatal mortality was least, 10% with epsolin while it was 20% when magnesium sulphate was used and 20% when pentazocine/diazepam were utilized. The perinatal morbidity was also least in the group where epsolin was utilized. Birth asphyxia, hyperbilirubinaemia and convulsions were significantly higher in the group utilizing pentazocine/diazepam.
The maternal and perinatal outcome in eclampsia is to a large extent dependent on the drug regime utilized. Of the 3 drug regimes utilized, magnesium sulphate was superior in controlling convulsions as compared to epsolin and pentazocine/diazepam.
In the current study, maternal mortality was least with magnesium sulphate. These findings correlate with the study of Nagar et al, who had no maternal mortality in 101 patients treated with magnesium sulphate as compared at 8.16% MMR, in 98 patients treated with lytic cock-tail. The overall maternal mortality rate of 8.1% is similar to the study of Goswami et al and Jain et al.
Magnesium sulphate therapy has the disadvantage of superadded uterine inertia in labour. The patients on epsolin therapy had the least incidence of DIC/accidental haemorrhage, but were complicated by a higher incidence of acute renal failure/ oliguria.
Diphenylhydantoin sodium has the advantage of causing least perinatal mortality and morbidity. The overall perinatal mortality rate of 17.1% in eclampsia is better than high perinatal mortality rate of 45% in the study of Goswami et al.
In conclusion, maternal outcome was best with magnesium sulphate while diphenyl hydantoin demonstrated the best perinatal outcome.
We thank the Dean, N.W.M. Hospital, Bombay for allowing us to conduct this study and using the hospital data for publication.
[Table - 1], [Table - 2], [Table - 3]