Eclampsia



The Game

I was walking back from the market, about ten minutes from the hospital, when I saw one of the midwives heading in the opposite direction. A couple of hours earlier we had seen all our patients together and all was well. We greeted each other and then he said “Doctor, I have admitted one lady with eclampsia, she has  magnesium sulfate and  hydrallazine, her BP is control, she has catheter and she is 6 centimeters”  This was pretty shocking news –  eclampsia – which is when a pregnant woman has convulsions because extremely  high blood pressure is causing her brain to become swollen and then perhaps start bleeding - is one of the most feared obstetric complications and can readily result in maternal death. Eclampsia occurs very rarely in the developed world but is a frequent killer in places like Ethiopia because women frequently receive no antenatal care the most important function of which is to detect the signs of imminent eclampsia. I mentioned a woman with these signs in a post a couple of weeks ago – she had Pre-eclampsia and we sent her to Bahir Dar.

Remarkably though, using the excellent simple and clear protocols one of my predecessors developed and taped to the wall in the office in Maternity -  the midwife in Motta had given this desperately ill woman exactly the right treatment. I was amazed at how expertly he had dealt with everything and not felt any need to ring me. Back home such a woman would usually be managed in a sparkling clean high tech intensive care unit, be attended by various specialist obstetricians and obstetric physicians and intensivists, along with their retinue of registrars, resident and student doctors , midwives and nursing students,  have a huge list of  laboratory investigations done and have them repeated 4 or 6 hourly, and be the focus of  much discussion and concern. This woman underwent no laboratory investigations and had seen one midwife and was nursed in a filthy room with dirt and litter and a caked and stinking  bedpan under the bed and flies coming in the window!

Intensive Care Bed

I hurried to the hospital. I was dismayed to find only student midwives in the unit, and no further observations had been taken of blood pressure, the baby’s heart rate or other vital signs. Worse, she was still fitting, and family members were crowded round her bed trying to stop her from falling off the bed as she arched her back and jerked her limbs violently. It was a ghastly sight. I shouted at the students to go and find the midwife and bring more Magnesium, and fortunately one turned up almost immediately and we gave her a top up dose, again as described in the protocol; whereupon she lapsed back into a state of deep unconsciousness.  I was told the convulsions had started at home, 60 or 70 km away the evening before  and they had bought her to Motta on the morning bus. I remembered  a 15 year old indigenous woman I once looked after in Darwin - she had a convulsion in a much more remote  community – at least in terms of raw kilometrese – but she arrived  at  our huge multistory modern hospital  in about 4 hours by helicopter! What a contrast! This poor young Ethiopian woman had been fitting on and off for nearly 24 hours -what I feared was that she might have  already sustained irreversible brain damage, and she might never wake up. She had not received any antenatal care and we knew nothing else about her pregnancy.

The labour had started spontaneously, but if it hadn’t we would have wanted to get it started, as the only definitive treatment of this killer condtion is to end the pregnancy. When I checked, labour had progressed to the point where I was able to quickly deliver the baby , but to our further dismay, though alive and active he was obviously far too premature to survive in Motta – in Darwin he would have been fine after a few weeks of “expensive care” All we could do was  wrap him up and put him on the bed with his mother, though she was unconscious and in an hour or so, his short little life came to an end. He weighed 1200 gms, about  2.5 pounds and had been born perhaps 8 weeks too soon. The family later took him to the church then returned his body to the hospital for disposal.

A drawer of dead insects

As for his mother, Tarike, there wasn’t much more we could do for her either, other than monitor and treat her blood pressure and fluid requirements, continue the magnesium for 24 hours and hope she might start to improve, and not develop any further complications – these can include liver and kidney failure, bleeding problems, brain damage, and of course death from the swelling or bleeding in the brain, but we had no way of testing for any of this. However for the rest of the afternoon her blood pressure remained stable and her kidneys seemed to be working as urine trickled slowly into her catheter bag.

I asked the midwives to check her every hour, and did myself as well for the next 4, and then I went home. I was hopeful by then she would survive.