Induction of labor in eclampsia

INDUCTION DAXIEL (From

the Department

OF LABOR

D. FRIED&AN, of Obstetrics

IN

ECLAMPSIA

M.D., CEDARHURST, N. Y. rind Gynecology,

Lincoln

Hosyital,

Bronx)

OST obstetricians agree that an interruption of pregnancy is indicated during the intercurrent phase of eclampsia. This is the period of relative improvement following convulsions, when no further convulsions occur, the bloold pressure falls, and the albuminuria diminishes. “The improvement is only temporary, ” to quote Stander,l “ and after a few days the blood pressure begins to rise, the albumen. to increase and the general condition to become less satisfactory. In such circumstances labor should be induced. . . .” It is during this intercurrent phase that obstetricians are faced with the problem of terminating the pregnancy. If labor should occur spontaneously or the fetus should die in utero, the maintenance of the patient in an adequate state of sedation usually suffices until the fetus is expelled. However, if interference is indicated, a medical induction of labor (rupture of membranes, castor oil, etc.) or a cesarean section must be employed. The former is unpredictable and the latter is not without danger. The purpose of this paper is to describe a method of terminating the pregnancy of an eclamptic patient by inducing labor with Pitocin. Case Reports CASE 1.-P. R. was a 26.year-old para 0, gravida ii (abortion at 2 months in 1946), who was admitted to the hospital in the twenty-sixth week of pregnancy on Nov. 10, 1947, following her first clinic visit, with the diagnosis of severe pre-eclampsia. The blood pressure on admission was 230/120, and a 4 plus albumin&a and generalized edema were present. She was asymptomatic but had noticed the edema for the past four days. The fundus was somewhat smaller than a 26 weeks’ gestation. The fetal heartbeat was regular and no uterine contractions were noted. The vertex was presenting and was floating. Sedation and diuretics were administered. After twenty-four hours the blood pressure had become relatively stable at 170/100. Thirty-five hours after admission the patient suddenly complained of blindness and a convulsion which lasted four minutes followed. The blood. pressure rose to 240/140. Fundoscopic examination revealed many small retinal hemorrhages. Following sedation the blood pressure was stabilized at 160/130. A vaginal examination was performed in bed. The cervix .was found to be partly effaced but un‘dilated. The fetal head was still floating. Membranes were ruptured with an orange stick. After four and one-half hours no uterine contractions were noted. Phenobarbital . . sodium, 2 grains, and morphine sulfate, % gram,’ were adrnlnmtered, and one hour later 3 minims of Pitocin were given intramuscularly. Labor started shortly thereafter. Uterine contractions became strong and regular, occurring every 11/z to 2 minutes and lasting 30 Pitocin had been administered a 2 to 40 seconds. Two hours and forty minute, Q after pound, 1/ ounce living infant was delivered. During labor the blood pressure varied beThe patient remained well sedated tween 160 and 170 systolic and 130 and 140 diastolic. throughout the entire labor. The baby survived for 33 hours. The patient made an un20, 1947, with blood pressure stabilized eventful recovery and was discharged on Nov. at 170/110. A 1 plus albuminuria was present and there was no edema.

1293

1294 Four years later the patient was seen again with her blood pressure was quite labile, it remained within nancy. Her delivery was uneventful.

a 10 weeks’ limits

normal

gestation. throughout

Although her preg-

26 weeks pregnant, who had not at2.-S. II. was a. 25year-old primigravida, the prenatal clinic. The patient was awakened at 4 A.M. on Aug. 13, 1950, with a severe headache. An ambulance was caRed at IO A.M. and en route. to the hospital the patient had a tonic convulsion, frothed at the mouth, and lost consciousness. She had regained consciousness when she arrived at the hospital but in the admitting room she had another convulsion. Following the second convulsion her blood pressure was 140/85. When she arrived on the ward. it was 164/X0. Examination revealed a lethargic, listless patient who was, A 1 plus pretibial edema and 4 plus albuminuria were present. The however, oriented. uterus was at the level of the umbilicus; the vertex was presenting and was unengaged. The fetal heartbeat was regular. The cervix was thick and undilated. The patient was not in labor. Sedation was administered and during the first 48 hours she remained relatively quiet. Her blood pressure varied from 120 to 180 systolic and from 80 to 130 diastolic. Urine output for the first 24 hours was 300 C.C. and for the second 24 hours was 695 C.C. It was noticed at this time that the uterus was very sensitive and contracted with slight stimulation. An attempt was made to rupture the membranes but the cervix was uneffaced and did not permit entry. At 10 A.M. on August 15, morphine sulfate, y4 grain, and Seconal, 1% grains, were administered. Forty minutes later, 1 L. of 10 per cent glucose solution with 0.25 C.C. of Pitocin was administered intravenously at the rate of 30 drops per minute. Uterine contra&ions began immediately and occurred every 1W to 2 minutes. The blood pressure was 140/100 prior to the induction and remained relatively stable around 160/100 during labor. The patient was completely insensible to the contractions. Two hours later the cervix was 50 per cent effaced and 2 cm. dilated. The membranes were ruptured with an orange stick. After six hours the cervix was 75 per cent effaced and 3 cm. dilated. The vertex was at minus 3 station. Two Allis clamps were applied to the scalp and a 1 pound weight was attached. The Pitoein infusion infiltrated shortly thereafter, and it was decided to permit labor to continue without it. However, the uterine contractions diminished and flnalIy ceased in two hours. The vertex had descended to the spines. One minim of Pitocin was given intramuscularly at 8 P.M. and 2 minims were given at 9 P.M. Uterine contractions became regular and strong after the first dose, and fourteen hours after labor was initiated a I pound, 14 ounce infant was delivered. The baby survived only a short while. The original sedation was supplemented with two injections of morphine sulfate, yh grain, and the patient remained insensible to contractions throughout labor and delivery. The patient signed out of the hospital on the fifth postpartum day with a blood pressure of 150/110, ?;o albuminuria or edema was present. No follow-up was obtained on this patie&. CASE

tended

CASE 3.--C. M. was a 19-year-old primigravida who was admitted to the hospital on Nov. 25, 1950, in the thirty-first week of gestation. She had not attended the prenatal clinic. The day before admission the patient noticed a severe headache and puffiness The morning of admission she complained of partial blindness, and at 11 of the face. Another convulsion occurred at 1 P.M. and another A.M. she had a convulsion at home. at 2 P.M., at which time an ambulance was called. When she was admitted to the hospital the blood pressure was 186/100; a 1 plus pretibial and facial edema and 4 plus albnminuria were present. The uterus was enlarged to 3 iingerbreadths below the xiphoid process. The Rectal examination revealed the vertex to be presenting fetal heartbeat was regular. and to be unengaged. The cervix was thick and undilated and no uterine contractions were felt. The patient was heavily sedated and was maintained in an adequately restful state until November 29. The bIood pressure during this period varied between 160 and 210 systolic and 130 and 180 diastolic. Ko further convulsions occurred. Intake and output were satisfactory. The edema subsided and the albuminuria decreased to 1 plus, On November 29 a sterile vaginal examination revealed the cervix to be about 75 per

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cent effaced with no dilatation. The vertex was still unengaged. The membranes were ruptured with an orange stick. Four hours later no uterine contractions were noted and the patient was sedated with Nembutal, 3 grains intramuscularly, and Demerol, 100 mg. by hypodermic. One-half hour later an infusion of 1,000 C.C. of 10 per cent glucose solution .with 0.25 cc. of Pitocin was started. Labor began immediately. After two hours the cervix was completely effaced and was 1 cm. dilated. The vertex had descended to plus 2 station. The fetal heartbeat remained regular. Six hours later the cervix was 7 cm. dilated. A saddle block was administered and fifty minutes later a 3 pound, 12% ounce infant was delivered in good condition. The duration of labor was nine hours. The blood pressure had risen slowly during labor to 204/170 at which point the saddle block was administered. The pressure then dropped to X0/122. The mother and baby did well post partnm. Edema and albuminuria subsided rapidly, and on the day of discharge the blood pressure was 120/86. The patient delivered a second child sixteen months later. She remained completely asymptomatic throughout this pregnancy and had an uneventful delivery.

CASE 4.-C. D. was a 28-year-old markedly obese para ii, gravida iii, clinic patient who was atdmitted on Feb. 1, 1951, during the thirty-sixth week of gestation for severe preeclampsia and hypertensive vascular disease. The patient delivered her first child at Lincoln Hospital in March, 1948. During the prenatal course she maintained a blood pressure around 140/90. Prior to delivery the blood pressure rose to 210/138 and a 4 plus albuminuria and She was admitted to the hospital, membranes ruptured 3 plus pretibial edema appeared. artificially, and labor and delivery followed with no complications. The second pregnancy terminated in September, 1949. During this prenatal course she m.aintained a blood pressure around 140/90, with no albuminuria or edema. She delivered rapidly with no complications. IDuring the course of the present.pregnancy, the patient was admitted to the hospital in the thirty-third week because of a sudden rise in blood pressure from 140/90 to 180/110. The urine was negative and no edema was present. During her hospital stay the patient was found to have a mild case of diabetes which was controlled by diet. She was discharged to the clinic after seventeen days with a blood pressure of 140/96. One month l;ater, in the thirty-seventh week, the patient was again admitted to the hospital for a sudden rise in blood pressure to 200/116, a 4 plus albuminuria, a.nd a 2 plus pretibial and The fetus was estimated to weigh facial edema. The urine also contained 3 plus glucose. The cervix was soft, thick, and around 5 pounds and the fetal heartbeat wa.s regular. undila.ted. The vertex was presenting and was floating. Sedation was administered and the diabetes was controlled with diet and small doses of regular insulin. The urine never Approximately twenty-four hours after admission contained more than a trace of acetone. the patient had a short clonic convulsion, following which the blood pressure was 180/120. Sedation and a glucose infusion were The urine contained 3 plus albumin and no sugar. After a six-day period no further convulsions had administered. The response was good. occurred, the blood pressure had dropped to 150/100, and the albnminuria had decreased to 2 plus. The diabetes remained well controlled. On the seventh day a vaginal examination revealed no change in fetus or cervix and no uterine contractions had occurred. One hundrted mg. of Demerol was administered intravenously, and a few minutes later a l:l,OOO Pitocin infusion was started. Labor began shortly thereafter. After five and one-half hours the Pitocin infusion stopped because of infiltration. The cervix was effaced and 6 cm. dilated. The vertex was at minus 2 station. The membranes were ruptured artificially. It was decided not to continue the Pitocin infusion as labor was progressing well without it. After six hours of labor the patient delivered a 5 pound infant in good condition. Prior to and throughout labor the blood pressure varied from 150 to 160 systolic and from 100 to 120 diastolic. ‘The postpartum course was uneventful and the patient was discharged on the tlhirteenth postpartum day with a blood pressure of 164/116, a trace of albuminuria, and no eldema. She did not return to the follow-up clinic.

primigravida clmic patient, 37 3eeks pregnant, CASE :5-x. I,. \I’&‘ 5 a Xi-year-old who was admitted to the hospital on Nov. 4, 1951, iu a semicomatose state following a con v&ion at home. Her prenatal course had been essentially normal. Four days prior to admission she attended the prenatal clinic and a rise in blood pressure from 110/50 to X3/96 and 1 plus albuminuria were noted. Red rest was prescribed and the patient a& vised to return to the c,linic in two days. 8he failed to keep her appointment and four days later was brought to the hospital by ambulance foilowing the convulsion. On admission the blood pressure was 170/120; a 4 plus albuminuria and a 2 plus generalized edema were present. The patient was semicomatose and extremely restless. The uterus ,$-as compatible in size to the period of gestation. The fetal heartbeat was regular. Rectal examination revealed the vertex presenting and not enga.ged. The cervix was uneifacecl itnd undilated. The patient was not in labor. After heavy sedation the blood pressure dropped to 140/110. However, the urinary output was only 2T5 C.C. in the first twenty-four hours and 245 C.C. in the next eighteen hours despite diuretics. On Sovember G the patient began vomiting coffee-ground material. The edema had increased to 4 pius in the extremities and fine scattered r$les were heard in the chest. Microscopic urinalysis revealed many red blood cells and granular casts. Blood pressure at this time was 162/1X, pulse 124, respirations 20, and the temperature spiked suddenly to 104” F. A diagnosis of lower nephron nephrosis and early pneumonitis was made. One-third grain of Panto;on was administered at 11 A.M., and at 11:30 AX. a 1:1,000 Pitocin infusion was started. Mild uterine contractions were noted immediately. Five hours later the cervix admitted one finger and membranes were ruptured artificially. Seven hours after the Pitocin infusion W&S start& the cervix was 5 cm. dilated, the vertex at minus two station in right occipitoposterior position, and the fetal heartbeat was regular. The blood pressure was 150/115, pulse 112, respirations 20. The temperature remained at 104” F. despite antibiotics. Thirteen hours after induction a normal 6 pound, 3 ounce infant was delivered by Szanzoni rotation and extraction. A saddle block was given for anesthesia. Following delivery the blood pressure was X33/130, pulse 96, and respirations 20. The temperature returned to normal on the first postpartum day and diuresis occurred on the second. The patient was discharged on the twentieth postpartum day with blood pressure of 140/90, negative urine, and no edema. The patient was seeu in the clinic one month later with a blood pressure of ISO/SO: uegative urine, and no edema,

Comment There are several

interesting facts to be noted in these five case reports. the response of the eclamptic patient to I’itocin. There is no doubt but that labor was suczessfully induced and completed in all five patients. This occurred despite the fact that cert,ain conditions were present that would under normal circumstances thwart an attempt to induce labor. Two patients were in the sixth month of pregnancy, two in the seventh, and one in the ninth. Sane was in labor prior to induction. In only two cases could the cervix be dilated sufficiently to rupture the membranes before induction. This measure did not induce labor after four and four and one-half hours respectively. The presenting part was not engaged prior to induction; however, no contraindication to vaginal delivery existed. Two of the primiparas with no softening or effacement of the cervix required fourteen and thirteen hours of labor before delivery. The other two primiparas with partially effaced cervices delivered in two hours and forty minutes and nine hours, respectively. It was possible to rupture membranes prior to induction in the former. The eclamptic process frequently initiates labor spontaneously regardless of the term of gestation. There is, however, an optimal time to initiate labor For which Nature is sometimes unprepared. It has been shown that maternal and fetal mortality increases with the duration of eclampsia. Diecl~mann2 hay ‘l’he

most

important

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found a 7 per cent maternal mortality if delivery is effected in less than 2 hours after the first convulsion, which increases to 28 per cent if over 21 hours elapse. Chesley and Somers3 found a 57.2 per cent fetal mortality when delivery is delayed more than 3 days following a convulsion, and a 25.8 per cent mortality if the fetus is delivered wit,hin 3 days. This is not to be construed to mean that imm.ediate delivery following an eclamptic convulsion is essential. Results can be most disastrous if the proper time is not selected to induce labor. The consensus among obstetricians is to wait 48 to 72 hours after the convulsions have been controlled before attempting to initiate labor, and, failing this, a cesarean section should be performed ( Mengert,4 Reids) . In severe eclampsia, Dieckmann6 advises waiting as little as 6 hours after the last convulsion before attempting delivery. We have followed this pattern in our treatment. We have induced labor in our patients only after we were certain that the convulsive stage was wen controlled or only when complications (renal shutdown and pneumonitis) led us t(D expect no amelioration. of symptoms. As we know, this intercurrent stage may persist for only a few days and may be followed by a recurrent eclampsia with its high mortality rate. Reinberger and Russell7 have indicated the symptoms marking the end point of intercurrent eclampsia. These are: (1) marked oliguria or anuria, (2) increase in temperature, pulse and respirations, (3) evidence of pulmonary edema, and (4) increased cyanosis. Rather than await thesle symptoms, we believe an attempt should be made to induce labor with Pitocin. Prematurity, intact membranes, and “unripe” cervices have thus far been. no barrier to indnction, probably because the eclamptic process would have precipitated labor spontaneously sooner or later. But there was an optimistic note in delivering these mothers early in their state of eclampsia. The hope of obtaining a living infant rather than anticipating a fetal death was present.

Summary Five cases of eclampsia have been presented in which labor was successfully induced and completed by the use of Pitocin. The use of Pitocin induction is recommended only during intercurrent eclampsia or possibly for eelampsia with complications, provided the eelamptic symptoms can be controlled for an adequate time to permit labor and delivery. The stetrjics during

author wishes to thank Dr. William Godsick, Director and Gynecology, Lincoln Hospital, and Dr. David Zakin the preparation of this paper.

of the Department for their helpful

of Ohcriticisms

References 1. Stander, 2. 3. 4. 5. 6. 7.

H. J.: Williams Obstetrics, ed. 8, New Pork, 1941, D. Appleton-Century Company, p. 688. Toxemias of Pregnancy, ed. 2, St. Louis, 1952, The C. V. Xoshy Dieckmann, W. J.: Company, p. 559. Surg., Gynec. & Obst. ‘72: 872, 1941. Chesley, L., and Somers, W.: Postgrad. Med. 6: 107, 1949. Mengert, W.: Pennsylvania M. J. 52: 1053,1949. Reid, D.: Toxemias of Pregnancy, ed. 2, St. Louis, 1952, The C. V. Mosby Dieckmann, W. J.: Company, p. 562. Reinberger, J. R., and Russell, P. B., Jr.: South. M. J. 29: 541, 1936.