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The failure of the conservative treatment of eclampsia
TEEFAIL~EOFTEECONSERVATIVET~EATB¶ENT OFECLAMPSIA" CARL P. HUBER, M.D., INDIANAPOLIS, INLL (From the Department of Obstetrics, Indiana Univewity Medical
School)
E
CLAMPSIA is justifiably considered preventable. Its development usually indicates the failure of the patient to obtain adequate prenatal care or the failure of the physician to recognize the severity of the developing toxemia. All patients with eclampsia do not have the same serious prognosis. The patient who develops her initial convulsion during the course of labor has, in general, a better prognosis than the patient with antepartum convulsions. The postpartum eclamptic, unless neglected, has a still better prognosis. There is, in fact, a great variation in the severity of eclampsia developing before the onset of labor so that some patients are easily controlled while others progress to a fatal termination in spite of any therapy that may be undertaken. During the five-year period from January 1, 1938 to December 31, 1943, there were 6,994 patients delivered in the William H. Coleman Hospital, Indiana University Medical Center. There were 51 eclamptic patients during this time. This represents a gross incidence of 7 in each 1,000 deliveries. Thirty-seven of the 51 eclamptic patients mere admitted to the hospital as emergencies and had not been previously seen by our staff. We accept responsibility for the development of cclampsia in the remaining 14 patients, an incidence of 2 in each 1,000 deliveries. It is perhaps interesting to note that eclampsia appeared in our service during every month of the year but January. Thirty-six per cent of the eclamptic patients, however, were seen during the months of May and June. Only 9 of the 51 patients had had more than one previous delivery and 35 were pregnant for the lirst time. Eighty-four per cent were under 30 years of age. In the total series there were 12 maternal deaths, a loss of 23.5 per cent. There were also 18 fetal and neonatal deaths, an infant mortality of 35 per cent. These results are so poor that further analysis of them is imperative. The 14 patients who developed eclampsia after receiving prenatal care in our clinic or in the private practice of our staff formed a distinct group. Eight of them developed their initial convulsion post partum and none had more than 3 convulsions. Thirteen infants survived. The one fetal death was a stillborn premature infant delivered at 30 weeks, 12 days following the only convulsion the patient experienced. One maternal death occurred in this group. *Read, cological
by invitation, at the Society. Hershey, Pa.,
Sixty-Eighth Annual June 19 to 21, 1944.
81
Meeting
of the
American
Gyne-
82
AYFftICAN
JOURNAL
OF
OBSTETRICS
:\\?u'D
GPNFXOLOGY
This patient was a 21-year-old primigravida, 6 meeks from term, who had been under hospit,al observation and treatment for 18 days with apparent improvement. She suddenly developed severe epigastric pain and headache and while preparat.ions were being made for cesarean delivery, she had a single eclamptic convulsion. A living prrmatnre infant was delivered. The patient failed to respond to therapy and died eight boars after the operation. In comparison the remaining 37 ltatients formed ;I definite];\- different. They were all emergemy admissions and had tlevcloped group. edampsia before t,hc onset of labor. T’sing the criteria suggested by Dieckmann,’ 13 of this group were classified as lrav’mq severe eclampsia. This inclnded patients who showed one or more of the following conditions : 1. Coma. 2. Temperature of 102” F. or more. 3. Pulse rate over 120.
4. Respiratory rate over 35. 5. More than 10 convulsions. 6. Cardiovasoulnr impairment (edema of the lungs, persistent or falling
cyanosis,
low
blood pressure, low pulse pressure, etc.).
7. Failure of treatment to: (a) Stop the convulsions or prevent their reeurzence. (b) Produce
a urinary
output
of ut least 700 C.C. pet twenty-four
hours.
(c) Prevent the onset of or increase in degree of coma. (d) Produce a dilut.ion of the blood as indicated by a denease of at least. 10 per cent in hemoglobin,
eel1 volume,
or serum protein
concentration.
Eleven of the 12 maternal deaths were in these 13 patients as were 9 of the 18 infant deaths. Only 2 of the pregnancies in this severe group In all but one instance, the fetal were less than 36 weeks in duration. heart was present for some .hours after admission. Prematurity was not an important factor in this group of infant deaths and they can be looked upon without additional exception, as due to the toxemia. IThere were no maternal deaths in the remaining milder 24 eclamptic patients, and of the 8 infant deaths, 6 were debvered before the thirty-sixthweek of pregnancy. The general plan of therapy in this series has been one of eonscrvative medical management in an attempt to control the convulsions and establish an increasing urinary output. For this purpose sodium amytal in dosages from 3aj to 71/2 grains has been given intramuscularly at intervals of 3 to 6 hours dependent npon the response. This has been supplemented by the administration of magnesium sulfate in- 106 cc. of a 25 per cent solution intramuscularly repeated as neeessary following convulsions. Rarely morphine sulfate gr. $6 to r& has been given dthough most of the patients have received morphine before admission to the hospital, and Some have received either chloroform or ether irihalations during transportation to the hospital. Intravenous 20 per cent glucose in distilled water has been given in amounts of 1,006 to 1;500
HUBER
:
FAILURE
OF
CONSERVATIVZ
TREATMENT
OF
ECL.4MPSIA
83
cc. repeated 2 to 3 times each 24 hours. Where this concentration failed to increase the urinary output, or where there was cardiac embarrassment or evidence of pulmonary edema, 30 per cent or 50 per cent glucose solutions in smaller amount has been used. Continuous oxygen by nasal catheter2 has been given to most patients. Veratrum veride3 has not been used. Following these procedures labor has been induced by rupture of the membranes alone or combined with the insertion of a bag, dependent upon the condition of the cervix or with the spontaneous onset of labor, it has been hastened by these procedures, Delivery has usually been performed under local infiltration or without anesthesia. In all but the group of severe eclamptics, this general plan of management has proved effective. In the 13 patients with severe eclampsia, it has failed. Four patients died undelivered, 4 died following the delivery of stillborn infants. One patient survived following the delivery of a premature infant that died 18 hours after delivery. One mother and her infant survived. The remaining 3 infants survived following their delivery accomplished by cesarean section, which was in each instance performed upon a moribund patient. Six of the 12 maternal deaths were believed to be due to cerebral hemorrhage. This diagnosis was based upon the development of varying degrees of hemiplegia, but was proved by necropsy in only one instance. The remaining maternal deaths were associated with respiratory or cardiac failure superimposed on what are presumably irreversible metabolic changes of severe eclampsia. It is my conviction that modification of our general plan of therapy would not have resulted in additional maternal or infant salvage. This group of severe eclamptic patients represents a failure of conservative treatment to produce any sort of satisfactory result. It is possible that any other plan of management would have been equally unsatisfactory. If we are to accept no other alternative as far as maternal salvage is concerned, there is certainly a possibility that a lessened infant mortality would result if more rapid delivery were accomplished. It seems justifiable with this in mind to undertake delivery by section in patients of this severe group. It is suggested that this be done as soon as possible following the initial establishment of conservative therapy. It is possible that termination may also result in the survival of some patients who might otherwise have been lost. Various studies are recorded in the literature which indicate that the maternal survival is greater where operative interference is not undertaken. This is unquestionably true as regards any type of accouehement force. It is less definitely demonstrated in relation to Cesarean section. Most reports of the use of cesarean section in the treatment of eclampsia are based on data collected more than fifteen years ago, and therefore, eliminate any improvement in technique that has occurred during that time. Most of them were sections done under general anesthesia.
84
AMERICAN
JOURNAL
03
OBSTETRICS
AND
GYNECOLOGY
Dieckmann quotes data from 3 large obstetric clinics showing that the maternal mortality increases from 7 per cent if delivery occurs within two hours of the first convulsion to 28 per cent if more than 21 hours elapse. He also states that, as a rule, where labor is slow, the eclampsia is likely to become more severe resulting in a higher maternal mortality. There seems no justification for the consideration of ccsarean section in those patients with cclampsis who respond well to medical management and in whom labor progresses rapidly. There does seem to bc justification for the consideration of it in those patients who fail to respond to conservative management and in whom the eclampsia had progressed to the scvcrc stage. The most satisfactory approach to the problem presented by this group of patients is the earlier recognition of the developing toxemia and the institution of adequate treatment before convulsions develop. It is significant in this connection, that in this series of patients with severe eclampsia, there had been lit‘tle or no prenatal management. Many of them were seen by their local physician for the first time after convulsions had occurred. In all of the remainder the prenatal care had been inadequate. The majority of these patients came from an area essentially rural, and mere of a relatively low economic level. They demonstrate the continuing need for additional public health and postgrnduatc medical education. It seems logical to make the following conclusions from a study of this series of patients. 1. Conservative medical management followed by vaginal delivery is recommended for the treatment of mild eclampsia. 2. Adequate prenatal care, if it does not prevent the development of eclampsia, decreases the severity of the process and greatly improves the chance of survival of mother and infant. 3. Conservative treatment of severe eclampsia gives unsa.tisfaetory results. 4. In severe cclampsia, the infant survival rate would be materially increased by the performance of cesarean section within a few hours following the institution of conservative medical management. 5. In scvcre eclampsia, the maternal survival rate is so.negligible that the performance of cesarcan section is justified in the interests of the infant and might be favorably influenced by the more rapid completion of the delivery. 6. Additional public health and postgraduate medical education is essential for the adequate prevention and control of eclampsia. References The Toxemias of Pregnancy, W. J.: Louis. J. A. M. A. 117: X238,1941. Nicodemus, R. E.: 3. A. hf. A. Bryant, R. D., and Fldg, J. (2.:
1. Dieckmann,
pony, St.
2. 3.
10455,
The .C. V. f&.&y
135: 1333, IQIO.
Com-
School)
E
CLAMPSIA is justifiably considered preventable. Its development usually indicates the failure of the patient to obtain adequate prenatal care or the failure of the physician to recognize the severity of the developing toxemia. All patients with eclampsia do not have the same serious prognosis. The patient who develops her initial convulsion during the course of labor has, in general, a better prognosis than the patient with antepartum convulsions. The postpartum eclamptic, unless neglected, has a still better prognosis. There is, in fact, a great variation in the severity of eclampsia developing before the onset of labor so that some patients are easily controlled while others progress to a fatal termination in spite of any therapy that may be undertaken. During the five-year period from January 1, 1938 to December 31, 1943, there were 6,994 patients delivered in the William H. Coleman Hospital, Indiana University Medical Center. There were 51 eclamptic patients during this time. This represents a gross incidence of 7 in each 1,000 deliveries. Thirty-seven of the 51 eclamptic patients mere admitted to the hospital as emergencies and had not been previously seen by our staff. We accept responsibility for the development of cclampsia in the remaining 14 patients, an incidence of 2 in each 1,000 deliveries. It is perhaps interesting to note that eclampsia appeared in our service during every month of the year but January. Thirty-six per cent of the eclamptic patients, however, were seen during the months of May and June. Only 9 of the 51 patients had had more than one previous delivery and 35 were pregnant for the lirst time. Eighty-four per cent were under 30 years of age. In the total series there were 12 maternal deaths, a loss of 23.5 per cent. There were also 18 fetal and neonatal deaths, an infant mortality of 35 per cent. These results are so poor that further analysis of them is imperative. The 14 patients who developed eclampsia after receiving prenatal care in our clinic or in the private practice of our staff formed a distinct group. Eight of them developed their initial convulsion post partum and none had more than 3 convulsions. Thirteen infants survived. The one fetal death was a stillborn premature infant delivered at 30 weeks, 12 days following the only convulsion the patient experienced. One maternal death occurred in this group. *Read, cological
by invitation, at the Society. Hershey, Pa.,
Sixty-Eighth Annual June 19 to 21, 1944.
81
Meeting
of the
American
Gyne-
82
AYFftICAN
JOURNAL
OF
OBSTETRICS
:\\?u'D
GPNFXOLOGY
This patient was a 21-year-old primigravida, 6 meeks from term, who had been under hospit,al observation and treatment for 18 days with apparent improvement. She suddenly developed severe epigastric pain and headache and while preparat.ions were being made for cesarean delivery, she had a single eclamptic convulsion. A living prrmatnre infant was delivered. The patient failed to respond to therapy and died eight boars after the operation. In comparison the remaining 37 ltatients formed ;I definite];\- different. They were all emergemy admissions and had tlevcloped group. edampsia before t,hc onset of labor. T’sing the criteria suggested by Dieckmann,’ 13 of this group were classified as lrav’mq severe eclampsia. This inclnded patients who showed one or more of the following conditions : 1. Coma. 2. Temperature of 102” F. or more. 3. Pulse rate over 120.
4. Respiratory rate over 35. 5. More than 10 convulsions. 6. Cardiovasoulnr impairment (edema of the lungs, persistent or falling
cyanosis,
low
blood pressure, low pulse pressure, etc.).
7. Failure of treatment to: (a) Stop the convulsions or prevent their reeurzence. (b) Produce
a urinary
output
of ut least 700 C.C. pet twenty-four
hours.
(c) Prevent the onset of or increase in degree of coma. (d) Produce a dilut.ion of the blood as indicated by a denease of at least. 10 per cent in hemoglobin,
eel1 volume,
or serum protein
concentration.
Eleven of the 12 maternal deaths were in these 13 patients as were 9 of the 18 infant deaths. Only 2 of the pregnancies in this severe group In all but one instance, the fetal were less than 36 weeks in duration. heart was present for some .hours after admission. Prematurity was not an important factor in this group of infant deaths and they can be looked upon without additional exception, as due to the toxemia. IThere were no maternal deaths in the remaining milder 24 eclamptic patients, and of the 8 infant deaths, 6 were debvered before the thirty-sixthweek of pregnancy. The general plan of therapy in this series has been one of eonscrvative medical management in an attempt to control the convulsions and establish an increasing urinary output. For this purpose sodium amytal in dosages from 3aj to 71/2 grains has been given intramuscularly at intervals of 3 to 6 hours dependent npon the response. This has been supplemented by the administration of magnesium sulfate in- 106 cc. of a 25 per cent solution intramuscularly repeated as neeessary following convulsions. Rarely morphine sulfate gr. $6 to r& has been given dthough most of the patients have received morphine before admission to the hospital, and Some have received either chloroform or ether irihalations during transportation to the hospital. Intravenous 20 per cent glucose in distilled water has been given in amounts of 1,006 to 1;500
HUBER
:
FAILURE
OF
CONSERVATIVZ
TREATMENT
OF
ECL.4MPSIA
83
cc. repeated 2 to 3 times each 24 hours. Where this concentration failed to increase the urinary output, or where there was cardiac embarrassment or evidence of pulmonary edema, 30 per cent or 50 per cent glucose solutions in smaller amount has been used. Continuous oxygen by nasal catheter2 has been given to most patients. Veratrum veride3 has not been used. Following these procedures labor has been induced by rupture of the membranes alone or combined with the insertion of a bag, dependent upon the condition of the cervix or with the spontaneous onset of labor, it has been hastened by these procedures, Delivery has usually been performed under local infiltration or without anesthesia. In all but the group of severe eclamptics, this general plan of management has proved effective. In the 13 patients with severe eclampsia, it has failed. Four patients died undelivered, 4 died following the delivery of stillborn infants. One patient survived following the delivery of a premature infant that died 18 hours after delivery. One mother and her infant survived. The remaining 3 infants survived following their delivery accomplished by cesarean section, which was in each instance performed upon a moribund patient. Six of the 12 maternal deaths were believed to be due to cerebral hemorrhage. This diagnosis was based upon the development of varying degrees of hemiplegia, but was proved by necropsy in only one instance. The remaining maternal deaths were associated with respiratory or cardiac failure superimposed on what are presumably irreversible metabolic changes of severe eclampsia. It is my conviction that modification of our general plan of therapy would not have resulted in additional maternal or infant salvage. This group of severe eclamptic patients represents a failure of conservative treatment to produce any sort of satisfactory result. It is possible that any other plan of management would have been equally unsatisfactory. If we are to accept no other alternative as far as maternal salvage is concerned, there is certainly a possibility that a lessened infant mortality would result if more rapid delivery were accomplished. It seems justifiable with this in mind to undertake delivery by section in patients of this severe group. It is suggested that this be done as soon as possible following the initial establishment of conservative therapy. It is possible that termination may also result in the survival of some patients who might otherwise have been lost. Various studies are recorded in the literature which indicate that the maternal survival is greater where operative interference is not undertaken. This is unquestionably true as regards any type of accouehement force. It is less definitely demonstrated in relation to Cesarean section. Most reports of the use of cesarean section in the treatment of eclampsia are based on data collected more than fifteen years ago, and therefore, eliminate any improvement in technique that has occurred during that time. Most of them were sections done under general anesthesia.
84
AMERICAN
JOURNAL
03
OBSTETRICS
AND
GYNECOLOGY
Dieckmann quotes data from 3 large obstetric clinics showing that the maternal mortality increases from 7 per cent if delivery occurs within two hours of the first convulsion to 28 per cent if more than 21 hours elapse. He also states that, as a rule, where labor is slow, the eclampsia is likely to become more severe resulting in a higher maternal mortality. There seems no justification for the consideration of ccsarean section in those patients with cclampsis who respond well to medical management and in whom labor progresses rapidly. There does seem to bc justification for the consideration of it in those patients who fail to respond to conservative management and in whom the eclampsia had progressed to the scvcrc stage. The most satisfactory approach to the problem presented by this group of patients is the earlier recognition of the developing toxemia and the institution of adequate treatment before convulsions develop. It is significant in this connection, that in this series of patients with severe eclampsia, there had been lit‘tle or no prenatal management. Many of them were seen by their local physician for the first time after convulsions had occurred. In all of the remainder the prenatal care had been inadequate. The majority of these patients came from an area essentially rural, and mere of a relatively low economic level. They demonstrate the continuing need for additional public health and postgrnduatc medical education. It seems logical to make the following conclusions from a study of this series of patients. 1. Conservative medical management followed by vaginal delivery is recommended for the treatment of mild eclampsia. 2. Adequate prenatal care, if it does not prevent the development of eclampsia, decreases the severity of the process and greatly improves the chance of survival of mother and infant. 3. Conservative treatment of severe eclampsia gives unsa.tisfaetory results. 4. In severe cclampsia, the infant survival rate would be materially increased by the performance of cesarean section within a few hours following the institution of conservative medical management. 5. In scvcre eclampsia, the maternal survival rate is so.negligible that the performance of cesarcan section is justified in the interests of the infant and might be favorably influenced by the more rapid completion of the delivery. 6. Additional public health and postgraduate medical education is essential for the adequate prevention and control of eclampsia. References The Toxemias of Pregnancy, W. J.: Louis. J. A. M. A. 117: X238,1941. Nicodemus, R. E.: 3. A. hf. A. Bryant, R. D., and Fldg, J. (2.:
1. Dieckmann,
pony, St.
2. 3.
10455,
The .C. V. f&.&y
135: 1333, IQIO.
Com-