Prevention of Pre-eclampsia and Eclampsia through Community Level Interventions in Bangladesh

Prof Latifa Shamsuddin President Elect, OGSB

Maternal Health Scenario- last 10 years

MMR:
322/100,000 live birth

MMR:
194/100,000 live birth

Annual maternal deaths: 12,000

Delivery by skill birth attendants: 18%

Annual maternal deaths: 7,332

Delivery by skill birth attendants: 32% Facility Delivery: 29%
(Source: BMMS: 2010 & BDHS 2011)

Facility Delivery: 15%

(Source: BMMS 2001)

During the period of 2001-2010 Maternal Mortality Ratio reduced by 40% Maternal Mortality Ratio reduced due to Eclampsia: 50%

MDG 5: To reduce maternal deaths by 2015 to 143/100,000 live births

Causes of Maternal Deaths in Bangladesh

Others 16%
Hemorrhage

28%

Obstructed Labor Abortion

7%
Hemorrhage

1% 31% Others 16%

Direct 15%

Indirect 17%

Eclampsia 24%

Direct 20%

Eclampsia

Indirect 5%

20%

Casue of Maternal deaths Source: BMMS-2001

Casue of Maternal deaths Source: BMMS-2010

Eclampsia Treatment Regimen in Bangladesh

Until 1968 Inj. Morphine / Pethedine

1972 Lytic cocktail: Inj. Pethedine, Inj. Largactil, Inj.

Phenargan with Normal saline/aqua 500 cc I/V

Diazepam therapy:
10 mg I/V slowly for 20 min; then maintain by 40 mg

diazepam in 500 ml I/V fluid in infusion form

Very high maternal mortality and morbidity (neurological,

CVS, RD Syndrome), bad fetal outcome (resp. depression)

Do not give 100 mg in 24 hours

Eclampsia Treatment Regimen (Contd.)

Hydralizine
5 mg I/V bolus every 5 min until BP decline

Infusion 25 mg in 200 CC in Normal Saline

Labetalal- 200 mg in 200 ml Normal Saline in 20 drops/hours 1994 MgSo4 In DMCH, first trial 68% eclamptic death 2001 MgSo4 in community . 1998-2001 Participated in Magpie trial- 22 countries including

Bangladesh
2003 Follow up study was done both for mother and child up to

2 years

Flow chart for MgSO4

Loading Dose ( 4 gm + 6gm) Magnesium Sulphate (4g= 8ml) IV diluted in 12 ml distilled water { 20 ml of 20% solution} Or Inj. Nalepsin MgSo4 4g = 100 ml

(Source: EmOC Protocol, OGSB, 2009)

Intravenous injection over a period of 10-15 minutes

60-70 drops/minute

Magnesium Sulphate (6g = 12ml) of 50% solution Maintenance Dose Magnesium Sulphate (2.5 g = 5ml) of 50% solution

Deep Intramuscular Injection, 3g=6 ml in each buttock

Deep Intramuscular injection 2.5 g every 4 hourly in alternate buttock. Continue for 24 hours after last convulsion or delivery (If needed)

Management of Severe Pre-eclampsia and Eclampsia

Control of B.P.

Diastolic Pressure more than 110 mm Hg.

Systolic pressure less than 80 mm Hg or BP is not recordable

Inj. Hydralazine, 1 amp (20mg) in 200 ml of NS IV @ of 8-10 d/m Or Injection Labeta is used to control acute hypertension.

Inj. Dopamin, 1 amp (200mg) in 200ml of NS IV @ 8-10 d/m till systolic pressure is 120 mm Hg.

Check BP every 15 min. interval and stop drip when Diastolic Pressure is 90 mm Hg.

Differences of Dose between Bangladesh and International Standard Regimen

Regimen used in Bangladesh Loading dose = 4gm I/V + 6gm I/M = 10 gram and maintenance dose is 2.5 x 6 = 15 gram Total dose = 10 + 15 = 25 gram Standard Regimen Loading dose = 4 gm I/V + 10 gm I/M = 14 gram and maintenance dose is 5 x 6 = 30 gram Total dose = 14 + 30 = 44 gram

Bangladeshi regimen is almost half of the standard

regimen

Study at the community level on Prevention of Severe Pre-Eclampsia and Eclampsia

Madhupur

Source: BMRC. Bulletin, 2005: 31 (2): 75-82

Objectives
To determine the effectiveness of early administration

of injection Magnesium Sulphate in PEE patients at the community level to prevent fits before referral to hospital
To examine whether early intervention of convulsion

by Magnesium Sulphate and proper obstetric management can reduce both maternal and perinatal mortality

Methodology
Type of Study:
Quasi-experimental

Community based prospective interventional study

Study Period:

July - December 2001

Study Population: Eclampsia and severe pre-eclampsia cases of study area Sample Size: 265 cases
133 were in intervention group (patients with eclampsia or severe

eclampsia receiving loading dose of MgSo4 before referral)

132 in non-intervention group (patients with eclampsia or severe

eclampsia coming directly to hospital from same area but without receiving loading dose of MgSo4 before referral; but they received injection MgSo4 after admission in the hospital)

Training of doctors

Involvement of the community health workers

To reduce maternal mortality community awareness

Awareness creation in the community

Maternal Outcome of the study

30 25 20 15
17.3 27.3

10 5 0
2.3 1.5 8.27 6.01 2.27 10.4

12.87 6.06

Intervention Group
Maternal Deaths Pulmonary edema

Non-intervention Group
Renal Failure Obstetric shock PPH

The number of patients who developed complications in intervention and non-intervention groups show statistically significant difference ( p<0.05)

Foetal outcome of the study

90 80 70 60 50 40 30 20 10 0 Intervention (n= 102) Non-Intervention ( n= 105)
18.6 13.7 20.4 86.2 84 67.6 52.4

27.6

Alive Healthy Asphyxia Stilborn

Perinatal out-come of non-intervention group was poorer than intervention group though both groups were managed in the same way after admission in the hospital

Study Conclusion
The findings of this study concluded Earlier administration of injection Magnesium Sulphate at the community level is effective before referral to hospital
Useful result was found regarding control of convulsion by

early loading dose, recurrence of fit, maternal and fetal outcome

Hence, the study highly recommended:

To administer early injection of MgSO4 To include the loading dose of MgSo4 before referral in the national protocol

Findings on Complete IM regimen

To find out the feasibility of using IM administration of MgSO4, study was conducted in Dhaka and Chittagong Medical Colleges:
Loading dose = 10gm I/M ( 5 gm in alternate buttock) and

maintenance dose is 2.5 x 6 = 15 gram

In Chittagong Medical College Hospital ( n= 300) There was no abscess Patient tolerable Recurrence of convulsion only 3% in absence of maintenance dose and no recurrent convulsion in presence of maintenance dose In Dhaka Medical College Hospital - DMCH( n = 200) Similar kinds of findings

Intramuscular loading dose vs combined IV and IM loading dose of MgSo4 in the management of eclampsia in a tertiary level hospital.
Study conducted by Dr. Salma Rouf, DMCH
A pilot project is conducting in DMCH where IM administration of MgSo4 is found to be equally effective both in preventing and controlling of recurrent fit.

Administration of MgSo4 at the Community Level

Pilot project at Hobiganj through

Govt., MaMoni, Mayer Hashi, OGSB & ICDDR,B. High numbers maternal and perinatal death FWV, SBA, HA will work in that area, they will diagnose severe PE and eclampsia and will administer IM MgSo4 (10 gm) referral center. Same type of work will be done in another district like Bramhanbaria. Referral center will manage according to OGSB protocol.

Decision Algorithm: Community management

Who and Where
CSBA at Home FWV at satellite clinic FWV, SACMO at FWC

What and How

Measure BP If diastolic is >= 90 mm Hg, repeat measure after 1 hour

Urine exam for protein
Advise to take rest Advise/educate on danger sign Re-check BP and urine for protein after 7 days If hypertension persists; refer to doctor at sub-district health complex for anti-hypertensive drug

DBP 90 --<99 on two readings, no proteinuria

DBP 100 --<109 on two readings, no proteinuria
DBP 90 --<110 on two readings, + proteinuria + no danger sign
DBP 90 --<110 on two readings, + proteinuria + danger sign

Pregnancy induced Hypertension Pregnancy induced Hypertension

Refer to doctor at sub-district health complex for anti hypertensive drug

Mild Pre-eclampsia

Management

Findings Diagnosis

Refer to district hospital or CmEOC

Severe Preeclampsia Severe Preeclampsia

Administer loading dose

Refer to district hospital or CmEOC

DBP 110 plus proteinuria

Administer loading dose

Refer to district hospital or CmEOC

DBP 90 -- convulsion

Eclampsia

Administer loading dose

Refer to district hospital or CmEOC

Challenges
Though, health infrastructure in Bangladesh exists up to the

grass root level; a system of registering pregnant women has not been developed re administering the loading dose

Lack of confidence among the facility based service providers

Large number of floating people in both urban and rural

areas with poor socio-economic conditions

Some families changed their residence without leaving a

forwarding address

Flood and river erosion affected the study. Thus it became

difficult to contact/trace the patients

Challenges