Eclampsia

Eclampsia is a life-threatening obstetric emergency characterized by new-onset tonic-clonic seizures in a pregnant woman with preeclampsia. It represents the most severe end of the hypertensive disorders of pregnancy spectrum and requires immediate medical intervention. Eclampsia can occur antepartum (before delivery), intrapartum (during labor), or postpartum (after delivery), with significant risks for both mother and baby.

🚨 OBSTETRIC EMERGENCY

CALL 911 IMMEDIATELY for any seizure during pregnancy or postpartum period. Position on left side, protect from injury, maintain airway. DO NOT attempt to restrain. This is a life-threatening emergency requiring immediate hospital care with magnesium sulfate and possible emergency delivery.

Medical Disclaimer: This information is for educational purposes only and should not replace professional medical advice. Always consult with a qualified healthcare provider for diagnosis and treatment of any medical condition.

Emergency Management of Eclamptic Seizure

Immediate Actions

  1. Call for emergency help
  2. Position patient on left side to improve blood flow
  3. Protect from injury (padding, remove objects)
  4. Maintain airway - suction if needed
  5. Administer oxygen 8-10 L/min by face mask
  6. Establish IV access
  7. Begin magnesium sulfate immediately
  8. Monitor vital signs and fetal heart rate

Magnesium Sulfate Protocol

  • Loading dose: 4-6g IV over 15-20 minutes
  • Maintenance: 2g/hour continuous infusion
  • Recurrent seizure: 2g IV bolus over 5 minutes
  • Continue: 24 hours postpartum

Understanding Eclampsia

Eclampsia represents the convulsive manifestation of preeclampsia, though seizures can occur without preceding severe features. The exact pathophysiology involves cerebral vasospasm, endothelial dysfunction, and blood-brain barrier disruption.

Key Statistics

  • Incidence: 1.6-10 per 10,000 deliveries in developed countries
  • Higher rates in developing countries
  • Maternal mortality: 1-2% in developed countries, up to 15% in developing
  • Perinatal mortality: 5-12%
  • Can occur without warning signs in 20-40%
  • Postpartum eclampsia: 30-50% of cases

Timing of Eclampsia

  • Antepartum: 38-53% (before labor)
  • Intrapartum: 18-36% (during labor)
  • Postpartum: 11-44% (after delivery)
    • Most within 48 hours
    • Can occur up to 4 weeks postpartum

Clinical Features

Prodromal Symptoms (60-80% of cases)

  • Severe headache: Persistent, frontal or occipital
  • Visual disturbances:
    • Blurred vision
    • Scotomata (blind spots)
    • Flashing lights
    • Temporary blindness
  • Epigastric/RUQ pain: From liver involvement
  • Altered mental status: Confusion, agitation
  • Nausea and vomiting
  • Hyperreflexia with clonus

Seizure Characteristics

  • Type: Generalized tonic-clonic (grand mal)
  • Duration: Usually 60-90 seconds
  • Phases:
    1. Facial twitching (15-20 seconds)
    2. Tonic phase: rigid body (15-20 seconds)
    3. Clonic phase: convulsions (60 seconds)
    4. Postictal phase: coma/confusion
  • Number: Usually single, but can be multiple

Associated Features

  • Hypertension: Usually severe (≥160/110)
  • Proteinuria: Often significant
  • Edema: Facial and peripheral
  • Oliguria: <500mL/24 hours
  • Pulmonary edema: 3-5% of cases
  • HELLP syndrome: 10-15% association

Pathophysiology

Mechanisms of Seizures

  • Cerebral vasospasm: Reduced perfusion
  • Hypertensive encephalopathy: Autoregulation failure
  • Endothelial dysfunction: BBB disruption
  • Cerebral edema: Vasogenic and cytotoxic
  • Microinfarctions and hemorrhages
  • Posterior reversible encephalopathy syndrome (PRES)

Risk Factors

Major Risk Factors

  • Preeclampsia with severe features
  • Previous eclampsia (2-16% recurrence)
  • HELLP syndrome
  • Nulliparity
  • Multiple gestation
  • Teenage pregnancy
  • Advanced maternal age (>35)

Additional Risk Factors

  • Chronic hypertension
  • Pregestational diabetes
  • Chronic kidney disease
  • Antiphospholipid syndrome
  • African ancestry
  • Low socioeconomic status
  • Limited prenatal care

Diagnosis and Evaluation

Clinical Diagnosis

Eclampsia is diagnosed when new-onset seizures occur in pregnancy or postpartum, not attributable to other causes. Preeclampsia is usually present but not required.

Laboratory Studies

  • CBC with platelets: Thrombocytopenia, hemolysis
  • Liver enzymes: AST, ALT elevation
  • Creatinine: Assess renal function
  • LDH: Hemolysis marker
  • Uric acid: Often elevated
  • Coagulation studies: PT, PTT, fibrinogen
  • Urinalysis: Proteinuria quantification

Imaging

  • Brain imaging (MRI/CT):
    • Not routine
    • If focal deficits
    • Atypical presentation
    • Prolonged coma
    • Shows PRES in 90%
  • Chest X-ray: If pulmonary edema suspected

Differential Diagnosis

  • Epilepsy
  • Cerebrovascular accident
  • Hypertensive encephalopathy
  • Metabolic disorders (hypoglycemia, uremia)
  • CNS infection
  • Intracranial mass
  • Drug toxicity
  • Thrombotic thrombocytopenic purpura

Treatment

Seizure Control and Prevention

Magnesium Sulfate (First-line)

  • Mechanism: Cerebral vasodilation, NMDA receptor blockade
  • Loading: 4-6g IV over 15-20 minutes
  • Maintenance: 2g/hour IV infusion
  • Duration: 24 hours postpartum or last seizure
  • Monitoring:
    • Deep tendon reflexes hourly
    • Respiratory rate
    • Urine output
    • Serum levels if toxicity suspected
  • Toxicity signs: Loss of DTRs, respiratory depression
  • Antidote: Calcium gluconate 1g IV

Alternative Agents (if MgSO4 contraindicated)

  • Phenytoin (less effective)
  • Diazepam (higher recurrence)
  • Levetiracetam (emerging option)

Blood Pressure Management

  • Goal: 140-160/90-110 mmHg
  • First-line agents:
    • Labetalol 20mg IV, then 40-80mg q10min
    • Hydralazine 5-10mg IV q20min
    • Nifedipine 10-20mg PO q30min
  • Avoid: Sudden BP drops (placental hypoperfusion)

Delivery Planning

  • Timing: After maternal stabilization
  • Not immediate: Unless fetal compromise
  • Mode:
    • Vaginal delivery preferred if stable
    • Cesarean for obstetric indications
    • Continuous fetal monitoring

Supportive Care

  • Foley catheter for strict I/O
  • Fluid restriction: 80mL/hour
  • Avoid diuretics unless pulmonary edema
  • Continuous pulse oximetry
  • Neurological assessments

Prevention

Primary Prevention (Preventing Preeclampsia)

  • Low-dose aspirin: 81mg daily from 12-28 weeks for high-risk
  • Calcium supplementation: If dietary intake <600mg/day
  • Regular prenatal care: Early detection
  • Risk factor modification: Weight, BP control

Secondary Prevention (Preventing Eclampsia)

  • Magnesium sulfate prophylaxis:
    • All women with preeclampsia with severe features
    • During labor and 24 hours postpartum
    • Reduces eclampsia risk by 50%
  • Timely delivery: For severe preeclampsia
  • Close monitoring: Symptoms, BP, labs
  • Patient education: Warning signs

Recurrence Prevention

  • Preconception counseling
  • Early prenatal care
  • Aspirin prophylaxis
  • Serial BP and urine monitoring
  • Growth ultrasounds
  • Antenatal testing

Complications

Maternal Complications

  • Neurological:
    • Intracranial hemorrhage (1-2%)
    • Cerebral edema
    • Cortical blindness
    • Status epilepticus
  • Cardiopulmonary:
    • Pulmonary edema
    • Aspiration pneumonia
    • Cardiac arrest
  • Renal:
    • Acute kidney injury
    • Permanent renal damage
  • Hepatic:
    • Hepatic rupture
    • Liver failure
  • Hematologic:
    • DIC
    • Severe thrombocytopenia

Fetal/Neonatal Complications

  • Placental abruption (10%)
  • Preterm delivery
  • IUGR
  • Hypoxic-ischemic encephalopathy
  • Stillbirth
  • Neonatal seizures

Long-term Outcomes

Maternal Outcomes

  • Most recover completely with proper treatment
  • Increased lifetime cardiovascular risk
  • Higher risk of:
    • Chronic hypertension
    • Stroke
    • Venous thromboembolism
    • Renal disease
  • Recurrence risk: 2-16% in subsequent pregnancies
  • Preeclampsia risk: 22-35% in future pregnancies

Follow-up Care

  • Immediate postpartum:
    • BP monitoring for 72 hours
    • Continue MgSO4 x 24 hours
    • Watch for late postpartum eclampsia
  • 6-week visit:
    • BP check
    • Proteinuria resolution
    • Contraception counseling
  • Long-term:
    • Annual BP screening
    • Cardiovascular risk assessment
    • Lifestyle modification counseling