Eclampsia

What is Eclampsia?

Eclampsia is a complication of preeclampsia among pregnant women which is characterized by abrupt tonic-clonic seizures and coma that are not associated with any other disorder.

Preeclampsia vs. Eclampsia

If you are going to think of preeclampsia and eclampsia as a movie, think of it as Preeclampsia (Part I) and Eclampsia (Part II). It’s like preeclampsia is the predecessor and eclampsia is the sequel. What do I mean? Preeclampsia happens first before eclampsia.

Preeclampsia is typically diagnosed to pregnant women with hypertension and proteinuria [1]. This may happen as early as 20 weeks in pregnancy to 6 weeks after delivery [2]. If left untreated, preeclampsia will progress to eclampsia which adds a life-threatening tonic-clonic seizure as a sign.

Postpartum Eclampsia

As the name suggests, postpartum eclampsia is an eclampsia that happens after birth. So technically, the baby is safe but the mother is not. Sudden tonic-clonic seizures may happen as soon as the mother gives birth but typically, the signs and symptoms happen within 48 hours after delivery [2]. Of course the patients were diagnosed with preeclampsia before this happens, unless the condition was undetected. So if the patient has preeclampsia, it is very important for her to be monitored even after the delivery of the baby. Most patients who develop postpartum eclampsia are women who gave her first birth at 40 years of age [3].

Causes and Pathophysiology of Eclampsia

Uteroplacental Ischemia

There is no precise cause of eclampsia. Most studies, however, point uteroplacental ischemia (oxygen deficiency of uterus and placenta) to be a great factor for developing preeclampsia [4], which may further progress to eclampsia if no prompt treatment is given. Further development of uteroplacental arteries itself is impeded [5]. It is believed that disruption of blood and oxygen supply to uterus and placenta will release biomedical mediators that will cause a constriction of arteries and defect in the endothelium [4].

Seizures

Seizures in eclampsia mostly affect the brain particularly the posterior parieto-occipital lobes [6]. The following is an indirect explanation of how seizures might develop, since brain is the organ which is more likely to dictate the body to have a seizure. Extreme hypertension in eclampsia disrupts blood flow in the brain. The blood vessels in the brain will compensate for this by dilating themselves and by allowing more permeability. Cerebral edema and vasospasm follows, then cerebral ischemia and encephalopathy will result from these [5].

Endothelial Dysfunction

Common among women with endothelial dysfunction is increased laboratory findings in:

  • Cellular fibronectin
  • Von Willebrand factor
  • Intercellular adhesion molecule-1
  • Tumor necrosis factor-α
  • Cytokines
  • Cell adhesion molecules
  • Tyrosine kinase 1
  • Activin A

High levels of these last two laboratory findings will result in lower vascular endothelial growth factor (VEGF). Low VEGF will result to endothelial cell dysfunction, because the primary factor for its growth is not sufficient enough to maintain its role[5]

Oxidative Stress

  • Increased leptin molecules results to oxidative stress.
  • Increased leptin molecules equal increased platelet aggregation.
  • Oxidative stress increases activin A.
  • Heightened systemic activity of white blood cells (WBC) intercedes oxidative stress and endothelial dysfunction.[5]

Risk Factors for Eclampsia

Pregnant with the following status or conditions are observed to be more likely to develop preeclampsia/eclampsia.

  • Teenagers
  • Women aged 40 and above
  • Nulliparous women (women who have never delivered a baby)
  • Primigravida (first pregnancy)
  • Complications in past pregnancy
  • Hypertension before pregnancy
  • Multiple gestation
  • Obesity
  • Hydatidiform mole
  • Fetal hydrops
  • Family history of eclampsia
  • Pregnancy through artificial insemination
  • Low socioeconomic factors
  • Preexisting health conditions: antithrombin deficiency, connective tissue disorders, diabetes, kidney disease, lupus, protein C and S deficiency, rheumatoid arthritis, sickle cell disease, thrombophilia, vascular disorders[7, 8]

Eclampsia Signs and Symptoms

  • Hypertension or high blood pressure – hallmark and most common symptom of eclampsia
  • Seizures or convulsions – hallmark symptom of eclampsia
  • Proteinuria – presence of proteins in the urine because the kidneys are unable to perform efficiently
  • Blurred vision – emergency
  • Severe headache – emergency
  • Pain in the upper abdomen
  • Excessive bruising

Eclampsia

Diagnostic Tests for Eclampsia

When signs and symptoms are present, consult your obstetrician immediately. The presence of hypertension, seizures or convulsions, anasarca or generalized edema, and proteinuria leads an obstetrician to diagnose a pregnant patient with eclampsia [9].

To ensure right diagnosis, the following diagnostic tests are performed: [10, 11]

  • Urine test
    • Presence of protein
    • Uric acid
  • Blood tests
    • Hematocrit
    • Platelet count
    • Liver function
    • Kidney function
  • Fetal tests
    • Non-stress test
    • Biophysical profile
    • Ultrasound
  • CT scan or MRI

Treatment and Management

The ultimate treatment for eclampsia is the delivery of the baby [12], as it would be hazardous for both the mother and baby if pregnancy continues.

  • Magnesium sulfate is the drug of choice for eclampsia. It is administered intravenously 1-2 days after the last convulsive episode. [12]
  • Sodium amobarbital, diazepam (Valium), and phenytoin (Dilantin) [12] may be used to alleviate seizures, in case magnesium sulfate cannot be used [13]
  • For hypertension, hydralazine (Apresoline) or labetalol (Normodyne, Trandate) may be used [12, 13]. However, blood pressure must be carefully monitored while administering these drugs because if the blood pressure drops, blood and oxygen supply to the fetus will also be depleted [13].
  • If pulmonary edema develops, a diuretic [13] will be administered to remove excess fluid.
  • Foley catheter is inserted because the patient won’t be able to control urination during seizures and this is also for obtaining precise measurement of urinary output.
  • Always raise the bed’s side rails and it must be in its lowest position.
  • Support the head, making sure there won’t be any physical trauma resulting from the seizure.

Postpartum Management

Terminating pregnancy may not be enough in eclampsia. Seizures may still be observed after the delivery of the baby. That is why postpartum mothers diagnosed with preeclampsia and/or eclampsia are recommended to stay in the hospital for 2 days postpartum or more, depending on the mother’s and baby’s conditions.

The following are the postpartum management:

  • Within 48 hours of delivery, close monitoring of signs and symptoms, vital signs, and fluid intake and output are done.
  • Pulmonary edema and severe hypertension is evaluated by careful monitoring of intravenous fluids, oral intake, urine output, pulmonary auscultation, pulse oximetry, and blood products.
  • Intravenous magnesium sulfate is continued 24 hours after delivery or 24 hours after the last convulsive episode.[9]

Eclampsia Prevention

The exact root cause of eclampsia is unknown. However, doctors and researchers believe that there are measures that can somehow decrease the likelihood of occurrence of preeclampsia and/or eclampsia. It won’t hurt if you follow them. So read the following prevention measures.

  • Be aware of the risk factors of eclampsia. Avoid them if you can.
  • If you notice any signs and symptoms of preeclampsia, go to your doctor at once! Prompt treatment is very necessary for both the mother and the fetus.
  • Eat healthy. Eat lots of fruits and vegetables, moderate carbohydrates and meats, and low salt and fats.
  • Exercise regularly.

References:

  1. http://emedicine.medscape.com/article/253960-overview
  2. http://en.wikipedia.org/wiki/Pre-eclampsia
  3. http://www.wisegeek.com/what-is-postpartum-eclampsia.htm
  4. http://www1.cgmh.org.tw/intr/intr5/c6700/obgyn/f/web/Eclampsia/index.htm
  5. http://emedicine.medscape.com/article/253960-overview#aw2aab6b5
  6. http://cjasn.asnjournals.org/content/2/3/543.full
  7. http://emedicine.medscape.com/article/253960-overview#aw2aab6b3c
  8. http://www.medicinenet.com/pregnancy_preeclampsia_and_eclampsia/page2.htm#who_is_at_risk_for_preeclampsia_and_eclampsia
  9. http://anesth-chips.fr/IMG/pdf/MATER_ECLAMPsieCAT_Sibai_OG_05.pdf
  10. http://www.emedicinehealth.com/eclampsia/page4_em.htm
  11. http://health.nytimes.com/health/guides/disease/eclampsia/overview.html
  12. http://www.emedicinehealth.com/eclampsia/page5_em.htm
  13. http://emedicine.medscape.com/article/253960-overview#a30



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