Eclampsia

Eclampsia (Greek, "shining forth"), an acute and life-threatening complication of pregnancy, is

characterized by the appearance of tonic-clonic seizures, usually in a patient who had developed pre-
eclampsia. (Preeclampsia and eclampsia are collectively called Hypertensive disorder of pregnancy and
toxemia of pregnancy.)

Eclampsia includes seizures and coma that happen during pregnancy but are not due to preexisting or
organic brain disorders.[1]

Signs and symptoms

Typically patients show signs of pregnancy-induced hypertension and proteinuria prior to the onset of the
hallmark of eclampsia, the eclamptic convulsion. Other cerebral signs may precede the convulsion such
as nausea, vomiting, headaches, and cortical blindness. In addition, with the advancement of the
pathophysiological process, other organ symptoms may be present including abdominal pain, liver failure,
signs of the HELLP syndrome, pulmonary edema, and oliguria. The fetus may have been already
compromised by intrauterine growth retardation, and with the toxemic changes during eclampsia may
suffer fetal distress. Placental bleeding and placental abruption may occur.

The eclamptic seizure

Chesley distinguishes these four stages of an eclamptic event: In the stage of invasion facial twitching can
be observed around the mouth. In the stage of contraction tonic contractions render the body rigid; this
stage may last about 15 to 20 seconds. The next stage is the stage of convulsion when involuntary and
forceful muscular movements occur, the tongue may be bitten, foam appears at the mouth. The patient
stops breathing and becomes cyanotic; this stage lasts about one minute. The final stage is a more or less
prolonged coma. When the patient awakens, she is unlikely to remember the event.[2] In some rare cases
there are no convulsions and the patient falls directly into a coma. Some patients when they awake from
the coma may have temporary blindness.

During a seizure, the fetus may experience bradycardia.[3]

Risk factors

Eclampsia, like preeclampsia, tends to occur more commonly in first pregnancies and young mothers
where it is thought that novel exposure to paternal antigens is involved. Further, women with preexisting
vascular diseases (hypertension, diabetes, and nephropathy) or thrombophilic diseases such as the
antiphospholipid syndrome are at higher risk to develop preeclampsia and eclampsia. Conditions with a
large placenta (multiple gestation, hydatiform mole) also predispose for toxemia. Further, there is a
genetic component; patients whose mother or sister had the condition are at higher risk.[4] Patients with
eclampsia are at increased risk for preeclampsia/eclampsia in a later pregnancy.

Pathophysiology

While multiple theories have been proposed to explain preeclampsia and eclampsia, it occurs only in the
presence of a placenta and is resolved by its removal.[5] Dr.Mayank suggested that placental
hypoperfusion is a key feature of the process. It is accompanied by increased sensitivity of the maternal
vasculature to pressure agents leading to vasospasm and hypoperfusion of multiple organs. Further, an
activation of the coagulation cascade leads to microthrombi formation and aggravates the perfusion
problem. Loss of plasma from the vascular tree with the resulting edema additionally compromises the
situation. These events lead to signs and symptoms of toxemia including hypertension, renal, pulmonary,
and hepatic dysfunction, and - in eclampsia specifically - cerebral dysfunction.[5] Preclinical markers of
the disease process are signs of increased platelet and endothelial activation[5]

Placental hypoperfusion is linked to abnormal modeling of the fetal-maternal interface that may be
immunologically mediated[5] The invasion of the trophoblast appears to be incomplete.[6] Adrenomedullin,
a potent vasodilator, is produced in diminished quantities by the placenta in preeclampsia (and thus
eclampsia).[7] Other vasoactive agents are at play including prostacyclin, thromboxane A2, nitric oxide,
and endothelins leading to vasoconstriction.[3] Many studies have suggested the importance of a woman's
immunological tolerance to her baby's father, whose genes are present in the young fetus and its placenta
and which may pose a challenge to her immune system.[8]

Eclampsia is seen as a form of hypertensive encephalopathy in the context of those pathological events
that lead to preeclampsia. It is thought that cerebral vascular resistance is reduced, leading to increased
blood flow to the brain. In addition to abnormal function of the endothelium, this leads to cerebral edema.
[9]
Typically an eclamptic seizure will not lead to lasting brain damage; however, intracranial hemorrhage
may occur.[10]

Diagnosis

Seizures during pregnancy that are unrelated to preeclampsia need to be distinguished from eclampsia.
Such disorders include seizure disorders as well as brain tumor, aneurysm of the brain, medication- or
drug-related seizures. Usually the presence of the signs of severe preeclampsia that precede and
accompany eclampsia facilitate the diagnosis.

Prevention

Detection and management of preeclampsia is critical to reduce the risk of eclampsia. Appropriate
management of patients with preeclampsia generally involves the use of magnesium sulfate as an agent to
prevent convulsions, and thus preventing eclampsia.

Treatment

The treatment of eclampsia requires prompt intervention and aims to prevent further convulsions, control
the elevated blood pressure and deliver the fetus.

Prevention of convulsions

Prevention of seizure convulsion is usually done using magnesium sulfate.[11] The idea to use Mg2+ for the
management of eclamptogenic toxemia dates from before 1955 when it was tested and published—the
serum Mg2+ therapeutic range for the prevention of the eclampsic uterine contractions is still considered:
4.0-7.0 mEq/L.[12] As per Lu and Nightingale,[13] serum Mg2+ concentrations associated with maternal
toxicity (also neonate depression or hypotonia and low Apgar scores) are:

• 7.0–10.0 mEq/L - loss of patellar reflex

• 10.0–13.0 mEq/L - respiratory depression
• 15.0–25.0 mEq/L - altered atrioventricular conduction and (further) complete heart block
• >25.0 mEq/L - cardiac arrest
Even with therapeutic serum Mg2+ concentrations, recurrent convulsions and seizures may occur—
patients would receive additional MgSO4 but under close monitoring for respiratory, cardiac and
neurological depression: 4–6 g loading dose in 100 mL IV fluid over 15–20 min., then 2 g/hr as a
continuous infusion.[3] If high Mg2+ concentrations fail to take effect, IV anticonvulsants will ease patient
intubation and mechanical ventilation as adjuvants against the eclamptic convulsions (plus the
hypermagnesemic thoracic muscle paralysis). Recently the long-term implications of the magnesium
sulfate therapies were evaluated by the international MAGPIE study.[14]

Antihypertensive management

Antihypertensive management at this stage in pregnancy may consist of hydralazine (5–10 mg IV every
15-20 min until desired response is achieved) or labetalol (20 mg bolus iv followed by 40 mg if necessary
in 10 minutes; then 80 mg every 10 up to maximum of 220 mg).[3]

Delivery

If the woman has not yet been delivered, steps need to be taken to stabilize the patient and deliver her
speedily. This needs to be done even if the fetus is immature as the eclamptic condition is unsafe for fetus
and mother. As eclampsia is a manifestation of a multiorgan failure, other organs (liver, kidney, clotting,
lungs, and cardiovascular system) need to be assessed in preparation for a delivery, often a cesarean
section, unless the patient is already in advanced labor. Regional anesthesia for cesarean section is
contraindicated when a coagulopathy has developed.

Invasive hemodynamic monitoring

Invasive hemodynamic monitoring may be useful in eclamptic patients with severe cardiac disease, renal
disease, refractory hypertension, pulmonary edema, and oliguria.

Eclampsia Overview

Eclampsia, a life-threatening complicatio of pregnancy, results when a pregnant woman

previously diagnosed with preeclampsia (high blood pressure and protein in the urine) develops
seizures or coma. In some cases, seizures or coma may be the first recognizable sign that a
pregnant woman has preeclampsia. Key warning signs of eclampsia in a woman diagnosed with
preeclampsia may be severe headaches, blurred or double vision, or seeing spots. Toxemia is a
common name used to describe preeclampsia and eclampsia.

There has never been any evidence suggesting an orderly progression of disease beginning
with mild preeclampsia progressing to severe preeclampsia and then on to eclampsia. The
disease process can begin mild and stay mild, or can be initially diagnosed as eclampsia
without prior warning.

• Approximately 5-7% of all pregnancies are complicated by preeclampsia.

• Preeclampsia usually occurs in a woman's first pregnancy but may occur for the first
time in a subsequent pregnancy.

• Less than one in 100 women with preeclampsia will develop eclampsia or (convulsions
or seizures) or coma.
 • Up to 20% of all pregnancies are complicated by high blood pressure. Complications
resulting from high blood pressure, preeclampsia, and eclampsia may account for up to 20%
of all deaths that occur in pregnant women.

Eclampsia Causes

• No one knows what exactly causes preeclampsia or eclampsia.

• Since we don't know what causes preeclampsia or eclampsia, we don't have any
effective tests to predict when preeclampsia or eclampsia will occur, or treatments to prevent
preeclampsia or eclampsia from occurring (or recurring).

• Preeclampsia usually occurs with first pregnancies. However, preeclampsia may be

seen with twins (or multiple pregnancies), in women older than 35 years, in women with high
blood pressure before pregnancy, in women with diabetes, and in women with other medical
problems (such as connective tissue disease and kidney disease).

• For unknown reasons, African American women are more likely to develop eclampsia
and preeclampsia than white women.

• Preeclampsia may run in families, although the reason for this is unknown.

• Preeclampsia is also associated with problems with the placenta, such as too much
placenta, too little placenta, or how the placenta attaches to the wall of the uterus.
Preeclampsia is also associated with hydatidiform mole pregnancies, in which no normal
placenta and no normal baby are present.

• There is nothing that any woman can do to prevent preeclampsia or eclampsia from
occurring. Therefore, it is both unhealthy and not helpful to assign blame and to review and
rehash events that occurred either just prior to pregnancy or during early pregnancy that may
have contributed to the development of preeclampsia.

Eclampsia Symptoms

The hallmark of eclampsia is seizures. Similar to preeclampsia, other changes and symptoms
may be present and vary according to the organ system or systems that are affected. These
changes can affect the mother only, baby only, or more commonly affect both mother and baby.
Some of these symptoms give the woman warning signs, but most do not.

• The most common symptom and hallmark of preeclampsia is high blood pressure. This
may be the first or only symptom. Blood pressure may be only minimally elevated initially or
can be dangerously high; symptoms may or may not be present. However, the degree of
blood pressure elevation varies from woman to woman, and also varies during the
development and resolution of the disease process. There are also some women who never
have significant blood pressure elevation (including approximately 20% of women with
eclampsia).
 • A common belief is that the risk of eclampsia rises as blood pressure increases above
160/110 mm Hg.

• The kidneys are unable to efficiently filter the blood (as they normally do). This may
cause an increase in protein to be present in the urine. The first sign of excess protein is
commonly seen on a urine sample obtained in your provider's office. Rarely does a woman
note any changes or symptoms associated with excess protein in the urine. In extreme cases
affecting the kidneys, the amount of urine produced decreases greatly.

• Nervous system changes can include blurred vision, seeing spots, severe headaches,
convulsions, and even occasionally blindness. Any of these symptoms require immediate
medical attention.

• Changes that affect the liver can cause pain in the upper part of the abdomen and may
be confused with indigestion or gallbladder disease. Other more subtle changes that affect
the liver can affect the ability of the platelets to cause blood to clot; these changes may be
seen as excessive bruising.

• Changes that can affect your baby can result from problems with blood flow to the
placenta and therefore result in your baby not getting proper nutrients. As a result, the baby
may not grow properly and may be smaller than expected, or worse the baby will appear
sluggish or seem to decrease the frequency and intensity of its movements. You should call
your doctor immediately if you notice your baby's movements slow down.

When to Seek Medical Care

• If you have any question about either your health or your baby's health

• If you have severe or persistent headache or any visual disturbance, such as double
vision or seeing spots (This may be a warning sign that preeclampsia could progress to
eclampsia.)

• If you take your own blood pressure and it is greater than or equal to 160/110 mm Hg,
call your doctor immediately!

• If you have severe pain in the middle of your belly or on the right side of your belly
under your ribs (This may be a warning sign that preeclampsia is worsening.)

• If you notice any unusual bruising or bleeding

• If you notice excessive swelling or weight gain

• If your baby has slowed down its movements

• If you have any vaginal bleeding or cramping

Exams and Tests

If you experience any of the above symptoms call your provider immediately and expect to
come to the office or hospital. If you have your own blood pressure device at home, report this
reading to your physician. However, do not substitute your home blood pressure reading for a
physician visit.

• Be sure to review all of your signs, symptoms, and concerns with your provider. Your
provider should check your blood pressure, weight, and urine at every office visit.

• If your provider suspects that you have preeclampsia, he or she will order blood tests to
check your platelet count, liver function, and kidney function. They will also check a urine
sample in the office or possibly order a 24-hour urine collection to check for protein in the
urine. The results of these blood tests should be available within 24 hours (if sent out), or
within several hours if performed at a hospital.

• The well-being of your baby should be checked by placing you on a fetal monitor.
Further tests may include nonstress testing, biophysical profile (ultrasound), and an
ultrasound to measure the growth of the baby (if it has not been done within the previous 2-3
weeks).

Eclampsia Treatment

Once eclampsia develops, the only treatment is delivery of your baby (if eclampsia occurs prior
to delivery). Eclampsia can also occur after delivery (up to 24 hours postpartum, typically).
Rarely, eclampsia can be delayed and occur up to one week following delivery. There is no cure
for eclampsia.

Magnesium sulfate (given intravenously) is the treatment of choice once eclampsia develops.
This treatment decreases the chances of having recurrent seizures. Magnesium treatment is
continued for a total of 24-48 hours after your last seizure. You may receive magnesium in an
intensive care unit or a labor and delivery unit. While magnesium is given you will be observed
closely, receive intravenous fluids, and have a Foley catheter placed in your bladder (to
measure your urine output).

Occasionally, recurrent seizures require additional treatment with a short-acting barbiturate such
as sodium amobarbital. Other medications including diazepam (Valium) or phenytoin (Dilantin)
have been used to treat eclampsia; however, they are not as effective as magnesium sulfate.

You may also receive treatment for elevated blood pressure while being treated for eclampsia.
Common blood pressure medications (for women with eclampsia) include hydralazine
(Apresoline) or labetalol (Normodyne, Trandate).

Once the mother's condition is stabilized following a seizure, your doctor will prepare to deliver
your baby. This can occur either by cesarean delivery or induction of labor and vaginal delivery.
If you are already in labor, labor can be allowed to progress provided there is no evidence that
your baby has become "distressed" or compromised by the seizure.
The closer you are to your due date, the more likely your cervix will be ripe (ready for delivery),
and that induction of labor will be successful. Sometimes medications, such as oxytocin
(Pitocin), are given to help induce labor.

• The earlier in pregnancy (24-34 weeks), the less chance of a successful induction
(although induction is still possible). It is more common to have a cesarean delivery when
eclampsia necessitates delivery early in pregnancy.

• If the baby shows signs of compromise, such as decreased fetal heart rate, an
immediate cesarean delivery will be performed.

Medications

• You may require medication to treat your high blood pressure during labor or after
delivery. It is unusual to require medication for high blood pressure after six weeks following
delivery (unless you have a problem with high blood pressure that is unrelated to pregnancy).

• During labor (and for 24-48 hours after delivery) you will be given a medication called
magnesium sulfate. This is to decrease your chances of having a recurrent seizure.

Medications such as oxytocin (Pitocin) or prostaglandins are given to induce labor and/or ripen
your cervix. A Foley catheter is sometimes placed in the cervix to mechanically "speed" the
dilation process.

Follow-up

Just as there were no tests to predict or prevent eclampsia, there are no tests to predict whether
preeclampsia or eclampsia will recur in a subsequent pregnancy. Unfortunately, in a small
number of women, preeclampsia and/or eclampsia will recur. This chance seems to increase if
preeclampsia or eclampsia was particularly severe or occurred very early in pregnancy (late
second trimester or early third trimester). Although, there are no tests to predict this occurring,
you should be followed more closely during a subsequent pregnancy.

Although there is limited experience in the use of birth control pills by women who have had
preeclampsia or eclampsia, the evidence suggests that birth control pills are a safe and valuable
means of birth control.

Outlook

Most women will have good outcomes for their pregnancies complicated by preeclampsia or
eclampsia. Some women will continue to have problems with their blood pressure and will need
to be followed closely after delivery.

Most babies will do well. Babies born prematurely will usually stay in the hospital longer. A rule
of thumb is to expect the baby to stay in the hospital until their due date.

Unfortunately, a few women and babies experience life-threatening complications from

preeclampsia or eclampsia.
•