Eclampsia Disease

BASICS

DESCRIPTION

The presence of seizure activity in an obstetric patient with the syndrome of hypertension, edema, and proteinuria (pre-eclampsia), in a patient without underlying neurological disease. Nearly all postpartum cases occur within 24 hours of delivery.

System(s) affected: Reproductive, Nervous, Hemic/Lymphatic/Immunologic
Genetics: There does seem to be some genetic predisposition. The single-gene model best explains the frequency of about 25%, but multifactorial inheritance is also possible.
Incidence/Prevalence in USA:
- Unclear; incidence varies, but preeclampsia has been reported to complicate 5% of all deliveries
- 0.5-2% of preeclamptic patients will progress to eclampsia. With improved monitoring and prepartum care, this number has decreased in recent years.
Predominant age: Most of the cases occur in younger women because of the higher incidence of preeclampsia in younger (nulliparous) women. However, older (> 40 years), preeclamptic patients have 4 times the incidence of seizures compared with patients in their 20's.
Predominant sex: Female only

SIGNS AND SYMPTOMS

Tonic-clonic seizure activity (focal or generalized)
Headache, visual disturbance and epigastric or right upper quadrant pain often precedes seizure
Seizures may occur once or repeatedly
Postictal coma, cyanosis (variable)
Temperatures > 39°C consistent with CNS hemorrhage
Disseminated intravascular coagulation (DIC), thrombocytopenia, liver dysfunction, renal failure associated
Proteinuria
Up to 30% may not have edema, 20% may not have proteinuria
Normal blood pressure - however, normal blood pressure, even in "response" to treatment, does not rule out potential for seizures
Hemoconcentration - predisposition to pulmonary and or cerebral edema with fluid therapy. There is actually an excess of extracellular fluid that is inappropriately distributed to the extracellular spaces.

CAUSES

Exact cause of seizures remains unclear
Trophoblastic tissue seems to be required, and somehow results in widespread vasospasm
Severe cerebral vasoconstriction; hemorrhages occur due to failure of the constriction to limit perfusion pressure in the capillaries, with consequent rupture and vasogenic cerebral edema and ring hemorrhages
Now considered to be primarily an endothelial disorder

RISK FACTORS

Young nulliparous woman
Nulliparity age > 35
Obstetric conditions associated with abundance of chorionic villi (multifetal gestation, trophoblastic disease, erythroblastosis)
Preexisting hypertension or renal disease
Strong family history of preeclampsia-eclampsia
Poor prenatal care prevents early detection and treatment of preeclampsia, thereby increasing the risk of progression to eclampsia
Tobacco use was associated with a lower risk of preeclampsia/eclampsia of unknown cause

DIAGNOSIS

LABORATORY

CBC/platelets
24 hour urine for protein/creatinine
Liver function testing (LDH, AST)
Uric acid
Electrolytes
BUN

Drugs that may alter lab results: Concurrent treatment with Dilantin, barbiturates (not with magnesium)
Disorders that may alter lab results: N/A

PATHOLOGICAL FINDINGS

Cerebral edema, hyperemia, focal anemia, thrombosis, and hemorrhage; cerebral lesions account for 40% of eclamptic deaths

SPECIAL TESTS

EEG, cerebral spinal fluid studies (CSF) - rarely useful in management

IMAGING

Computed tomography can evaluate for mass lesions, infarct, hemorrhages, but is rarely used when usual clinical picture is present. Should be considered if focal findings persist or uncharacteristic signs/symptoms present.

DIAGNOSTIC PROCEDURES

No additional procedures generally applicable
EEG may vary from posterior slow waves to status epilepticus, but is rarely useful
Cerebral spinal fluid studies are of no value unless other causes (e.g., meningitis) are seriously considered in differential diagnosis

TREATMENT

APPROPRIATE HEALTH CARE

Inpatient, with parenteral access for medications and availability for invasive monitoring if necessary
Adequacy of newborn care facilities should be considered and transport arranged for newborn if needed

GENERAL MEASURES

Control of convulsions, correction of hypoxia and acidosis, lowering blood pressure, steps to effect delivery as soon as convulsions are controlled
See Medications

SURGICAL MEASURES

If fetal distress is evident or maternal condition at high risk of deterioration in spite of medical therapy, Cesarean section may be indicated. Patient is still at some risk for post partum eclampsia, however.

ACTIVITY

Bedrest

DIET

Nothing by mouth until stable, then usual seizure precautions; low salt diet commonly recommended

PATIENT EDUCATION

Explain to the patient and partner/family what has happened and the need for the prompt actions necessary to ensure the safety of the mother and infant
Additional materials from: American College of Obstetricians & Gynecologists, 409 12th St., SW, Washington, DC 20024-2188, (800)762-ACOG

FOLLOW UP

PREVENTION/AVOIDANCE

Adequate prenatal care
Good control of preexisting hypertension
Recognition and treatment of preeclampsia

POSSIBLE COMPLICATIONS

56% have transient deficits including cortical blindness
Most women do not have long-term sequelae from eclampsia
Death from toxemia or its complications
Death of fetus

EXPECTED COURSE AND PROGNOSIS

25% of eclamptic women will have hypertension in subsequent pregnancies, but only 5% of these will be severe, and only 2% will be eclamptic again
Eclamptic, multiparous women may be at higher risk for subsequent essential hypertension
Multiparous women with eclampsia have higher mortality in subsequent pregnancies than primiparous women
Racial factors are unclear, since the higher incidence of essential hypertension in blacks may predispose them to higher rates of hypertension postpartum, rather than a history of eclampsia

MISCELLANEOUS

ASSOCIATED CONDITIONS

None

AGE-RELATED FACTORS

Pediatric: Essential for adequate neonatal care/facilities
Geriatric: N/A
Others: Younger patients have highest incidence, but most likely related to the fact that younger patients represent largest numbers of primigravidas

PREGNANCY

By definition, a complication of pregnancy

OTHER NOTES

N/A

ABBREVIATIONS

N/A

Clinical Investigations

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