Acute Eclampsia


Article Author:
Prabhcharan Gill
Anita Tamirisa


Article Editor:
James Van Hook MD


Editors In Chief:
Ann Anderson Berry
Mark Hudak
Sumesh Parat


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Frank Smeeks
Kristina Soman-Faulkner
Trevor Nezwek
Radia Jamil
Patrick Le
Sobhan Daneshfar
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
5/18/2019 7:40:00 AM

Introduction

Eclampsia is a uniquely pregnancy-related disorder that manifests as new onset of generalized tonic colonic seizures. It typically occurs after 20 weeks of concluded gestation, although it may occur sooner with plural gestations or molar pregnancies, and may additionally occur in the 6-week postpartum window. It represents the severe end of the preeclampsia spectrum. Preeclampsia spectrum includes symptoms of the central nervous system (CNS), for example, severe headaches or vision changes, and may involve hepatic abnormalities (such as elevated liver transaminases with right upper quadrant/epigastric discomfort), elevated blood pressures, and also may include thrombocytopenia, renal abnormalities, and pulmonary edema. In developed countries, resultant maternal mortality may be as high as 1.8%, and in the developing countries, it may be as high as 14%.[1]

Etiology

The etiology of the disorder remains elusive. The placenta seems to have a prime role in its etiology. An increase in placental mass, as in plural pregnancies, increases the risk for the preeclampsia-eclampsia spectrum, as does placental edema that occurs in pregnancies complicated by fetal hydrops. Molar pregnancies that impact placental architecture also have a higher risk of the complication.

Epidemiology

In the developed countries, the incidence of preeclampsia has been described to be between 1.5 to 10 cases in 100,000 deliveries. The condition is more prevalent in the developing countries. The risk factors of preeclampsia are similar to those of preeclampsia and include nulliparity, non-white, low socioeconomic backgrounds, plural pregnancies, and extremes of maternal age. Additionally, it is associated with and an array of maternal medical conditions such as chronic hypertension, chronic renal disease, and autoimmune disorders. Obesity and maternal diabetes are also recognized as increasingly important etiologies. Fetal conditions such as fetal hydrops have been associated with preeclampsia. 

Pathophysiology

Some have suggested hypertension causes breakdown of the autoregulatory mechanisms of cerebral circulation inducing endothelial dysfunction that concludes in cytotoxic edema and expression of a generalized seizure. Inflammation of the cerebrum seems to play a role in the pathophysiology. In some scenarios, it may be associated with posterior reversible encephalopathy syndrome due to posterior circulation's inability to autoregulate itself in response to acute hypertension.[2]

Histopathology

In a 1973 report, findings at autopsy include more than 50% of women who died within 2 days of seizures had evidence of cerebral hemorrhages. It also described brain histopathology. Occipital lobe petechial hemorrhages were a common finding. Cerebral venous thrombosis was also frequently observed. Since then some studies have used free radical stains to demonstrate endothelial, histiocytic, and platelet markers suggestive of capillary injury in otherwise intact brain parenchyma.

History and Physical

There may history of worsening headaches with vision changes such as blurred vision or “spots.” Hypertension and proteinuria may be present or absent. Impending eclampsia may have clonus. Eclampsia is a clinical diagnosis that is described by the occurrence of new-onset generalized tonic-clonic seizures in a woman with preeclampsia; however, on occasion, it may be the first presentation of preeclampsia.  Clinical findings may include posterior reversible encephalopathy syndrome (due to vasogenic edema predominantly localized in the posterior cerebral hemispheres), which include a headache, confusion, visual symptoms, and seizure.

Evaluation

Women known to have preeclampsia may develop eclamptic, generalized, tonic-clonic seizures that conclude with no persistent neurologic deficit, meaning they do not deserve diagnostic evaluation beyond that performed for preeclampsia. A preeclampsia workup would include an evaluation of renal function, liver function, complete blood count, and imaging of fetoplacental unit. Obstetric ultrasound imaging of the fetus includes an assessment of fetal growth as well as fetal health (biophysical profile and as indicated umbilical artery cord Doppler studies), including fetal heart rate strip. [3]Clinical monitoring for placental abruption is heightened and is maternal monitoring for evolving complications such as pulmonary edema or renal dysfunction. Neuroimaging should be considered if:

  • There are persistent neurologic deficits
  • The loss of consciousness is prolonged
  • The onset of seizures is 48 hours beyond delivery
  • An eclamptic seizure occurs before 20 weeks
  • Recurrent seizures in spite of adequate magnesium sulfate therapy.

Treatment / Management

Acute care is prioritized to maintain the airway, prevent aspiration, and prevent maternal injury. The patient should be shifted onto her left side and once the seizures have concluded maternal oxygenation is optimized with the supplemental oxygen of 8 to 10 liters per minute administered via a nonrebreathing face mask to treat hypoxemia that occurs from hypoventilation during the seizure activity.[3]

Magnesium sulfate is a treatment of choice to prevent recurrent seizures; however, approximately 10% of will have a repeat a seizure despite magnesium sulfate therapy. Recurrent seizures require surveillance for rhabdomyolysis, metabolic acidosis, aspiration pneumonia, and neurogenic pulmonary edema. Magnesium sulfate remains superior for recurrent seizure activity (an additional 2 gm bolus can be considered in those already on magnesium sulfate therapy), but the addition of intravenous lorazepam 2mg intravenously over 3 to 5 minutes may also be considered. The initial loading bolus of magnesium sulfate is 4 gm to 6 gm intravenously over 15 to 20 minutes with a maintenance dose of 1 gm to 3 gm an hour, depending on renal function. Blood levels of magnesium are monitored every four hours and targeted at four mEq/L to -7 mEq/L or 5 mg/dl to 9 mg/dl. Urine output is closely monitored. Should magnesium sulfate toxicity occur calcium, gluconate 1 gm intravenously can be administered.

Management of severe hypertension is the next focus of patient care.  A preferred agent for the treatment of severe hypertension is intravenous labetalol (initial dose of 20 mg and for recalcitrant severe hypertension follow-up dose of 40 mg and 80 mg every 15 minutes). Maintaining systolic blood pressure between 140 mm Hg to 160 mmHg and diastolic blood pressure between 90 mmHg to  105 mmHg are targeted treatment goals.

Fetal bradycardia lasting 3 to 5 minutes is a common finding during and immediately after the seizure and does not indicate emergency cesarean delivery.  Stabilization of the mother by stabilizing the seizure activity and correction of maternal hypertension if present and oxygen to treat hypoxemia and hypercarbia is the mainstay of initial supportive therapies are part of fetal intrauterine fetal resuscitation.  However, if the fetal heart rate strip does not improve after 15 minutes of maternal and fetal resuscitative interventions then a differential diagnosis of occult abruption should be considered, and emergent cesarean delivery may be indicated. Eclampsia represents an absolute contraindication to expectant management. Once the maternal-fetal condition is stabilized, delivery should be accomplished labor induction. This is a particularly reasonable option after 32 weeks of gestation. It may be an option at early gestations with a favorable Bishop score; however, long induction-delivery intervals are best avoided with a clear end-point for delivery to be concluded within 24 hours.

Complications

  • Cortical blindness
  • Neurological deficits
  • Stroke
  • Coronary event
  • Renal failure
  • Liver dysfunction
  • DIC
  • Death
  • Intrauterine growth retardation

Pearls and Other Issues

As a point of caution, when an eclamptic seizure is diagnosed before 20 weeks, it deserves careful exclusion of non-obstetric etiologies such as brain tumor or ruptured aneurysm as does the diagnosis of delayed postpartum eclampsia. Approximately 60% of the cases occur antepartum, and 20% occur intrapartum, and finally, 20% of the cases occur postpartum. Approximately 90% of the postpartum seizures occur within one week of delivery.

Enhancing Healthcare Team Outcomes

Eclampsia is a serious disorder of pregnancy that can jeopardize the lives of both the mother and the fetus. Because the condition can affect many organ systems, a multidisciplinary approach to management is highly recommended. The nurse looking after a patient with eclampsia must be aware of the potential complications so that a prompt physician referral can be made. Over the past 3 decades, the outcomes of eclampsia have improved chiefly due to improvements in healthcare. However, morbidity from the disorder still occurs. At least 20% of women with eclampsia will go on to develop hypertension in subsequent pregnancies and another 2-5% will develop eclampsia in a future pregnancy. Overall, multiparous females are not only likely to develop hypertension but also have a higher mortality compared to primiparous women. Because there is no reliable test to predict who will develop pre-eclampsia, all high risk women are urged to take a low dose aspirin during pregnancy. Finally, all pregnant women should be educated about the signs and symptoms of preeclampsia and when to seek medical help.


Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Acute Eclampsia - Questions

Take a quiz of the questions on this article.

Take Quiz
A pregnant female at 26 weeks gestation presents with vague complaints of fatigue. Work up reveals that she has hypocalciuria. She may be at a risk for development of which of the following?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What is the most common cause of death in patients with eclampsia?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What should the continuous infusion rate of magnesium sulfate be for treatment of eclampsia?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following drugs is best to be used for eclampsia?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A patient who is 34 weeks pregnant presents with a blood pressure of 150/90 and begins to seize. What is the diagnosis?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which is the best description of eclampsia?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
When is eclampsia most commonly seen?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Who is most likely to suffer from eclampsia?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following is a complication of eclampsia affecting the fetus?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following is true regarding maternal complications of eclampsia?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
In addition to preeclampsia, which of the following characterizes eclampsia?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 31-year-old woman with BMI of 45 has chronic hypertension normalized with oral labetalol 200mg three times a day. She is also carrying a triamniotic gestation. You have had an opportunity at 10 weeks to see her and again at 21 weeks 2 days when her blood pressure is 158/100 mmHg, and she has new onset of proteinuria at 3+. Two days later days later the blood pressure is 165/110 mmHg, and pulse ox is 90% on room air, and chest x-ray shows mild pulmonary edema. She then has a generalized seizure. Which of the below care plan should be endorsed?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 19-year-old black female at 32 weeks gestation is admitted to labor and delivery with blood pressure of 165/110 mmHg in triage and proteinuria. Her boyfriend brought her in as she complained of headaches and seemed agitated and restless. She had the curtains pulled. She was diagnosed to have preeclampsia with severe features. Her blood pressure settled to 155/100 mmHg. She has three beat clonus, and the headache is better. However she remains agitated, and somnolence is evident. What would the care plan be?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A pregnant female patient directly admitted with a diagnosis of eclampsia has just arrived. Which of the following are risk factors for this disorder? Select all that apply.



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A pregnant female is in the emergency department and has just been diagnosed with eclampsia. What nursing interventions are appropriate? Select all that apply.



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

Acute Eclampsia - References

References

Gyamfi-Bannerman C,Pandita A,Miller EC,Boehme AK,Wright JD,Siddiq Z,D'Alton ME,Friedman AM, Preeclampsia outcomes at delivery and race. The journal of maternal-fetal     [PubMed]
Liu L,Dai D,Cao F,Zhang L,Wang X, Posterior reversible encephalopathy syndrome with spinal cord involvement but without hemisphere lesions: A case report. Medicine. 2019 Jan;     [PubMed]
Ackerman CM,Platner MH,Spatz ES,Illuzzi JL,Xu X,Campbell KH,Smith GN,Paidas MJ,Lipkind HS, Severe cardiovascular morbidity in women with hypertensive diseases during delivery hospitalization. American journal of obstetrics and gynecology. 2019 Feb 8;     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of Pediatric-Neonatal/Perinatal. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for Pediatric-Neonatal/Perinatal, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in Pediatric-Neonatal/Perinatal, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of Pediatric-Neonatal/Perinatal. When it is time for the Pediatric-Neonatal/Perinatal board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study Pediatric-Neonatal/Perinatal.