Eclampsia (from Greek "eclampsia" meaning "lightning" is the onset of seizures in a woman with pre-eclampsia (i.e. HTN+proteinuria, or other organ dysfunction). Onset may be before, during, or after delivery. Most often, it is during the 2nd half of the pregnancy.
Patient information
What is eclampsia, and how's it different from pre-eclampsia?
It's where you get seizures. In pre-eclampsia, you don't yet have seizures. You just have high blood pressure in protein in your urine, at that point. So it's a step down from eclampsia.
Sx
Preictal Sx, including:
Nausea
Vomiting
Headaches
Cortical blindness
Tonic-clonic seizure, typically for about 1 min
Postictal Sx, including:
Confusion
Coma
Amaurosis fugax (dark and fleeting unilateral temporary blindness)
Multi-organ failure eventually, causing:
Abdominal pain
Jaundice
SOB
Diminished urine output
Patient information
What happens in eclampsia?
So there's the seizure, it's usually a full scale shake, lasting for about 1 minute. And you can also get things which indicate that the seizure is about to happen, which we call preictal symptoms. And there can be things that sustain following the seizure, which we call postictal symptoms.
Anything else apart from the seizure?
Yep. Remember that pre-eclampsia also involved end organ problems starting. So eventually, you'll get end organ failure.
Whilst the mother has convulsions, the baby may experience:
Bradycardia
Fetal distress
Patient information
Anything happen with bub?
Low heart rate. And fetal distress, which means things like decreased fetal movement, mecnoium in the amniotic fluid, problems with the CTG, and pH issues with the baby's blood.
Pathophysiology
Pre-eclampsia results in prolonged HTN
Eclampsia is a form of hypertensive encephalopathy. Cerebral vascular resistance is reduced, leading to increase blood flow to the brain, causing cerebral edema, and resulting in convulsions
Eclamptic convulsions usually does not cause chronic brain damage unless ICH occurs
Patient information
Why does seizure happen in pregnancy, particularly due to high blood pressure? It seems a strange link?
Not really. High blood pressure means that there's going to be reduced resistance, to blood pushing through the blood system. Therefore, there's going to be increased blood flow to the brain. This can cause fluid to be pushed out of the blood vessels, into the brain itself. This is what causes the seizures.
Risk factors
Primi's → novel exposure to paternal antigens
Young mothers → novel exposure to paternal antigens
Pre-existing vascular disease:
HTN
Diabetes
Nephropathy
Pre-existing thrombophilic diseases:
Antiphospholipid syndrome
Large placenta:
Multiple gestation
Molar pregnancy/hydatidiform mole
Genetic component, w/ a woman's mother/sister having the condition at highest risk than otherwise
PMH of preeclampsia/eclampsia
Patient information
What makes it more likely that you have seizures in pregnancy?
First baby. New mom. If you already have heart system, or blood disease. A big placenta, which can be because of twins/triplets. Having previously had pre-eclampsia or eclampsia. And a family history of someone having seizure in pregnancy, like a lot in medicine.
DDx
Convulsions unrelated to pre-eclampsia, including: → usually won't be preceded by signs of severe pre-eclampsia
Seizure disorder
Brain tumor
Brain aneurysms
Drug-related seizures
Ix
FBC, showing depleted platelets, due to blood clotting → thrombocytopenia
Renal function test → kidney damage
24 hour urine creatinine and protein → kidney damage. Note that 20% of Pt's Dx w/ eclampsia, show no evidence of proteinuria
Liver function test → liver damage
Coagulation screen → thrombocytopenia
Fetal/placenta U/S → check placental function
Patient information
How can you look deeper into seizures during pregnancy?
Blood tests, indicating platelets being used up due to blood clotting. Testing coagulation itself. And checking end organ damage, testing kidney, as well as liver function. You can also do an ultrasound to check for how well the placenta is working.
Tx
Prevention:
Tx of prior HTN with antihypertensives, including hydralazine and/or labetalol, due to their effectiveness, and lack of negative effects on fetus
Mx of pre-eclampsia, w/ magnesium sulfate to reduce risk of eclampsia
Aspirin, in those at high risk
Calcium supplementation, in areas with low intake
Exercise during pregnancy may also be useful
ABC's, including intubation, mechanical ventilation
IV or IM magnesium sulfate, can be used to Tx convulsions. Following IV administration the onset of anticonvulsant action is fast and lasts about 30 minutes. Following IM administration the onset is about 1 hour and lasts for 3-4 hours. Even w/ therapeutic serum magnesium concentrations, and additional magnesium may be required, but w/ close monitoring for respiratory, cardiac, and neurological depression
Addition of other IV anticonvulsants can be used, although MgSO4 has better outcomes. Other anticonvulsants include diazepam, phenytoin, or a combination of chlorpromazine, promethazine, pethidine
Emergency delivery of baby either vaginally or by C-section. This needs to occur even if the fetus is premature, because the eclamptic condition is unsafe for both the baby and mother
Monitor closely for the onset of multi-organ failure, including liver, kidneys, lungs, cardiovascular system, and coagulation system. Regional anesthesia for C section is contraindicated when coagulopathy has developed
Patient information
Anything you can do to prevent seizure in pregnancy?
You can try bringing blood pressure down with medication. Magnesium sulfate can both used to treat, as well as prevent seizure. Aspirin can be given to thin the blood, in those with high risk.
OK, if it's already happening, what do you do?
Resuscitation, what we call ABC's, is the most important thing. Ensure the patient has a clear airway, and can breathe. Magnesium sulfate should be immediately given. Other anticonvulsants can also be given, but magnesium sulfate is preferred. We also need to very carefully monitor end organ damage, to essentially every system in th ebody... the liver, kidneys, lungs, heart system, and blood system.
How about bub? What do we do for them?
Deliver. They need to pop out, because Houston... we have a problem . So this is either emergency delivery by vaginally, or if this is not possible, by C section.
Complications
Maternal:
Pulmonary edema (common complication, affecting 3%) → too much intravenous fluid
Aspiration pneumonia
Cerebral hemorrhage
Kidney failure
Cardiac arrest
Placental bleeding
Placental abruption
Fetal:
IUGR
Patient information
What bad things can happen due to seizure in pregnancy?
The seizure itself can cause bleeding in the brain. The end organ damage however, can also damage the lungs, causing water in the lungs, or a lung infection due to aspiration. The kidneys, heart, or placenta can also be damaged.
How about bub?
Remember that they're protected by the amniotic sac, which cushions them. But they do need to come out immediately. Therefore, they might be small, particularly due to medical problems, which we call IUGR.
Epidemiology
Whilst pre-eclampsia affects about 5% of deliveries, eclampsia affects 1.4% of deliveries
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