Eclampsia

Background

• Preeclampsia and eclampsia are diagnosed after 20wks gestation and <4wk post-partum
  • May occur sooner with gestational trophoblastic disease
• Suspect in any pregnant patient who is >20wk or <4wk postpartum who develops seizures

Differential Diagnosis

Preeclampsia

Seizure

• Epileptic seizure
  • First-time seizure
  • Seizure with known seizure disorder
  • Status epilepticus
  • Temporal lobe epilepsy
  • Non-compliance with anti-epileptic medications
  • Hyponatremia
  • INH toxicity
• Non-epileptic seizure
  • Meningitis
  • Encephalitis
  • Brain abscess
  • Intracranial hemorrhage
  • Alcohol withdrawal
  • Benzodiazepine withdrawal
  • Barbiturate withdrawal
  • Baclofen withdrawal
  • Metabolic abnormalities: hyponatremia, hypernatremia, hypocalcemia, hypomagnesemia, hypoglycemia, hyperglycemia, hepatic failure, uremia
  • Eclampsia
  • Neurocysticercosis
  • Posterior reversible encephalopathy syndrome
  • Impact seizure (head trauma)
  • Acute hydrocephalus
  • Arteriovenous malformation
  • Seizure with VP shunt
  • Toxic ingestion (amphetamines, anticholinergics, cocaine, INH, organophosphates, TCA, salicylates, lithium, phenothiazines, bupropion, camphor, clozapine, cyclosporine, fluoroquinolones, imipenem, lead, lidocaine, metronidazole, synthetic cannabinoids, theophylline, Starfruit)
  • Psychogenic nonepileptic seizure (pseudoseizure)
• Intracranial mass
• Syncope
• Hyperventilation syndrome
• Migraine headache
• Movement disorders
• Narcolepsy/cataplexy
• Post-hypoxic myoclonus (Status myoclonicus)

3rd Trimester/Postpartum Emergencies

• Acute fatty liver of pregnancy
• Amniotic fluid embolus
• Chorioamnionitis
• Eclampsia
• HELLP syndrome
• Mastitis
• Peripartum cardiomyopathy
• Postpartum endometritis (postpartum PID)
• Postpartum headache
• Postpartum hemorrhage
• Preeclampsia
• Resuscitative hysterotomy
• Retained products of conception
• Septic abortion
• Uterine rupture

Management

1. Delivery
2. Seizure treatment
   • Magnesium 4-6 g load in 100 mL over 20-30 min, then 1-2 g/hr maintenance IV
     • If no IV Access, give Magnesium sulfate 50% solution IM 10g Loading Dose (5g in each buttock), followed by 5 g IM q 4 hours
     • Observe for loss of reflexes, respiratory depression
     • If seizure responds and unable to urgently transport to Ob Unit: Monitor serum Mg Levels q 4 hours (therapeutic range: 4.9-8.5mg/dL) and obtain CTH
     • Must adjust dose in patients with renal failure
   • If seizures recur:
     • Consider alternative diagnosis
     • Consider other anticonvulsant drugs
       • Lorazepam, diazepam, phenytoin, levetiracetam
   • Contraindications to magnesium:
     • Severe renal failure
     • Pulmonary edema
     • Myasthenia gravis
3. BP Control (target Sys 130-150, Dia 80-100)
   • Labetalol 20 mg IV initial; then 20-80 mg q10min (max 300 mg total) OR 20 mg IV then infusion 1-2 mg/min IV (max 300 mg total)
   • Hydralazine 5 mg IV over 1-2 min; repeat 5-10 mg q20min PRN IV (max 30 mg total)
4. Persistent seizure
   • See status epilepticus
   • Plan appropriately for delivery

Disposition

• Admit, emergent OB/GYN consultation

See Also

• Post-Partum Emergencies
• Preeclampsia
• ACOG Eclampsia Checklist

References

• EBM, Volume 12, Number 8, Aug 2010. Postpartum Emergencies
• Uptodate