Eclampsia
Background
- New-onset seizures in a patient with preeclampsia, not attributable to other causes
- Occurs after 20 weeks gestation or up to 6 weeks postpartum[1]
- May occur earlier with gestational trophoblastic disease
- Can occur without preceding hypertension or proteinuria in up to 20% of cases
- Maternal mortality ~1% in developed countries; leading cause of maternal death worldwide[2]
Clinical Features
- Generalized tonic-clonic seizures (typically self-limited, 60-90 seconds)
- Often preceded by:
- Severe headache (occipital or frontal)
- Visual disturbances (blurred vision, scotomata, cortical blindness)
- Epigastric or RUQ pain
- Hyperreflexia / clonus
- Hypertension (SBP >=160 or DBP >=110), though may be absent
- Peripheral edema, facial edema
- May progress to status epilepticus, HELLP syndrome, abruption, or DIC
Differential Diagnosis
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)
Evaluation
- Labs
- CBC with platelets (thrombocytopenia suggests HELLP syndrome)
- CMP (creatinine, LFTs, uric acid)
- LDH, haptoglobin, peripheral smear (evaluate for hemolysis)
- Urinalysis (proteinuria)
- Coagulation studies (PT/INR, fibrinogen)
- Type and screen
- Imaging
- CT head if atypical features, focal deficits, or prolonged postictal state
- Fetal assessment — continuous cardiotocography
Management
Seizure Treatment
- Magnesium sulfate — first-line for eclamptic seizures[3]
- Loading: 4-6 g IV over 15-20 min
- Maintenance: 1-2 g/hr IV infusion
- If no IV access: 10 g IM (5 g in each buttock), then 5 g IM q4h
- Monitor for toxicity: loss of deep tendon reflexes, respiratory depression
- Therapeutic range: 4.8-8.4 mg/dL
- Antidote for Mg toxicity: Calcium gluconate 1 g IV
- If seizures recur despite magnesium:
Blood Pressure Control
- Target: SBP 130-150, DBP 80-100
- Labetalol 20 mg IV, then 40 mg, then 80 mg q10-20 min (max 300 mg)
- Hydralazine 5 mg IV over 1-2 min, repeat 5-10 mg q20 min (max 30 mg)
- Nicardipine infusion 5 mg/hr, titrate by 2.5 mg/hr q5-15 min (max 15 mg/hr)
Delivery
- Definitive treatment is delivery
- Emergent OB/GYN consultation
- Stabilize mother before delivery
- Continue magnesium 24-48 hours postpartum
Disposition
- Admit to ICU or labor and delivery
- Emergent OB/GYN consultation
See Also
References
- ↑ ACOG Practice Bulletin No. 222: Gestational Hypertension and Preeclampsia. Obstet Gynecol. 2020;135(6):e237-e260. PMID 32443079.
- ↑ Duley L. The global impact of pre-eclampsia and eclampsia. Semin Perinatol. 2009;33(3):130-137. PMID 19464502.
- ↑ The Magpie Trial Collaborative Group. Do women with pre-eclampsia, and their babies, benefit from magnesium sulphate? Lancet. 2002;359(9321):1877-1890. PMID 12057549.