Gaining Insight into Eclampsia

A patient who is full term presents with eclamptic convulsion. Following a successful caesarian section and the birth of a healthy child, she had two additional convulsions. After she improved, she was discharged from the hospital four days later. At home, she suddenly collapsed and eventually died.

This scenario was recently shared on the OBGYN.net forum. The case may be puzzling, but the reality of eclampsia and resulting death is very real. Although it may not happen often, a clear understanding of eclampsia can help prevent adverse events and even death.

A complication of severe preeclampsia, eclampsia is the new onset of grand mal seizure activity and/or unexplained coma during pregnancy or postpartum in a woman with signs or symptoms of preeclampsia. However, in a review of cases in the United States, 16% of the patients did not have hypertension. Most often eclampsia surfaces during or after 20 weeks gestation or during postpartum, with about 80% of eclamptic seizures occurring intrapartum or within the first 48 hours following delivery. It occurs in about 1 out of every 2,000 to 3,000 pregnancies. Generally, women at risk for eclampsia have preeclampsia and abnormal blood tests, headaches, very high blood pressure, and vision changes, but there is no reliable screen or test. Risk factors include advanced maternal age (>35 years), race (African American), first pregnancy, history of diabetes, kidney disease, multiple pregnancies, and teenage pregnancy.

Eclamptic seizures are divided into two phases. The first phase is about 15 to 20 seconds in duration. It begins with facial twitching and then, after the body becomes rigid, generalized muscular contractions ensue. In the second phase, which lasts about 60 seconds, the twitching moves first from the jaw, then to the muscles of the face, and finally it spreads throughout the rest of the body. After the second phase, the patient goes into a coma or unconsciousness that can last for variable periods of time. Hyperventilation occurs after the seizure.

Complications associated with eclampsia include death (0.5 to 2% of cases), intracerebral hemorrhage (<1%), aspiration pneumonia (2% to 3%), disseminated coagulopathy (3% to 5%), pulmonary edema (3% to 5%), acute renal failure (5% to 9%), abruptio placentae (7% to 10%), and HELLP syndrome (10% to 15%).

Proper management of convulsions is essential for the mother’s and fetus’ well-being.1  No attempt should be made to stop the first convulsion. If diazepam is given, it is important to not exceed 5 mg over 60 seconds, as rapid administration may lead to apnea and/or cardiac arrest. A face mask should be used to provide supplemental oxygen, with or without an oxygen reservoir, at 8 to 10 L per minute. Transcutaneous pulse oximetry should be used to monitor oxygenation after the convulsion ends.

To better understand the efficacy of magnesium sulfate in managing eclampsia, researchers conducted a review of 7 trials looking at magnesium versus diazepam.2  They found magnesium sulfate was associated with a reduction in maternal deaths and recurrence of seizures as compared with those patients on diazepam. Infants also seemed to fare better with magnesium sulfate. Fewer liveborn babies whose mother had received magnesium sulfate had an Apgar score less than seven at one minute and fewer needed intubation at birth as compared with those exposed to diazepam. The authors concluded, “Magnesium sulphate for women with eclampsia reduces the risk ratio of maternal death and op recurrence of seizures, compared with diazepam.”

Meanwhile, another set of researchers conducted a randomized comparative study of low-dose magnesium sulfate and standard intramuscular regimen for treating eclampsia.3 The study included 144 women with eclampsia who were divided into two groups-a study group, which received 0.75 g/h of magnesium sulfate intravenously after a loading intravenous dose of 4 g, and a control group, which received the standard intramuscular regimen. No patient in the study group developed magnesium toxicity, and all patients received significantly lower doses of magnesium sulfate. The researchers concluded, “Low-dose intravenous magnesium sulphate was found to be as effective as the standard intramuscular regimen, while maintaining a high safety margin.”

Overall, experts agree that careful monitoring is necessary. While very few obstetricians and gynecologists may have experience in treating and managing eclampsia, all clinicians need to be prepared to diagnose and manage this threat to maternal and fetal well-being.

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References:

References:1.Sibai BM. Managing an eclamptic patient. OB Management. 2005; 37-50.2. Duley L, Henderson-Smart DJ, Walker GJ, Chou D. Magnesium sulphate versus diazepam for eclampsia. Cochrane Database Syst Rev. 2010 Dec 8;(12):CD0001273. Bhattacharjee N, Saha SP, Ganguly RP, et al. A randomised comparative study between low-dose intravenous magnesium sulphate and standard intramuscular regimen for treatment of eclampsia. J Obstet Gynaecol. 2011 May;31(4):298-303.