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Print this section Print the entire contents of Overview Etiologic and Risk Factors for Preeclampsia/Eclampsia Multiorgan System Effects Pathophysiology of Eclampsia Evaluation Differential Diagnosis Diagnostic Overview Urinalysis and Uric Acid levels Hematologic Studies Serum Creatinine level Liver Function Tests CT Scanning Magnetic Resonance Imaging of the Head Transabdominal Ultrasonography Electroencephalography and CSF Studies Medical Therapy Surgical Therapy Postpartum Outpatient Monitoring Prevention of Preeclampsia/Eclampsia Complications of Eclampsia Outcome Show All
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Overview
Ten percent of all pregnancies are complicated by hypertension. Eclampsia and preeclampsia account for about half of these cases worldwide and have been recognized and described for years despite the general lack of understanding of the disease.[1] In the fifth century, Hippocrates noted that headaches, convulsions, and drowsiness were ominous signs associated with pregnancy. In 1619, Varandaeus coined the term eclampsia in a treatise on gynecology.[2, 3]
Definition
Eclampsia, which is considered a complication of severe preeclampsia, is commonly defined as new onset of grand mal seizure activity and/or unexplained coma during pregnancy or postpartum in a woman with signs or symptoms of preeclampsia.[4] It typically occurs during or after the 20th week of gestation or in the postpartum period. Nonetheless, eclampsia in the absence of hypertension with proteinuria has been demonstrated to occur in 38% of cases reported in the United Kingdom.[5] Similarly, hypertension was absent in 16% of cases reviewed in the United States.[4]
The clinical manifestations of maternal preeclampsia are hypertension and proteinuria with or without coexisting systemic abnormalities involving the kidneys, liver, or blood. There is also a fetal manifestation of preeclampsia involving fetal growth restriction, reduced amniotic fluid, and abnormal fetal oxygenation.[5] HELLP syndrome is a severe form of preeclampsia and involves hemolytic anemia, elevated liver function tests (LFTs), and low platelet count. Most cases of eclampsia present in the third trimester of pregnancy, with about 80% of eclamptic seizures occurring intrapartum or within the first 48 hours following delivery. Rare cases have been reported before 20 weeks' gestation or as late as 23 days postpartum. Other than early detection of preeclampsia, no reliable test or symptom complex predicts the development of eclampsia. In developed countries, many reported cases have been classified as unpreventable.
Nulliparity Family history of preeclampsia, previous preeclampsia and eclampsia[2] Poor outcome of previous pregnancy, including intrauterine growth retardation, abruptio placentae, or fetal death Multifetal gestations, hydatid mole, fetal hydrops, primigravida Teen pregnancy
The following preexisting medical conditions are also considered risk factors[4] :
Obesity Chronic hypertension Renal disease Thrombophilias-antiphospholipid antibody syndrome Protein C deficiency and protein S deficiency Antithrombin deficiency Vascular and connective tissue disorders Gestational diabetes Systemic lupus erythematosus
Cardiovascular concerns
Eclampsia is associated with cardiovascular derangements such as generalized vasospasm, increased peripheral vascular resistance, increased left ventricular stroke work index, decreased central venous pressure, and decreased pulmonary wedge pressure.
Hematologic concerns
Hematologic problems associated with eclampsia can include decreased plasma volume, increased blood viscosity, hemoconcentration, and coagulopathy.
Renal concerns
Eclampsia-associated renal abnormalities can include decreases in glomerular filtration rate, renal plasma flow, and uric acid clearance.
Hepatic concerns
Hepatic derangements associated with eclampsia can include periportal necrosis, hepatocellular damage, and subcapsular hematoma.
Pathophysiology of Eclampsia
Endothelial dysfunction
Factors associated with endothelial dysfunction have been shown to be increased in the systemic circulation of women suffering from eclampsia. These include the following[1] :
Cellular fibronectin Von Willebrand factor Cell adhesion molecules (ie, P-selectin, vascular endothelial adhesion molecule-1 [VCAM-1] Intercellular adhesion molecule-1 [ICAM-1]) Cytokines (ie, interleukin-6 [IL-6]) Tumor necrosis factor- [TNF-]
In addition, it is believed that antiangiogenic factors, such as placental protein fms-like tyrosine kinase 1 (sFlt-1) and activin A, antagonize vascular endothelial growth factor (VEGF).[7] Elevated levels of these proteins cause a reduction of VEGF and induce systemic and local endothelial cell dysfunction.[1] Leakage of proteins from the circulation and generalized edema are sequelae of the endothelial dysfunction and thus a defining factor associated with preeclampsia and eclampsia.
Oxidative stress
Evidence indicates that leptin molecules increase in the circulation of women with eclampsia, inducing oxidative stress, another factor in eclampsia, on cells. (The leptin increase also results in platelet aggregation, most likely contributing to the coagulopathy associated with eclampsia.)[2, 8] Oxidative stress has been found to stimulate the production and secretion of the antiangiogenic factor activin A from placental and endothelial cells.[7] Studies in pregnant mouse models have proposed that there is a dysregulation in the reactive oxygen species (ROS) signaling pathway.[8, 9] Studies also suggest that increased systemic leukocyte activity plays a role in the mediation of oxidative stress, inflammation, and endothelial cell dysfunction. Histochemistry studies indicate that there is predominantly an increase in neutrophil infiltration of vasculature in patients with eclampsia.[9]
Evaluation
Eclampsia always should be considered in a pregnant patient with a seizure episode. A pregnant patient who has been involved in an unexplained trauma (such as a single-vehicle auto accident) and has exhibited seizure activity should be evaluated for eclampsia. Eclampsia can occur during the
antepartum, intrapartum, and postpartum periods. Ninety percent of eclampsia cases occur after 28 weeks' gestation.[2] Preeclampsia can quickly develop into eclampsia. The natural progression of the disease is from symptomatic severe preeclampsia (differentiated from preeclampsia by specific vital signs, symptoms, and laboratory abnormalities) to seizures. Features of eclampsia include the following:
Seizure or postictal state (100%) Headache (80%), usually frontal Generalized edema (50%) Vision disturbance (40%), such as blurred vision and photophobia Right upper quadrant abdominal pain with nausea (20%) Amnesia and other mental status changes
Headache (83%) Hyperactive reflexes (80%) Marked proteinuria (52%) Generalized edema (49%) Visual disturbances (44%) Right upper quadrant pain or epigastric pain (19%)
Before delivery (>70%) Before labor (antepartum) (25%) During labor (intrapartum) (50%) After delivery (postpartum) (25%)
Although patients with severe preeclampsia are at greater risk for seizures, 25% of patients have symptoms consistent with mild preeclampsia before the seizures.
Physical findings
Most patients with eclampsia present with hypertension and seizures, along with some combination of proteinuria and edema. Findings at physical examination may include the following:
Sustained systolic BP greater than 160 mm Hg or diastolic BP greater than 110 mm Hg Tachycardia Tachypnea Rales Mental status changes Hyperreflexia Clonus
Papilledema Oliguria or anuria Localizing neurologic deficits Right upper quadrant or epigastric abdominal tenderness Generalized edema Small fundal height for the estimated gestational age Apprehension
Cervical examination of the patient with eclampsia should not be overlooked, because the delivery mode may largely depend upon the patients cervical status.
Differential Diagnosis
Adrenal Insufficiency and Adrenal Crisis Cerebellar Hemorrhage Cerebral Aneurysms Cerebral Venous Thrombosis Encephalopathy, Hypertensive Encephalitis Gestational Trophoblastic Neoplasia Head Trauma Hyperaldosteronism, Primary Hypertensive Emergencies Hypoglycemia Meningitis Neoplasms, Brain Pregnancy, Preeclampsia Seizures and Epilepsy: Overview and Classification Shock, Septic Stroke, Hemorrhagic Stroke, Ischemic Subarachnoid Hemorrhage Systemic Lupus Erythematosus
Thrombotic Thrombocytopenic Purpura Withdrawal Syndromes Angiomas Cerebral Vasculitis Drug Overdose Metabolic Disorders Undiagnosed Brain Tumors
Diagnostic Overview
Seizures in the first trimester or well into the postpartum period probably are due to CNS pathology and warrant full evaluation, including computed tomography (CT) scanning of the head, lumbar puncture (if clinical evidence of meningitis or concern for hemorrhage exists), determination of electrolyte levels, and urine or serum toxicologic screening. Do not overlook other neurologic causes of seizure, particularly if the seizure occurs more than 24 hours after delivery. In addition, rule out hypoglycemia as cause of seizure or result of seizure, and rule out hyperglycemia as cause of mental status changes. When preeclampsia occurs in the early second trimester (ie, 14-20 weeks' gestation), the diagnosis of hydatiform mole or choriocarcinoma should be considered. Ruling out eclampsia in an obstetric patient who has been involved in an unexplained trauma is important. Immediately consult an obstetrician/gynecologist when the diagnosis of eclampsia is being considered. No single laboratory test or set of laboratory determinations is useful in predicting maternal or neonatal outcome in women with eclampsia. Imaging studies may be indicated after initial stabilization, especially if there is doubt about the diagnosis or possible injuries secondary to seizure activity.
Hematologic Studies
A complete blood cell (CBC) count may reveal the following:
Anemia due to microangiopathic hemolysis, hemoconcentration due to third spacing, or physiologic hemodilution of pregnancy Peripheral smear (schistocytes, burr cells, echinocytes) Increased bilirubin (>1.2 mg/dL)
Thrombocytopenia (< 100,000) due to hemolysis and low platelet count associated with HELLP syndrome (seen in 20-25% of patients with eclampsia)[4] Low serum haptoglobin levels Elevated lactate dehydrogenase (LDH) levels (threshold of 180600 U/L)
The coagulation profile may reveal normal prothrombin (PT) and activated partial thromboplastin (aPTT) times, fibrin split products, and fibrinogen levels. Rule out associated disseminated intravascular coagulation (DIC).
Aspartate aminotransferase (SGOT) level higher than 72 IU/L Total bilirubin levels higher than 1.2 mg/dL LDH level higher than 600 IU/L[2] Elevated levels due to hepatocellular injury and HELLP syndrome
CT Scanning
CT scanning of the head, with or without contrast, can exclude cerebral venous thrombosis, intracranial hemorrhage, and central nervous system lesions, all of which can occur in pregnancy and present with seizures. Consider CT scanning in patients who have been involved in trauma, are refractory to magnesium sulfate therapy, or have atypical presentations (eg, seizures >24 h after delivery). Although obtaining a CT scan in eclampsia is not routine, abnormalities have been observed in up to 50% of women imaged. Characteristic CT scan findings include cortical hypodense areas, particularly in the occipital lobes, and diffuse cerebral edema, which is believed to correspond to petechial hemorrhages and diffuse edema noted in postmortem studies. CT scan findings may include the following:
Cerebral edema Diffuse white matter low-density areas Patchy area of low density Occipital white matter edema Loss of normal cortical sulci Reduced ventricular size Cerebral hemorrhage Intraventricular hemorrhage Parenchymal hemorrhage (high density)
Transabdominal Ultrasonography
Transabdominal ultrasonography is used to estimate gestational age. This may also be used to rule out abruptio placentae, which can complicate eclampsia.
Medical Therapy
Eclamptic convulsions are life-threatening emergencies and require the proper treatment to decrease maternal morbidity and mortality. Delivery is the only definitive treatment for eclampsia. The patient should be advised and educated on the course of the disease and any residual problems. She should also be educated on the importance of adequate prenatal care in subsequent pregnancies. Several organizations have developed screening, treatment, and prevention guidelines for preeclampsia and eclampsia.[11, 12]
Supportive care
Emergency medical services personnel should (1) secure an intravenous (IV) line with a large-bore catheter, (2) initiate cardiac monitoring and administer oxygen, and (3) transport the patient in the left lateral decubitus position. Supportive care for eclamptic convulsions includes the following:
Place the patient in the left lateral position. This positioning decreases the risk of aspiration and will help to improve uterine blood flow by relieving obstruction of the vena cava by the gravid uterus. Protect the patient against injury during the seizure by padding and raising guardrails, using a padded tongue blade between the teeth, and suctioning the oral secretions as needed. After the seizure has ended, a 16- to 18-gauge IV line should be established for drawing specimens and administering fluids and medications. (Fluid management is critical in patients with eclampsia.) IV fluids should be limited to isotonic solutions to replace urine output plus about 700 mL/d to replace insensible losses.
BP should be assessed with the goal of maintaining the diastolic BP at less than 110 mm Hg with administration of antihypertensive medications as needed (eg, hydralazine, labetalol). Keep nothing by mouth (including medications) until the patient is medically stabilized or delivered, because she is at risk for aspiration when postictal and may have recurrent seizures.
Maternal monitoring
Depending on the clinical course, regularly check the patients neurologic status for signs of increased intracranial pressure or bleeding (eg, funduscopic examination, cranial nerves) Monitor fluid intake and urine output, maternal respiratory rate, and oxygenation, as indicated, and continuously monitor fetal status. Pulmonary arterial pressure monitoring is rarely indicated but may be helpful in patients who have evidence of pulmonary edema or oliguria/anuria. Once the seizure is controlled and the patient has regained consciousness, the patients general medical condition should be assessed to identify any other causes for seizures. Induction of labor may be initiated when the patient is stable.
Fetal monitoring
Fetal heart rate and uterine contractions should be continuously monitored. Fetal bradycardia is common following the eclamptic seizure and has been reported to last from 30 seconds to 9 minutes. The interval from the onset of the seizure to the fall in the fetal heart rate is typically 5 minutes or less. Transitory fetal tachycardia may occur following the bradycardia. After the initial bradycardia, during the recovery phase, the fetal heart rate tracing may reveal a loss of short- and long-term variability and the presence of late decelerations. These abnormalities are most likely due to the decrease in uterine blood flow caused by the intense vasospasm and uterine hyperactivity during the convulsion. If the fetal heart tracing does not improve following a seizure, further evaluation should be undertaken. Growth-restricted and preterm fetuses may take longer to recover following a seizure. Placental abruption may be present if uterine hyperactivity remains and fetal bradycardia persists.
complications. When emergent cesarean delivery is indicated, substantiating the absence of coagulopathy before the procedure is important. (See Surgical Therapy.)[16] Intrapartum complications include the following:
Fetal growth retardation (30%) Nonreassuring fetal heart rate patterns (30%) Placental abruption (23%)
Irrespective of gestational age, a prolonged induction with clinically significant worsening of maternal cardiovascular, hematologic, renal, hepatic, and/or neural status is generally an indication for cesarean delivery when the anticipated delivery time is remote.
Surgical Therapy
Cesarean delivery may be necessary for obstetric indications or a deteriorating maternal condition. The patient should be stabilized with respect to seizures, oxygenation, and hemodynamic status before the initiation of cesarean delivery. BP should be controlled and coagulopathies monitored or corrected.
Anesthesia
An anesthesiology consultation may be obtained. Early evaluation is recommended to assist with cardiopulmonary stabilization and to prepare for a possible operative delivery or endotracheal intubation. For nonemergency cesarean delivery, epidural or combined techniques of regional anesthesia are preferred. Regional anesthesia is contraindicated in the presence of coagulopathy or severe thrombocytopenia (< 50,000 platelets/L). General anesthesia in women with eclampsia increases the risk of aspiration, and airway edema may make intubation difficult. It also can produce significant increases in systemic and cerebral pressures during intubation and extubation. The use of spinal anesthesia requires caution because of the possibility of total sympathetic blockade, resulting in maternal hypotension and uteroplacental insufficiency.
Prevention of Preeclampsia/Eclampsia
Preventing the development of preeclampsia in high-risk patients could theoretically decrease the risk of eclampsia and its complications later in pregnancy. Aspirin blocks platelet aggregation and vasospasm in preeclampsia, and it may be effective in preventing preeclampsia. Studies have shown that low-dose aspirin in women at high risk for preeclampsia can contribute to a decreased risk of preeclampsia, a reduction in preterm delivery rates, and a reduction in fetal death rates, without increasing the risk of placental abruption. An obstetrician should directly supervise aspirin therapy in high-risk patients. If the patient has preexisting hypertension, she should have good control before conception and throughout her pregnancy. Her case should be followed for recognition and treatment of preeclampsia.
Complications of Eclampsia
As many as 56% of patients with eclampsia may have transient deficits, including cortical blindness. However, studies have failed to demonstrate evidence of persisting neurologic deficits after uncomplicated eclamptic seizures during the follow-up period.[17] Studies suggest that there is an increased risk for cerebrovascular accidents (CVAs) and coronary artery disease (CAD) in eclamptic mothers later in life.
Other potential complications of eclampsia include the following: Permanent neurologic damage from recurrent seizures or intracranial bleeding Renal insufficiency and acute renal failure Fetal changes IUGR, abruptio placentae, oligohydramnios Hepatic damage and rarely hepatic rupture Hematologic compromise and DIC Increased risk of recurrent preeclampsia/eclampsia with subsequent pregnancy Maternal or fetal death
Outcome
Five percent of patients with hypertension develop severe preeclampsia, and about 25% of women with eclampsia have hypertension in subsequent pregnancies. About 2% of women with eclampsia develop eclampsia with future pregnancies. Multiparous women with eclampsia have a higher risk for the development of essential hypertension; they also have a higher mortality rate in subsequent pregnancies than do primiparous women
Maternal morbidity
Maternal complications from eclampsia include the following:
Permanent CNS damage from recurrent seizures or intracranial bleeds Disseminated intravascular coagulopathy Renal insufficiency Pulmonary edema Cardiopulmonary arrest
The most significant maternal complication of eclampsia is permanent CNS damage secondary to recurrent seizures or intracranial bleeding. The maternal mortality rate is 8-36% in these cases.[14]
Maternal mortality
Eclampsia and preeclampsia account for approximately 63,000 maternal deaths annually worldwide.[18] In developed countries, the maternal death rate is reportedly 0-1.8%. The perinatal mortality rate from eclampsia in the United States and Great Britain ranges from 5.6% to 11.8%. The maternal mortality rate is as high as 14% in developing countries.[5, 15, 17] A study from the US Centers for Disease Control and Prevention (CDC) found an overall preeclampsia/eclampsia case-fatality rate of 6.4 per 10,000 cases at delivery. The study also found a particularly high risk of maternal death at 20-28 weeks gestation.[19] Black woman have twice the risk that white women have for mortality associated with preeclampsia/eclampsia. This is most likely due to inadequate access to prenatal care among black
women, as well as to increased incidences in black women of genetic diseases associated with circulating antiphospholipids. It has been proven that patients with elevated antiphospholipid plasma levels have a higher incidence of preeclampsia and eclampsia.[2] However, whether this is due to the antiphospholipids themselves or to some other underlying process is not clear.[6] A majority of women who suffer eclampsia-associated death have concurrent HELLP syndrome.[18] A report of an international study demonstrated that serious complications among patients with eclampsia (including maternal mortality) may be predicted by the use of a model that incorporates gestational age, chest pain or dyspnea, oxygen saturation, platelet count, and creatinine and aspartate transaminase concentrations. Although clinical use of the model awaits future validation, the identification of the predictive variables may aid in management decisions.[20]
Fetal/neonatal mortality
The fetal mortality rate varies from 13-30% due to premature delivery and its complications. Placental infarcts, abruptio placentae, intrauterine growth retardation, and fetal hypoxia also contribute to fetal demise.[2]