Eclampsia
Eclampsia | |
---|---|
hypertensive diseases of pregnancy (2015)[6] |
Eclampsia is the onset of
The diagnostic criterion for pre-eclampsia is high blood pressure, occurring after 20 weeks gestation or during the second half of pregnancy.
Low dose
Signs and symptoms
Eclampsia is a disorder of pregnancy characterized by seizures in the setting of pre-eclampsia.[17] Most women have premonitory signs/symptoms in the hours before the initial seizure. Typically the woman develops hypertension before the onset of a convulsion (seizure).[18] Other signs and symptoms to looks out for include:[19]
- Long-lasting (persistent) frontal or occipital headaches or thunderclap headaches)[20]
- Visual disturbance (blurred vision, photophobia, diplopopia)
- Photophobia (i.e. bright light causes discomfort)
- Abdominal pain
- Either in the epigastric region (the center of the abdomen above the navel, or belly-button)
- And/or in the right upper quadrant of the abdomen (below the right side of the rib cage)
- Altered mental status (confusion)
Any of these symptoms may be present before or after the seizure.[21] It is also possible for the woman to be asymptomatic prior to the onset of the seizure.
Other cerebral signs that may precede the convulsion include nausea, vomiting, headaches, and cortical blindness. If the complication of multi-organ failure ensues, signs and symptoms of those failing organs will appear, such as abdominal pain, jaundice, shortness of breath, and diminished urine output.
Onset
The seizures of eclampsia typically present during pregnancy and prior to delivery (the antepartum period),[22] but may also occur during labor and delivery (the intrapartum period) or after the baby has been delivered (the postpartum period).[17][21][23] If postpartum seizures develop, it is most likely to occur within the first 48 hours after delivery. However, late postpartum seizures of eclampsia may occur as late as 4 weeks after delivery.[17][21]
Characteristics
Eclamptic seizure is typically described as a tonic–clonic seizure which may cause an abrupt loss of consciousness at onset.[24] This is often associated with a shriek or scream followed by stiffness of the muscles of the arms, legs, back and chest. During the tonic phase, the mother may begin to appear cyanotic. This presentation lasts for about a minute, after which the muscles begin in jerk and twitch for an additional one to two minutes.[25] Other signs include tongue biting, frothy and bloody sputum coming out of the mouth.[26]
Complications
There are risks to both the mother and the
In the mother, changes in vision may occur as a result of eclampsia, and these changes may include blurry vision, one-sided blindness (either temporary due to
Risk factors
Eclampsia, like pre-eclampsia, tends to occur more commonly in first pregnancies than subsequent pregnancies.
Mechanism
The mechanisms of eclampsia and preeclampsia are not definitively understood, but following provides some insight. The presence of a
Hypoperfusion of the placenta is associated with abnormal modelling of the fetal–maternal placental interface that may be immunologically mediated.[45] The pathogenesis of pre-eclampsia is poorly understood and may be attributed to factors related to the woman and placenta since pre-eclampsia is seen in molar pregnancies absent of a fetus or fetal tissue.[46] The placenta normally produces the potent vasodilator adrenomedullin but it is reduced in pre-eclampsia and eclampsia.[47] Other vasodilators, including prostacyclin, thromboxane A2, nitric oxide, and endothelins, are reduced in eclampsia and may lead to vasoconstriction.[30]
Eclampsia is associated with
Diagnosis
If a pregnant woman has already been diagnosed with pre-eclampsia during the current pregnancy and then develops a seizure, she may be assigned a 'clinical diagnosis' of eclampsia without further workup. While seizures are most common in the third trimester, they may occur any time from 20 weeks of pregnancy until 6 weeks after birth.[50] Because pre-eclampsia and eclampsia are common conditions in women, eclampsia can be assumed to be the correct diagnosis until proven otherwise in pregnant or postpartum women who experience seizures.[51] However, if a woman has a seizure and it is unknown whether or not they have pre-eclampsia, testing can help make the diagnosis clear.
Pre-eclampsia is diagnosed when repeated blood pressure measurements are greater or equal to 140/90mmHg, in addition to any signs of organ dysfunction, including: proteinuria, thrombocytopenia, renal insufficiency, impaired liver function, pulmonary edema, cerebral symptoms, or abdominal pain.[52]
Vital signs
One of the core features of pre-eclampsia is the new onset of high blood pressure. Blood pressure is a measurement of two numbers: systolic blood pressure and diastolic blood pressure. A systolic blood pressure (the top number) of greater than 140 mmHg and/or a diastolic blood pressure (the bottom number) of greater than 90 mmHg is higher than the normal range. If the blood pressure is high on at least two separate occasions after the first 20 weeks of pregnancy and the woman has signs of organ dysfunction (e.g. proteinuria), then they meet the criteria for a diagnosis of pre-eclampsia.[33] If the systolic blood pressure is greater than 160 or the diastolic pressure is greater than 110, the hypertension is considered to be severe.[17]
Laboratory testing
Another common feature of pre-eclampsia is proteinuria, which is the presence of excess protein in the urine. To determine if proteinuria is present, the urine can be collected and tested for protein; if there is 0.3 grams of protein or more in the urine of a pregnant woman collected over 24 hours, this is one of the diagnostic criteria for pre-eclampsia and raises the suspicion that a seizure is due to eclampsia.[17]
In cases of severe eclampsia or pre-eclampsia, the woman can have low levels of platelets in the blood, a condition termed thrombocytopenia.[53][30] A complete blood count, or CBC, is a test of the blood that can be performed to check platelet levels.
Other investigations include:
Differential diagnosis
Convulsions during pregnancy that are unrelated to pre-eclampsia need to be distinguished from eclampsia. Such disorders include seizure disorders as well as brain tumor, aneurysm of the brain, and medication- or drug-related seizures. Usually, the presence of the signs of severe pre-eclampsia precede and accompany eclampsia, facilitating the diagnosis.[36]
Prevention
Detection and management of pre-eclampsia is critical to reduce the risk of eclampsia. The
Treatment
The four goals of the treatment of eclampsia are to stop and prevent further convulsions, to control the elevated blood pressure, to deliver the baby as promptly as possible, and to monitor closely for the onset of
Convulsions
Convulsions are prevented and treated using magnesium sulfate.[56] The study demonstrating the effectiveness of magnesium sulfate for the management of eclampsia was first published in 1955.[57] Effective anticonvulsant serum levels range from 2.5 to 7.5 mEq/L,[58] however the ideal dosing regime (dose, route of administration, timing of dosing) to prevent and treat eclampsia is not clear.[59]
With intravenous administration, the onset of anticonvulsant action is fast and lasts about 30 minutes. Following intramuscular administration the onset of action is about one hour and lasts for three to four hours. Magnesium is excreted solely by the kidneys at a rate proportional to the plasma concentration (concentration in the blood) and glomerular filtration (rate at which the blood is filtered through the kidneys).[58] Magnesium sulfate is associated with several minor side effects; serious side effects are uncommon, occurring at elevated magnesium serum concentrations greater than 7.0 mEq/L. Serious toxicity can be counteracted with calcium gluconate.[60]
Even with therapeutic serum magnesium concentrations, recurrent convulsions may occur, and additional magnesium may be needed, but with close monitoring for respiratory, cardiac, and neurological depression. If magnesium administration with resultant high serum concentrations fails to control convulsions, the addition of other intravenous
Magnesium sulfate results in better outcomes than diazepam, phenytoin or a combination of chlorpromazine, promethazine, and pethidine.[61][62][63]
Blood pressure management
Blood pressure is controlled to prevent stroke, which accounts for 15 to 20 percent of deaths in women with eclampsia.[64] Common drugs used for blood pressure control during eclampsia are hydralazine or labetalol,[30] due to their effectiveness, lack of negative effects on the fetus, and mechanism of action. Blood pressure management is indicated with a diastolic blood pressure above 105–110 mm Hg.[32] Normal blood pressure levels for pregnant women vary between trimesters and as so blood pressure management will be tailored accordingly.[65]
Delivery
If the baby has not yet been delivered, steps need to be taken to stabilize the woman and deliver her speedily. This needs to be done even if the baby is immature, as the eclamptic condition is unsafe for both baby and mother. As eclampsia is a manifestation of a type of non-infectious multiorgan dysfunction or failure, other organs (liver, kidney, lungs, cardiovascular system, and coagulation system) need to be assessed in preparation for a delivery (often a caesarean section), unless the woman is already in advanced labor. Regional anesthesia for caesarean section is contraindicated when a coagulopathy has developed.
There is limited to no evidence in favor of a particular delivery method for women with eclampsia. Therefore, the delivery method of choice is an individualized decision.[31]
Monitoring
Invasive hemodynamic monitoring may be elected in an eclamptic woman at risk for or with heart disease, kidney disease, refractory hypertension, pulmonary edema, or poor urine output.[30]
Etymology
The
Notable deaths from eclampsia
- Tori Bowie (fetus died too)[68][69]
Popular culture
- In Downton Abbey, a historical drama television series, the character Lady Sybil dies (in series 3, episode 5) of eclampsia shortly after child birth.[70]
- In Call the Midwife, a medical drama television series set in London in the 1950s and 1960s, the character (in series 1, episode 4) named Margaret Jones is struck with pre-eclampsia, ultimately proceeding from a comatose condition to death. The term "toxemia" was also used for the condition, in the dialogue.[71]
- In House M.D., a medical drama television series set in the U.S., Dr. Cuddy, the hospital director, adopts a baby whose teenage mother dies from eclampsia and had no other parental figures available.[72]
- In The Lemon Drop Kid, the main character's wife dies of eclampsia shortly after giving birth to a boy.
- In Fringe, a science fiction series, the character Olivia (in the parallel universe) is diagnosed with a fictionalized version of the disorder, called "viral-propagated eclampsia", which threatens her and her unborn child (series 3, episode 18).[73]
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- ^ "Olympic medallist Tori Bowie's cause of death revealed to be childbirth complications". ABC News. 13 June 2023.
- ^ "Tori Bowie, an elite Olympic athlete, died of complications from childbirth". NPR.
- ^ Stone, Rachel Marie (January 30, 2013). "Stop With All the Dangerous Childbirth Stories Already". Christianity Today. Archived from the original on March 11, 2016. Retrieved March 11, 2016.
- ^ "Episode #1.4". 5 February 2012. Archived from the original on 10 September 2017. Retrieved 4 September 2016 – via IMDb.
- ^ "House" Joy to the World (TV Episode 2008) - IMDb, retrieved 2021-10-02
- ^ "Fringe" Bloodline (TV Episode 2011) - IMDb, retrieved March 23, 2023
External links
- Eclampsia at Curlie