Clinical Review

Managing an eclamptic patient

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Most Ob/Gyns have little experience managing acute eclampsia, but all maternity units and obstetricians need to be prepared to diagnose and manage this grave threat.


 

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An eclamptic convulsion is frightening to behold. First, the woman’s face becomes distorted, and her eyes protrude. Then her face acquires a congested expression, and foam may exude from her mouth. Breathing stops.

Because eclampsia is so frightening, the natural tendency is to try to stop a convulsion, but this is not the wisest strategy.

Rather, the foremost priorities are to avoid maternal injury and support cardiovascular functions. How to do this, and how to prevent further convulsions, monitor and deliver the fetus, and avert complications are the focus of this article.

Since eclampsia may be fatal for both mother and fetus, all labor and delivery units and all obstetricians should be prepared to diagnose and manage this grave threat. However, few obstetric units encounter more than 1 or 2 cases a year; most obstetricians have little or no experience managing acute eclampsia. In the Western world, it affects only 1 in 2,000 to 1 in 3,448 pregnancies.1-4

How a convulsion happens

Most convulsions occur in 2 phases and last for 60 to 75 seconds. The first phase, lasting 15 to 20 seconds, begins with facial twitching, soon followed by a rigid body with generalized muscular contractions.

In the second phase, which lasts about a minute, the muscles of the body alternately contract and relax in rapid succession. This phase begins with the muscles of the jaw and rapidly encompasses eyelids, other facial muscles, and body. If the tongue is unprotected, the woman often bites it.

Coma sometimes follows the convulsion, and deep, rapid breathing usually begins as soon as the convulsion stops. In fact, maintaining oxygenation typically is not a problem after a single convulsion, and the risk of aspiration is low in a well managed patient.

Upon reviving, the woman typically remembers nothing about the seizure.

If convulsions recur, some degree of consciousness returns after each one, although the woman may become combative, agitated, and difficult to control.

Harbingers of complications

In the developed world, eclampsia increases the risk of maternal death (range: 0 to 1.8%).1-5 A recent review of all reported pregnancy-related deaths in the United States from 1979 to 1992 found 4,024 cases.6 Of these, 790 (19.6%) were due to preeclampsia-eclampsia, 49% of which were caused by eclampsia. The risk of death from preeclampsia or eclampsia was higher for the following groups:

  • women over 30,
  • no prenatal care,
  • African Americans, and
  • onset of preeclampsia or eclampsia before 28 weeks.6

Maternal morbidity

Pregnancies complicated by eclampsia also have higher rates of maternal morbidity such as pulmonary edema and HELLP syndrome (TABLE 1). Complications are substantially higher among women who develop antepartum eclampsia, especially when it is remote from term.1-3

TABLE 1

Maternal complications

Antepartum eclampsia, especially when it is remote from term, is much more likely to lead to complications

COMPLICATIONRATE (%)REMARKS
Death0.5-–2Risk of death is higher:
  • Older than 30 years of age
  • No prenatal care
  • African Americans
  • Onset of preeclampsia or eclampsia before 28 weeks’ gestation
Intracerebral hemorrhage<1Usually related to several risk factors
Aspiration pneumonia2–3Heightened risk of maternal hypoxemia and acidosis
Disseminated coagulopathy3–5Regional anesthesia is contraindicated in these patients, and there is a heightened risk of hemorrhagic shock
Pulmonary edema3–5Heightened risk of maternal hypoxemia and acidosis
Acute renal failure5–9Usually seen in association with abruptio placentae, maternal hemorrhage, and prolonged maternal hypotension
Abruptio placentae7–10Can occur after a convulsion; suspect it if fetal bradycardia or late decelerations persist
HELLP syndrome10–15

Adverse perinatal outcomes

Perinatal mortality and morbidity are high in eclampsia, with a perinatal death rate in recent series of 5.6% to 11.8%.1,7 This high rate is related to prematurity, abruptio placentae, and severe growth restriction.1

Preterm deliveries occur in approximately 50% of cases, and about 25% occur before 32 weeks’ gestation.1

Diagnosis can be tricky

When the patient has generalized edema, hypertension, proteinuria, and convulsions, diagnosis of eclampsia is straightforward. Unfortunately, women with eclampsia exhibit a broad spectrum of signs, ranging from severe hypertension, severe proteinuria, and generalized edema, to absent or minimal hypertension, nonexistent proteinuria, and no edema (TABLE 2).1

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