Eclampsia is the occurrence of seizures or coma in a woman with preeclampsia, occurring at >20 wk of gestation or <48 hr postpartum. Atypical eclampsia occurs at <20 wk of gestation or as much as 14 days postpartum.
PHYSICAL FINDINGS & CLINICAL PRESENTATION
• Seizure begins as facial twitching, then spreads to generalized clonicotonic state, with cessation of respiration followed by a postictal period of amnesia, agitation, and confusion.
• 40% have severe hypertension, 40% have mild to moderate hypertension, and 20% are normotensive.
• Generalized edema with rapid weight gain (>2 lb/wk) may be one of the earliest signs of eclampsia.
• Persistent occipital headache and hyperreflexia with clonus occur in 80% of patients with eclampsia; epigastric pain occurs in 20% of these patients.
• Exact etiology unknown.
• Common pathway relates to abnormalities in autoregulation of cerebral blood flow. This may involve transient vasospasm, ischemia, cerebral hemorrhage, and edema occurring by a mechanism involving hypertensive
encephalopathy, decreased colloid osmotic pressure, and prostaglandin imbalance.
• Proteinuria: severe (49%), mild to moderate (29%), absent (22%)
• HCT: elevated as a result of hemoconcentration
• Platelet count: decreased; LFTs elevated in HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count)
• BUN and creatinine: elevated with renal involvement
• Serum electrolytes, glucose, calcium, toxicology profile: rule out other causes of seizures
• Hyperuricemia: >6.9 mg/dl found in 70% of eclamptics
• ABG: maternal acidemia and hypoxia.
• CT scan or MRI indicated in atypical presentation, suspected intracerebral bleeding, or focal neurologic deficit.
• There are abnormal findings, including cerebral edema, hemorrhage, and infarction, in 50% of patients.
• Airway protection (risk of aspiration)
• Supportive care during acute event
ACUTE GENERAL Rx
• Maintain airway, adequate oxygenation, and IV access.
• Fetal resuscitation, involving maternal oxygenation, left lateral positioning, and continuous fetal heart rate monitoring, is needed.
• Magnesium sulfate is the drug of choice. Give magnesium sulfate 6 g IV load over 20 min, then 3 g/hr maintenance, for recurrent seizure prophylaxis. If repeated convulsions, may give an additional 2 g IV over 3 to 5 min. Approximately 10% to 15% of patients will have a second seizure after initial loading dose. Check magnesium level 1 hr after loading dose, then q6h (therapeutic range 4 to 6 mg/dl). Antidote for toxicity is calcium gluconate 10 ml of 10% solution. Phenytoin has been used as an alternative in patients in whom magnesium sulfate is contraindicated
(renal insufficiency, heart block, myasthenia gravis, hypoparathyroidism).
• Give sodium amobarbital 250 mg IV over 3 min for persistent seizures.
• Treat blood pressure if >160 mm Hg/110 mm Hg with labetalol 20- to 40-mg IV bolus, hydralazine 10 mg IV, or nifedipine 10 to 20 mg sublingual q20min.
• Evaluate patient for delivery.
• The first priority is stabilization of the mother in terms of adequate oxygenation, hemodynamics, and laboratory abnormalities, such as associated coagulopathies.
• Cervical status and gestational age should be assessed. If unfavorable cervix and <30 wk of gestation, consider C-section; otherwise consider induction.
• Controlled epidural is the anesthesia of choice for labor or C-section.
• Avoid general anesthesia in uncontrolled hypertension to minimize risk of catastrophic cerebral events.