- These are rare but truly emergent conditions of both pre- and post-partum women, with documented cases of both found up to 6 weeks postpartum!
- Pregnant pt >20wks is pre-eclamptic if…
- +HTN (>140/90)
- Proteinuria (>300mg/24h)
- You won’t diagnose this in the ED, but a dip w/ large protein is indicative
- If <20wks with HTN and proteinuria likely has a molar pregnancy
- 16% of pts w/ eclampsia may not have HTN, 38% might not have proteinuria!
- Mattar, F, Sibai BM. Eclampsia. VIII. Risk Factors for maternal morbidity. Am J Ob Gyn. 1990;163:1049-55.
- Douglas KA, Redman CW. Eclampsia in the United Kingdom. BMJ. Nov 26 1994;309(6966):1395-400
- Pre-eclampsia + seizure = eclampsia
- Seizure not secondary to…
About the Seizure
- 80% of seizures occur intrapartum or w/in 48h postpartum
- Seizure is classically tonic-clonic and triphasic…
- Phase 1: 15-20sec, begins w/ facial twitching, body becomes rigid, leading to generalized muscular contractions
- Phase 2: ~60 sec, starting in the jaw, moves to the muscles of the face and eyelids, and then spreads throughout the body
- Typically there is a cessation of breathing during this phase
- Phase 3: Coma or post-ictal state with hopeful recovery to confused or normal state, but patient will have no recollection of even
- May have hyperventilation to compensate for previous breath-holding
Pathogenesis
- Eclamptic pts have insufficient uteroplacental arterial development and there is an imbalance in vascular growth factors
- Endothelial dysfunction is prominent in the brain and kidneys and increased leptin levels increase oxidative stress and neutrophil invasion into blood vessels and subsequent destruction
- Decreased cerebral blood flow due to HTN, along with increased vascular permeability subsequently leads to cerebral edema and encephalopathy
Clinical Features
- Headache (80%, usually frontal)
- Generalized edema (50%)
- Visual disturbances (30-40%, usually photophobia or blurred vision)
WORKUP |
DIFFERENTIAL |
POC Tests: dexi, pulse ox, udip |
Adrenal insufficiency/crisis |
|
Intracranial pathology (stroke, tumor…) |
Labs: CBC+smear, DIC panel (coags, fibrin split products, haptoglobin, LDH), CMP, lactate, protein/Cr ratio (urine) helps the floor |
Sepsis |
|
Hypoglycemia |
Imaging: CT Head (not routine, but 50% of women imaged show abnormalities) |
Drugs/EtOH (or withdrawal) |
Diagnostics: Continuous fetal monitoring |
Metabolic derangement |
Management:
- IV, O2, monitor, advanced airway equipment to the bedside
- Activate OB early (delivery is the only cure)
- Move pt to left lateral decubitus position and pad gurney
- Medications…
- Sz first line: Mag sulfate (load 6mg over 20min, then 2g/h gtt)
- If seizing after initial bolus, additional 2g bolus can be given
- Monitor DTRs for signs of toxicity and consider Ca if decreased
- 85% of seizure activity responds to Mag alone
- Sz second line: BZDs or phenytoin
- HTN: Hydralazine (5-10mg) or labetalol (20-40mg q15min prn)
- Ensure sBP>90 (will cause placental insufficiency)
- If <32wks gestation: betamethasone (12 mg IM q24h × 2 doses) or dexamethasone (6 mg IM q12h × 4 doses) for fetal lung development