Eclampsia

Occurrence of generalized tonic-clonic seizures in a woman with pre-eclampsia (new-onset hypertension + proteinuria and/or other organ dysfunction after 20 weeks gestation), not attributable to other causes.

Represents the severe end of the pre-eclampsia/HELLP spectrum, a hypertensive emergency of pregnancy with significant maternal and fetal mortality risk. Can occur antepartum, intrapartum, or postpartum (up to 6 weeks, though most occur within 48 hours).

Pre-eclampsia severity features indicating progression risk: severe hypertension (≥160/110), severe headache, visual disturbance (scotomata, blurred vision), epigastric/RUQ pain, hyperreflexia/clonus, rapidly worsening renal function, pulmonary edema, HELLP features (Hemolysis, Elevated Liver enzymes, Low Platelets).

• Generalized tonic-clonic seizure, typically preceded by (though sometimes without) warning signs: severe headache, visual disturbance, epigastric pain, hyperreflexia/clonus, sudden severe hypertension
• Post-ictal confusion/drowsiness as with any generalized seizure
• May occur with BP not extremely elevated — eclampsia can occur even with only mild-moderately elevated BP, so absence of severe hypertension does not exclude the diagnosis
• Signs of associated HELLP/severe pre-eclampsia: RUQ/epigastric tenderness, jaundice, easy bruising/petechiae, oliguria
• Fetal status: assess for distress (abnormal CTG); placental abruption can coexist (vaginal bleeding, abdominal pain, uterine tenderness)
• Complications: HELLP syndrome, DIC, placental abruption, acute kidney injury, pulmonary edema, cerebral hemorrhage (leading cause of eclampsia-related death), hepatic rupture, aspiration pneumonia

Primarily clinical — a new seizure in a pregnant or recently postpartum woman with hypertension/proteinuria is eclampsia until proven otherwise; treatment should not be delayed for extensive workup.

• BP measurement, urinalysis (proteinuria — though not required for diagnosis if other severe features present)
• FBC (platelets — thrombocytopenia in HELLP), LFTs (elevated transaminases), U&E/creatinine, coagulation profile if HELLP/abruption suspected
• Uric acid: often elevated, supportive but not diagnostic
• LDH, peripheral blood film (schistocytes — microangiopathic hemolysis)
• CTG: assess fetal wellbeing once mother stabilized
• CT/MRI head: NOT routinely required if typical eclamptic seizure with prompt recovery — reserved for atypical presentation (focal deficit, onset >48h postpartum, refractory to magnesium, diagnostic uncertainty) to exclude hemorrhage, PRES, venous sinus thrombosis

Differentials: epilepsy, other causes of seizure in pregnancy (hypoglycemia, electrolyte disturbance, cerebral venous sinus thrombosis, PRES, intracranial hemorrhage, TTP) — consider particularly if atypical features (focal deficit, seizure before 20 weeks, very late postpartum onset, poor response to magnesium).

Immediate priorities — ABC, protect airway, prevent injury:

• Position in left lateral position (reduces aortocaval compression, protects airway)
• Oxygen, suction as needed, protect from injury (do not restrain forcefully)
• Most eclamptic seizures are self-limiting within 1-2 minutes

Magnesium sulfate — the definitive treatment, for both acute seizure control AND prevention of further seizures (superior to benzodiazepines/phenytoin for this indication):

• Loading dose: 4g IV over 5-10 minutes (or 4-6g per local protocol)
• Maintenance infusion: 1g/hour IV, continued for 24 hours after the last seizure or after delivery, whichever is later
• If further seizure despite magnesium: additional bolus 2g IV
• Monitor for magnesium toxicity — narrow therapeutic window: deep tendon reflexes hourly (loss of reflexes is the earliest sign), respiratory rate (maintain >12/min), urine output (≥25mL/hour — magnesium is renally excreted and accumulates in oliguria)
• Antidote for toxicity: calcium gluconate 10mL of 10% solution IV over 10 minutes

BP control (severe hypertension, ≥160/110):

• IV labetalol (10-20mg bolus, repeat/double every 10 min to max 80mg per dose or start infusion), or
• IV hydralazine (5-10mg bolus, repeat every 20-30 min), or
• Oral nifedipine (10mg immediate-release) if IV access delayed
• Target: gradual reduction, avoid precipitous drops (uteroplacental perfusion) — SBP 140-150, DBP 90-100

Definitive management — delivery:

• Eclampsia is an indication for delivery once the mother is stabilized — delivery is the only definitive cure
• Mode per obstetric factors; vaginal delivery not contraindicated by eclampsia alone if maternal/fetal condition allows
• Do NOT delay delivery to achieve an arbitrary gestational age once mother stabilized — maternal condition takes priority
• Continue magnesium through delivery and postpartum

Fluid management: cautious, restricted to avoid pulmonary edema — typically total fluids limited to 80mL/hour or 1mL/kg/hr unless significant hemorrhage.

Postpartum monitoring: close BP/neurological/renal monitoring for at least 24-48 hours postpartum, watch for HELLP progression.

Referral: obstetric emergency — senior obstetrician, anesthetist, and neonatal team from presentation; ICU/HDU for severe cases; neurology if atypical features.