Postpartum Eclampsia

Postpartum eclampsia is a generalised seizure after delivery in a woman with preeclampsia, occurring within hours to 6 weeks of birth. A substantial share of eclampsia occurs after delivery, most within 48 hours. Many women had no antenatal hypertension, so it is easily missed at discharge.

• Risk factors: severe preeclampsia, HELLP syndrome, no magnesium sulphate during labour, delayed antenatal care.
• Seizures after 48 hours need brain imaging for other causes.
• Magnesium sulphate remains the drug of choice.

A woman who has delivered presents with a seizure, often preceded by severe headache, visual disturbance, epigastric pain and high blood pressure. Some have no warning.

• Blood pressure 140/90 mmHg or more.
• Headache and visual change in the days after birth.
• Differential diagnosis: cerebral venous thrombosis, posterior reversible encephalopathy syndrome, stroke, post-dural puncture headache with seizure, epilepsy, cerebral malaria, meningitis, hyponatraemia, hypoglycaemia, thrombotic thrombocytopenic purpura.
• Complications: aspiration, stroke, cerebral oedema, pulmonary oedema, acute kidney injury, HELLP syndrome, venous thrombosis, maternal death.

The diagnosis is clinical, with brain imaging when the picture is atypical.

• Blood pressure, urine protein, temperature, glucose, sodium; malaria test.
• Full blood count and film, creatinine, liver enzymes, lactate dehydrogenase, coagulation screen.
• CT or MRI with venography of the brain for seizures after 48 hours, focal deficit, persistent headache, or no response to magnesium.
• Lumbar puncture if fever with neck stiffness.

The principle is airway protection, magnesium sulphate and blood pressure control, with a search for other causes if onset is late.

• Supportive: left lateral position; protect the airway; oxygen 10 to 15 L/minute; two cannulae; urinary catheter with hourly output; total fluids 80 mL per hour; admit to high dependency care.
• Pharmacological: magnesium sulphate 4 g IV over 20 minutes then 1 g per hour for 24 hours after the last seizure, or where infusion is not possible give 4 g IV plus 10 g IM (5 g in each buttock) then 5 g IM 4-hourly; for a repeat seizure give 2 g IV over 5 minutes; stop for absent reflexes, respiratory rate below 12 per minute or urine below 30 mL per hour and give calcium gluconate 1 g IV over 10 minutes for toxicity; labetalol 20 mg IV over 2 minutes then 40 mg, 80 mg and 80 mg at 10 minute intervals (maximum 220 mg) or nifedipine immediate release 10 mg oral repeated once after 30 minutes or hydralazine 5 mg IV then 5 to 10 mg every 20 to 30 minutes (maximum 20 mg); then nifedipine modified release 30 to 60 mg oral once daily (maximum 120 mg) or enalapril 5 mg oral once daily increased to 20 mg (maximum 40 mg) for ongoing control; furosemide 20 mg oral daily for 5 days for fluid overload; enoxaparin 40 mg subcutaneous daily if cerebral venous thrombosis or reduced mobility, increased to 1 mg/kg 12-hourly for confirmed thrombosis; ibuprofen avoided if blood pressure is high or kidney function is poor; paracetamol 1 g oral 6-hourly (maximum 4 g in 24 hours).
• Procedures: brain imaging; intubation for coma; evacuation of retained products if bleeding or sepsis suggests it.
• Special groups: breastfeeding is compatible with magnesium sulphate, nifedipine, labetalol and enalapril; kidney disease reduces magnesium sulphate to 0.5 g per hour with level monitoring.
• Red flags: repeated seizures, persistent headache, focal deficit, blood pressure 160/110 mmHg or more, saturation below 94 percent, oliguria, heavy bleeding.
• Follow-up: blood pressure at 6 hours, daily in hospital and weekly to 6 weeks; wean antihypertensives slowly; neurological review at 6 weeks; annual blood pressure, glucose and lipids.