Eclampsia

Eclampsia is the onset of fits (convulsions) in a woman whose pregnancy is usually complicated by pre-eclampsia. The fits may occur in pregnancy after 20 weeks gestation, in labour, or during the first 48 hours of the postpartum period. Pre-eclampsia and eclampsia are part of the same disorder with eclampsia being the severe form of the disease.

Pre-eclampsia almost always precedes eclampsia. However, not all cases follow an orderly progression from mild to severe disease and some women develop severe pre-eclampsia or eclampsia very suddenly. Most cases of eclampsia present in the third trimester of pregnancy, with about 80% of eclamptic seizures occurring intrapartum (during labour) or within the first 48 hours following delivery.

Among the hypertensive disorders, preeclampsia and eclampsia have the greatest impact on maternal and newborn morbidity and mortality. Nearly one-tenth of maternal deaths in Asia and Africa and one-quarter of maternal deaths in Latin America are associated with hypertensive disorders of pregnancy. Eclampsia accounts for 12% of all maternal deaths in developing countries.

Eclampsia is also an important etiological factor for maternal/perinatal morbidity and mortality in India. In a study from a large population-based nationally representative sample of women in India, out of 4925 live births during the study period, there were 158 women with eclampsia, giving an incidence of 3.2 %. *

Majority of deaths related to pre-eclampsia and eclampsia could be avoided by timely and effective antenatal care and hospital delivery.

References-

https://apps.who.int/iris/bitstream/handle/10665/44145/9789241546669_2_eng.pdf?sequence=2

https://www.acog.org/~/media/Task%20Force%20and%20Work%20Group%20Reports/public/HypertensioninPregnancy.pdf

https://emedicine.medscape.com/article/253960-overview

Nobis P.N., Hajong Anupama, Eclampsia in India Through the Decades, J Obstet Gynaecol India; 2016 Oct; 66(Suppl 1): 172–176, accessed from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5016424/

https://apps.who.int/iris/bitstream/handle/10665/119627/WHO_RHR_14.17_eng.pdf;jsessionid=72FF177A0C847E7B7B8DA5DD77ABAC6D?sequence=1

https://apps.who.int/iris/bitstream/handle/10665/44703/9789241548335_eng.pdf?sequence=1

*Agrawal S. et al, Prevalence of and risk factors for eclampsia in pregnant women in India, Family Medicine and Community Health 2017;5(4):225–244 accessed from http://fmch-journal.org/prevalence-risk-factors-eclampsia-pregnant-women-india/

 

 

Eclampsia is the onset of fits in a woman whose pregnancy is usually complicated by pre-eclampsia. The fits may occur in pregnancy after 20 weeks gestation, in labour, or during the first 48 hours of the postpartum period.

Symptoms and signs of severe preeclampsia such as: diastolic blood pressure 90mm Hg or more after 20 weeks gestation, hyper-reflexia, headache (increasing frequency, unrelieved by regular analgesics), clouding of vision, oliguria (passing less than 400ml urine in 24 hours), upper abdominal pain (epigastric pain or pain in right upper quadrant), difficulty in breathing (pulmonary oedema) may precede eclamptic fit.

Stages of an eclamptic fit:

Premonitary stage: This lasts 10–20 seconds, during which:

  • the eyes roll or stare
  • the face and hand muscles may twitch.

Tonic stage: This lasts up to 30 seconds, during which:

  • the muscles go into violent spasm
  • the fists are clenched and arms and legs are rigid
  • the diaphragm (which is a muscle separating the chest from the abdomen) is in spasm, so that breathing stops and the colour of the skin becomes blue or dusky (cyanosis)
  • the back may be arched
  • the teeth are clenched
  • the eyes bulge.

Clonic stage: This lasts 1–2 minutes and is marked by:

  • violent contraction and relaxation of the muscles
  • increased saliva causes “foaming” at the mouth and there is a risk of inhalation
  • deep, noisy breathing
  • the face looks congested (filled with blood) and swollen.

Coma stage: This may last for minutes or hours. The woman is deeply unconscious and often breathes noisily. The cyanosis fades but her face may still be swollen and congested. Further fits may occur. The woman may die after only one or two fits.

References-

https://apps.who.int/iris/bitstream/handle/10665/44145/9789241546669_2_eng.pdf?sequence=2

https://www.nhp.gov.in/disease/gynaecology-and-obstetrics/preeclampsia

 

 

The causes of preeclampsia and eclampsia are not known.

The common pathophysiology of preeclampsia results from:

1. Vasoconstriction with exaggerated response to vasoactive substances.

2. Plasma volume reduction due to capillary leakage and redistribution and shift of the extracellular volume from the intravascular to the interstitial compartments

3. Platelet aggregation triggered by endothelial dysfunction which leads to intravascular thrombosis.

These three factors cause reduced perfusion of the brain, liver, kidneys, and the utero-placental complex and causing organ failure that endangers the lives of mother and fetus.

Effects on the mother:

These include:

  • Respiratory problems (asphyxia, aspiration of vomit, pulmonary oedema, broncho-pneumonia)
  • Hepatic disease (liver necrosis)
  • Renal complications (acute kidney failure)
  • Visual disturbances (temporary blindness due to oedema of the retina)
  • Effects on the brain (haemorrhage, thrombosis, oedema)
  • Cardiac problems (heart failure)
  •  HELLP syndrome (haemolysis, elevated liver enzymes, low platelet count)
  • Coagulopathy (clotting/coagulation failure)
  • Injuries during convulsions (fractures). The main causes of maternal death in eclampsia are intracerebral haemorrhage, pulmonary complications, kidney failure, liver failure and failure of more than one organ (e.g. heart + liver + kidney).

Effects on the fetus:

Pre-eclampsia is associated with a reduction in maternal placental blood flow which results in:

  • Hypoxia which may cause brain damage if severe or prolonged, and can result in physical or mental disability.
  • Intrauterine growth retardation (IUGR)
  • In severe cases the baby may be stillborn.

 

Risk factors-

The risk of eclampsia is more common in:

  • primigravidae (especially young teenagers and women over 35 years)
  •  obese women
  • women with essential or renal hypertension
  • multiple pregnancy
  • women with – diabetes, hydatidiform mole, polyhydramnios, hydrops fetalis.

Community risk factors These include:

  • Lack of awareness about symptoms of severe pre-eclampsia and eclampsia and the importance of early and regular antenatal care
  • Transportation problems
  • Financial hardship and inability to pay for transport and medical care
  • Low socioeconomic status
  • Community distrust of health care personnel

Health service risk factors These include:

  • Failure to monitor blood pressure and urine during antenatal care
  • Failure to counsel women and families about dangerous symptoms of severe pre-eclampsia and the importance of regular antenatal care
  • Delay in referral of women with symptoms and signs of severe pre-eclampsia or eclampsia
  • Lack of a clear-cut management strategy/clinical protocols for dealing with pre-eclampsia and eclampsia
  • Lack of proper equipment and drugs to treat eclampsia
  • Inadequately trained staff to treat women with severe preeclampsia or eclampsia

References-

https://apps.who.int/iris/bitstream/handle/10665/44145/9789241546669_2_eng.pdf?sequence=2

https://www.acog.org/~/media/Task%20Force%20and%20Work%20Group%20Reports/public/HypertensioninPregnancy.pdf

 

 

 

Diagnosis of eclampsia is done with the medical history and clinical examination along with some tests/ investigations. As preeclampsia precedes eclampsia, symptoms and signs of severe preeclampsia should be checked.

Symptoms and signs of eclampsia -

  • May have headache, visual disturbance, epigastric pain
  • Well-defined stages of fit - but no characteristic warning with which patient is familiar
  • Convulsions
  • Diastolic blood 90mm Hg or more after 20 weeks gestation
  • Proteinuria 2+ or more
  • May be unconscious
  • May pass less than 400ml urine in 24 hours
  • May have pulmonary oedema

Tests /investigation to confirm diagnosis

Urine test-The urine will show presence of protein.

Blood tests for renal and liver function tests and coagulation; and may show impaired renal and liver function and coagulation defects in women with eclampsia.

Blood film examination is done to exclude malaria.

Eclampsia should be differentiated from following diseases:

Epilepsy, cerebral malaria, meningitis, tetanus, puerperal sepsis (septicaemia).

Epilepsy- There is a history of epilepsy before pregnancy. There may be characteristic warning before convulsion, blood pressure is normal. Tests may show normal kidney function.

Cerebral malaria-If a woman living in an area endemic for malaria having fever, headaches with convulsions, malaria should be excluded by examination of blood film for malaria parasite.

Meningitis-Coma may precede convulsions, but hypertension is not a common feature. Stiffness of neck is there. Brudzinski’s neck sign and Kernig’s sign are positive. Diagnosis can be confirmed by lumber puncture.

Tetanus- A woman is considered protected from tetanus when she has received 2 doses of tetanus toxoid at least 4 weeks apart, and with an interval of at least 4 weeks between the last vaccine dose and pregnancy termination (delivery or abortion). Women who have received a vaccination series (5 injections) more than 10 years before the present pregnancy, should be given a booster.

Puerperal sepsis (septicaemia)- There is fever (temperature 38°C or more )with chills and general malaise, lower abdominal pain, tender uterus, subinvolution of uterus, purulent, foul-smelling lochia. There may also be light vaginal bleeding and shock.

References-

https://apps.who.int/iris/bitstream/handle/10665/44145/9789241546669_2_eng.pdf?sequence=2

https://www.acog.org/-/media/Districts/District-II/Public/SMI/v2/sm02a170713EclampsiaCheckRev072017.pdf?dmc=1&ts=20190328T1110104145  Page no 19

 

Eclampsia is managed with the following steps:

1. Making sure the airways are clear and the woman can breathe.

2. Controlling the fits.

3. Controlling the blood pressure.

4. General care and monitoring, including controlling fluid balance.

5. Delivering the baby.

6. Monitoring carefully to prevent further fits and identify complications.

1. Making sure the airways are clear, and the woman can breathe:

  • Place the woman on her left side to reduce the risk of aspiration of secretions, vomit and blood
  • Give oxygen (if available) and continue for five minutes after each fit, or longer if cyanosis persists
  • After a convulsion, aspirate the mouth and throat as necessary to clear the airway
  • Stay with the woman and ensure that her airway is clear.

2.Controlling fits:

Fits are controlled by giving the woman anticonvulsant drugs. Magnesium sulfate is used for both the prevention and treatment of eclampsia.

Magnesium sulfate is the anticonvulsant of choice for women with severe pre-eclampsia or eclampsia. If possible, give a full regimen of magnesium sulfate to women with eclampsia or severe pre-eclampsia. If the administration of a full regimen is not possible, these women should be given the loading dose of magnesium sulfate and should be immediately transferred to a higher-level health care facility for further treatment.

If magnesium sulphate is not available, diazepam may be given, but there is a greater risk of neonatal depression because diazepam crosses the placenta freely. A single dose of diazepam is unlikely to cause much neonatal depression but, if treatment continues with this drug, the risk of neonatal depression increases and the effect may last for several days.

3.Controlling blood pressure:

Antihypertensive drugs should be given if the diastolic blood pressure is 110mmHg or more. The aim is to keep the diastolic blood pressure between 90–100mmHg to prevent cerebral haemorrhage. A smooth and sustained reduction in blood pressure over a three–hour period is preferred to a sudden drop.

4.General management and monitoring, including controlling of fluid balance:

The woman is nursed in a quiet, single room and must never be left alone, because she could fit at any time and inhale secretions or vomit and/or sustain serious injuries if there is no one in the room to gently restrain her.

Only essential care should be given such as turning the woman two–hourly, mouth care, (no oral fluids are given), insert a urinary catheter and monitor the urinary output and proper fluid balance.

5.Delivering the baby:

Delivery should take place as soon as the woman’s condition has stabilized, regardless of gestational age. In cases of eclampsia, delivery should occur within 12 hours of the onset of convulsions.

Medical professional may decide the method of delivery by taking into account the. gestational age, fetal and cervical status and urgency.

6.Monitoring carefully to prevent further fits and identify complications:

Fits can also recur after delivery or can occur for the first time after delivery, within the first 48 hours. Therefore, the woman must be very carefully observed for at least 48 hours after delivery.

Anticonvulsive therapy should be maintained for 24 hours after delivery or the last convulsion, whichever occurs last.

Antihypertensive therapy should be continued until the diastolic blood pressure decreases to less than 110mmHg. Urinary output should be monitored.

Four–hourly blood pressure checking should be continued for a few days.

References-

https://apps.who.int/iris/bitstream/handle/10665/44145/9789241546669_2_eng.pdf?sequence=2

https://www.acog.org/-/media/Districts/District-II/Public/SMI/v2/sm02a170713EclampsiaCheckRev072017.pdf?dmc=1&ts=20190328T1110104145

 

Effects of eclampsia on mother

Maternal death –The main causes of maternal death in eclampsia are inhalation of vomit or other secretions, pulmonary oedema, pneumonia, kidney failure, liver failure intracerebral haemorrhage, and failure of more than one organ (e.g. heart + liver + kidney).

Effects of eclampsia on the fetus:

It causes placental dysfunction which may lead to intrauterine growth restriction, hypoxia, and intrauterine death. Hypoxia may cause brain damage if severe or prolonged, and can result in physical or mental disability.

Reference-

https://apps.who.int/iris/bitstream/handle/10665/44145/9789241546669_2_eng.pdf?sequence=2

 

Education of women, families and the community about the disease and the importance of early and regular antenatal care, may promote early detection and treatment of the disease. All women should be checked for pre-eclampsia at each antenatal visit.

Sometimes women with pre-eclampsia do not feel ill until the condition is severe.

Early detection of preeclmpsia by regular antenatal monitoring and careful follow-up of those with mild pre-eclampsia is therefore essential for the early diagnosis and treatment of severe preeclampsia. Thus eclampsia can be prevented by proper management of preeclampsia.

In populations with low dietary calcium intake, daily calcium supplementation (1.5–2.0g oral elemental calcium) is recommended for pregnant women to reduce the risk of pre-eclampsia.

Low-dose acetylsalicylic acid (aspirin, 75 mg) may be advised for the prevention of pre-eclampsia in women at high risk of developing the condition.

Antihypertensive drugs are given to pregnant women with severe hypertension.

Magnesium sulfate is recommended for the prevention of eclampsia in women with severe preeclampsia. Magnesium sulfate is the anticonvulsant of choice for women with severe pre-eclampsia or eclampsia. If possible, give a full regimen of magnesium sulfate to women with eclampsia or severe pre-eclampsia. If the administration of a full regimen is not possible, these women should be given the loading dose of magnesium sulfate and should be immediately transferred to a higher-level health care facility for further treatment.

Induction of labour is recommended for women with severe pre-eclampsia at a gestational age when the fetus is not viable or unlikely to achieve viability within one or two weeks.

In women with severe pre-eclampsia, if there is a viable fetus and the pregnancy is less than 37 weeks of gestation, expectant management can be considered, provided that uncontrolled maternal hypertension, increasing maternal organ dysfunction, and fetal distress do not occur and the conditions can be monitored.

In women with severe preeclampsia at term, early delivery is recommended.

References-

https://apps.who.int/iris/bitstream/handle/10665/119627/WHO_RHR_14.17_eng.pdf;jsessionid=72FF177A0C847E7B7B8DA5DD77ABAC6D?sequence=1

https://apps.who.int/iris/bitstream/handle/10665/277236/9789241550444-eng.pdf?ua=1

https://apps.who.int/iris/bitstream/handle/10665/44703/9789241548335_eng.pdf?sequence=1

https://apps.who.int/iris/bitstream/handle/10665/277235/9789241550451-eng.pdf?ua=1

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3931898/

https://www.acog.org/~/media/Task%20Force%20and%20Work%20Group%20Reports/public/HypertensioninPregnancy.pdf

 

  • PUBLISHED DATE : Apr 01, 2019
  • PUBLISHED BY : NHP Admin
  • CREATED / VALIDATED BY : Dr. Aruna Rastogi
  • LAST UPDATED ON : Apr 01, 2019

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