CASE

A 17-year-old female presents via EMS from her boyfriend’s home after a report of two separate episodes of generalized tonic-clonic seizure like activity. She has no previous history of seizures. Per EMS, she was given versed on scene for seizure like activity lasting roughly 5 minutes. The emergency department team is unable to obtain a detailed history from the patient and unable to reach the family when the patient first presents to the ED. Physical exam shows an adolescent female who is alert but confused and appears post-ictal.

Vitals: BP 147/95, T 100.8°F, HR 121, RR 18, SpO2 97%. During the interview with the patient’s family, it is uncovered that the patient recently vaginally delivered a baby girl 3 days prior.

DIAGNOSIS

Eclampsia

DISCUSSION

A Brief History Lesson:

Eclampsia has long been a known complication during pregnancy. Even before Hippocrates, ancient Greek writers referred to eclampsia in the Coacae Praenotiones (Coan Prognosis), XXXI, No. 507, stating, “In pregnancy, drowsiness and headache accompanied by heaviness and convulsions, is generally bad”. [1] Later, Francois Mauriceau, a French obstetrician during the 17th century, helped to establish obstetrics as a specialty and was the first to describe eclampsia systematically. Additionally, he noted that primigravidas were at greater risk for convulsions than multigravidas. [2,3] In his 1620 treatise on gynecology, “Tractatus de affectibus Renum et Vesicae”, Johannes Varandaeus was the first to utilize the term “eclampsia”, from the Greek noun eklampsía meaning a "light burst". [4]

Although our management of eclampsia has advanced since it was first recognized, as a scientific community we still do not fully understand the mechanism behind the disease. Currently there are two major theories regarding the pathogenesis of seizures in eclampsia, with both revolving around the development of edema. One theory posits hypertension disrupts the autoregulatory system of the brain leading to hyperperfusion and ultimately vasogenic or cytotoxic edema; the alternative theory is hypertension activates the autoregulatory system causing vasoconstriction and hypoperfusion, leading to vasogenic or cytotoxic edema. [5]

Typical Presentation of Eclampsia:

Your patient will often be a pregnant or post-partum female without a history of seizure disorder presenting with generalized tonic-clonic seizure. The most common features antecedent to seizure include hypertension (75%), headache (66%), visual disturbances (27%), right upper quadrant pain (25%), and proteinuria [6]. Most presentations of eclampsia occur in the third trimester and when eclampsia presents in the post-partum period, 90% present within one week of delivery.

Expanding the Differential:

Although eclampsia should be at the top of your differential in a seizing pregnant/post-partum patient, it is critical to consider additional etiologies of seizure. Traumatic brain injury, CNS infections, cerebral venous thrombosis, electrolyte imbalance, and toxicity are all important considerations in a patient that is 3 days post-partum and presenting with seizure. It is also important to remember the highest risk of pregnancy related thrombotic events is in the post-partum period. Although unlikely to be confirmed in the emergency department, any first time seizure may also be the initial presentation of a primary seizure disorder.

Radiology:

Although there are no specific radiographic studies required for diagnosis, other etiologies on the differential may necessitate brain imaging including: CT brain without contrast, CTA brain and neck, or CT venogram/MRI venogram. These studies will help differentiate eclampsia from intracranial bleed, stroke, and cerebral venous thrombosis. If imaging is obtained, the most common findings in eclampsia are those similar to reversible posterior leukoencephalopathy syndrome (RPLS) including bilateral white matter edema in the posterior cerebral hemispheres and generalized vasogenic edema. [7]

Management:

Labwork should be obtained with consideration for HELLP syndrome [hemolysis, elevated liver enzymes, low platelets] and for any other presumptive etiologies. Treatment should not be delayed and traditional anti-epileptics are indicated when etiology is unclear. However definitive treatment for eclampsia is initiated with with magnesium sulfate (6 g Mg sulfate over 15 min followed by magnesium infusion at 2 g/hrt). In addition, anti-hypertensive treatment is critical (SBP ≥160, DBP ≥110) as 15-20% of deaths in the setting of eclampsia are due to stroke secondary to hypertensive emergency. Labetalol and hydralazine are the preferred agents in eclampsia blood pressure management. [9] Ultimately delivery of the fetus is the definitive treatment for eclampsia although it is not applicable in post-partum patients.

Case Resolution:

As our patient presented altered and febrile in the setting of seizure, laboratory work-up including CBC, CMP, magnesium level, urinalysis, drugs of abuse screen, urine protein/creatinine ratio, and blood cultures were also drawn. She was given Tylenol and covered for meningitis/encephalitis with vancomycin, ceftriaxone, ampicillin, and acyclovir. Lumbar puncture was deferred as our most likely diagnosis was eclampsia. We obtained CTA brain as we initially had limited collateral information regarding events leading up to our patient’s presentation and had thrombotic events and intracranial bleed in our differential.

The patient was started on a magnesium sulfate infusion and her mental status improved while she was in the ED. Further discussion with patient and her mother who arrived at the bedside, uncovered that the pregnancy was complicated by hypertension just prior to and after delivery. Her imaging was unremarkable, and she was admitted to OB/Gyn service for close monitoring. She was ultimately discharged home without a recurrent seizure.

TAKE HOME POINTS

• If a pregnant or post-partum patient presents with seizure, think of eclampsia

• Eclampsia can occur in the post-partum period

  • 90% of post-partum eclamptic seizures occur within 1 week of delivery

• Treat eclampsia with magnesium sulfate (6 g Mg sulfate over 15 min followed by magnesium infusion at 2 g/hr)

  • Treatment reduces rate of recurrent seizure by 50 - 66% and rate of maternal death by 33%.8

  • Target serum Mg level is 4.8-8.4

• If magnesium toxicity occurs treat with Calcium gluconate 1g IV

  • Signs of Mg toxicity include loss of deep tendon reflexes, respiratory depression, decreased urine output

• Treat severe persistent hypertension (SBP ≥160, DBP ≥110) with labetalol or hydralazine

• Seizures refractory to magnesium may be treated with barbiturates (amobarbitol/thiopental) or phenytoin and often require intubation and ICU admission

• If patient is pregnant, consult obstetrics and pediatrics for delivery

  • Depending on gestational age and obstetrician/patient preference cesarean section vs. induction of labor may be undertaken for delivery 

AUTHOR: Derek Lubetkin, MD is a third-year Emergency Medicine resident at Brown University/Rhode Island Hospital.

FACULTY REVIEWER: Meghan Beucher, MD is an Assistant Professor of Pediatric Emergency Medicine and Clinician Educator at Brown University/Hasbro Children’s Hospital.

REFERENCES

1. Chadwick J, Mann WN, translators. Hippocrates. The medical works of Hippocrates. England: Blackwell Scientific Publications; 1950. (Original work published 5th century B.C.)

2. Speert H. Obstetric and gynecologic milestones: Essays in eponymy. NY: The Macmillan Company; 1958.

3. McMillen S. Eclampsia. In: Kiple KF, editor. The Cambridge historical dictionary of disease. New York, NY: Cambridge University Press; 2003. pp. 110–112.

4. Ong, S. (2003). "Pre-eclampsia: A historical perspective". In Baker, P.N.; Kingdom, J.C.P. (eds.). Pr-eclampsia: Current perspectives on management. Taylor & Francis. pp. 15–24.

5. Marra A, Vargas M, Striano P, et al. Posterior reversible encephalopathy syndrome: the endothelial hypotheses. Med Hypotheses 2014; 82:619.

6. Berhan Y, Berhan A. Should magnesium sulfate be administered to women with mild pre-eclampsia? A systematic review of published reports on eclampsia. J Obstet Gynaecol Res 2015; 41:831.

7. Kalimo H, Fredriksson K, Nordborg C, et al. The spread of brain oedema in hypertensive brain injury. Med Biol 1986; 64:133.

8. Sibai BM. Magnesium sulfate prophylaxis in preeclampsia: Lessons learned from recent trials. Am J Obstet Gynecol 2004; 190:1520.

9. ACOG Practice Bulletin 222. Gestational Hypertension and Preeclampsia.  Obstetrics and Gynecology. VOL. 135, NO. 6, June 2020.