Severe pre-eclampsia & eclampsia
Introduction
Eclampsia is the onset of seizures in a patient who has pre-eclampsia. Pre-eclampsia is a multi-system disorder characterized by hypertension which develops after the 20th week of gestation and involvement of one or more other organ systems. Proteinuria is the second most common feature of pre-eclampsia but is NOT mandatory for diagnosis.
Pre-eclampsia occurs in roughly 3% of pregnancies. Most women will be diagnosed while asymptomatic during routine antenatal care however some patients may present de novo to the ED with severe pre-eclampsia or eclampsia and as such all doctors working in the ED should be familiar with initiating emergency management of these conditions.
Clincal Features
Pre-eclampsia
Pre-eclampsia is the new onset of hypertension after 20 weeks gestation (systolic >140mmHg or diastolic >90mmHg)
And either
Proteinuria
Or
Other features of pre-eclampsia:
Renal dysfunction (creatinine >90mmol/L)
Liver dysfunction (ALT >140 / RUQ pain)
New severe persistent headaches in the absence of alternative diagnosis
Haematologic complications (Plt <150 / DIC / haemolysis)
Neurologic complications (clonus, hyper-reflexia, visual disturbance / stroke)
Pulmonary oedema
Uteroplacental dysfunction (Fetal growth restriction / placental abruption / intrauterine death)
Severe pre-eclampsia
Severe hypertension (systolic >160mmHg or diastolic >110mmHg) with significant proteinuria
Or
Hypertension with other severe features;
Ongoing severe headache
Onset < 32 weeks
Visual scotoma
Nausea and vomiting
Epigastric pain
Oliguria
Rising creatinine (>100mmol/L) and or rising transaminases
Falling platlets (<100)
Fetal growth restriction or abnormal umbilical artery dopplers
Eclampsia
Eclampsia is pre-eclampsia complicated by generalised tonic-clonic seizures
It occurs any time after 20 weeks gestation
35% occur pre-partum
9% intra-patum
28% post-partum (usually within 24 hours).
It is important to rule out other causes of seizures
Symptoms
The following can be symptoms of pre-eclampsia and pregnant women should be advised to seek medical attention if they develop any of the following;
Sudden swelling of the hands, feet or face
Severe headache
Severe upper abdominal pain
Visual disturbance
Vomiting
All of the above symptoms have other potential causes which should also be considered in the work up of these patients.
Risk Factors
Obstetric
First pregnancy (or first pregnancy with a new partner)
Pre-eclampsia in prior pregnancy
Multiple gestation (eg:twins/ triplets)
Long interval between pregnancies (>10 years)
Maternal Factors
Obesity
Age > 40
Family history of pre-eclampsia
Pre-existing renal disease, vascular disease, hypertension, diabetes
maternal autoimmune disease (eg: SLE)
Investigations
Bedside
Urine dip – proteinuria
Blood glucose – other causes of seizures / symptoms
ECG – arrhythmias can have similar appearance to seizures – pay attention to the corrected QT interval
Laboratory
FBC – check platlet count, signs of haemolysis
U/E – creatinine
LFT’s – transaminases
Coagulation screen
Radiologic
POCUS
check for presence or absence of a foetal heartbeat.
Caution – in the hands of emergency physicians the only thing commented on is the presence or absence of a heartbeat. No diagnostic or prognostic information can be obtained by practitioners untrained in obstetric ultrasound
CT brain
Should be performed in all patients with refractory seizures looking for alternative diagnosis such as cerebral venous sinus thrombosis
Management & Disposition
Severe pre-eclampsia
Urgent obstetric referral
Initiation of antihypertensives or magnesium prior to transfer can be considered in collaboration with receiving obstetrician on call
Eclampsia
Immediate
As with any seizing patient
Nurse on their side – left side in pregnant patients
ABCDE approach
Suction airway as required
Apply high flow O2 via face mask
Apply monitors
Check blood glucose (hypoglycaemia also causes tonic clonic seizures)
Gain IV access
Call for help – anaesthesia and obstetric as urgent delivery will be required (or gynaecology on call if no obstetrics on site)
Specific treatment
Magnesium sulphate 4g over 5-10mins iv
Commence Magnesium sulphate infusion at a rate of 1g/hour
Further 2g boluses of Magnesium Sulphate can be given if further seizures occur after initial loading dose
In patients not responding to magnesium consider traditional status epilepticus management and alternative diagnosis
If inadequate ventilation consider early RSI - experienced physician as difficult intubation is likely
Disposition
Consider delivery as soon as the patient is stable
Urgent delivery once the patient is stable & monitoring in a HDU setting after delivery will be required
If no obstetrics on site the patients stability, duration of transfer and any onsite persons capable of delivery ie: gynaecology on call, as well as the availability of neonatal retrieval teams should all be considered when making the decision to transfer to obstetric centre or deliver on site
References
Hutcheon JA, Lisonkova S, Joseph KS. Epidemiology of pre-eclampsia and the other hypertensive disorders of pregnancy. Best Practice Res Clin Obstet Gynaecol. 2011 Aug; 25(4): p. 391-403.
Cooper J, Primrose N. Hypertensive disorders in pregnancy. HELLP! In RCEM learning. London; 2021.
Gynaecologists IoOa. The diagnosis and managment of severe pre-eclampsia and eclampsia. Clinical Practice Guideline. Dublin: Institute of Obstetricians and Gynaecologists, Royal College of Physicians Ireland; 2016.
National Institure for Health and Care Excellence. Hypertension in pregnancy: diagnosis and management. Clinical guideline. NICE; 2019.
Lee M. 19.7 Pre-eclampsia and eclampsia. In Cameron P, Jelinek G, Kelly A, Brown A, Little M, editors. Textbook of Adult Emergency Medicine.: Churchill Livingstone p. 651-655.
This blog was written by Dr. Emer Kidney and was last updated in May 2021