The purpose of this video is to review diagnosis and incidence of eclampsia, discuss stepwise approach to the management of eclampsia, review the treatment of severe acute hypertension, review delivery considerations, consider alternative diagnoses. Hi, this is Dr. Woldemichael, OB-ED. Hold on just a second, please. We have a pregnant patient, she's 32 years old, G7, G3, 1, 2, 4, at 35 weeks, 3 days, who was found after the loss of consciousness after an acute seizure in her home this morning.
To her family's knowledge, she has no history of seizures or epilepsy. Has been reported to no history of substance abuse and no known pre-existing hypertension. Is she currently seizing? What are her vital signs? Is she stable?
Her blood pressure is 160 over 95, temperature 37.5. heart rate 80, respiratory rate is 22, her O2 saturation is 97% on room air. She's currently hemodynamically stable and not seizing.
Her airway is secure. Sounds like they'll be here soon. This is likely to be eclampsia.
Let's take a minute to review what eclampsia is and how to manage it. Eclampsia is defined as either new onset tonic-clonic focal or multifocal seizures in the absence of other causative conditions or one or more seizures in the absence of other in the setting of preeclampsia. Eclampsia occurs in 1.9% of patients with preeclampsia and 3.2% of patients with preeclampsia with severe features.
20 to 38% of eclampsia cases may not be associated with hypertension or proteinuria prior to the seizure. When managing an acute seizure episode, it's important to keep a clear checklist in mind. It may be helpful to post a copy of the checklist somewhere that can be easily seen.
First, call for assistance. Designate roles including the team leader, someone to read the checklist, and a primary nurse. Ensure the side rails are up on the bed that the patient's seizing in.
Protect the patient's airway and administer oxygen. Consider the possible need for intubation. Begin continuous fetal monitoring.
Draw preeclampsia labs including a clot tube and place a large-bore IV. Start magnesium and, if necessary, administer antihypertensive therapy. Finally, discuss delivery planning with the patient and their family members. Once the patient is stable, As with any emergency situation, debrief the patient, family, and the entire team. So I've got the baby on the monitor.
We're getting an IV. We should think about some labs. She's pretty groggy.
I don't know. She's having another seizure. Okay. If you could call for help, please.
And then if you'll be our lead RN and designate someone to be the recorder, let's drop the bed and get her onto her side, protect her airway. All right. We ready?
One, two, three. All right, we've got an IV, so let's start mag sulfate. We'll start with a six gram bolus, followed by two grams per hour maintenance dose.
And then we'll need labs, a CBC, CMP, a type and screen, and let's draw a clot tube. Does she have any known kidney disease? No. Okay, we'll need to follow up her creatinine when we get that back.
If you're unable to gain IV access, don't delay magnesium administration. An alternative regimen is 10 grams IM. in two 5-gram doses, followed by 5 grams IM every four hours.
Remember that there are certain scenarios where magnesium sulfate is contraindicated, and in these cases, you should consider using benzodiazepine or phenytoin. Okay, it looks like her blood pressure is 173 over 101 and her heart rate's 118. Let's avoid giving the nifedipine or hydralazine pathway as those can both cause reflex tachycardia. Does she have any history of asthma? No, she does not. Okay, let's go ahead and start the lip-ALL pathway.
Magnesium sulfate reduces the risk for more seizures, but it is not a treatment for acute severe hypertension. It's important to treat acute severe hypertension, which is defined as accurate measurement of systolic blood pressure greater than or equal to 160 or diastolic blood pressure greater than or equal to 110 millimeters of mercury, which persists for 15 minutes. The goal is not to normalize blood pressure, but to achieve a range of 140 to 150 over 90 to 100 millimeters of mercury in order to prevent repeated prolonged exposure to severe systolic hypertension with subsequent loss of cerebral vasculature autoregulation, which can result in hemorrhagic or ischemic stroke.
First-line medications include IV labetalol, IV hydralazine, and oral nifedipine. When considering which acute treatment pathway to use, it is important to consider the patient's past medical history and any suspicion for cocaine intoxication. How does our baby look on my fetal heart rate monitor? It looks like it's fetal bradycardia, which is to be expected.
Let's continue to monitor for resolution, otherwise that clot tube will be very useful. Once maternal stabilization has occurred, it is important to monitor fetal status. Of course, maternal hypoxemia will result in transient abnormalities in the fetal heart rate tracing. including bradycardia, transient late decelerations, and decreased variability. As maternal and fetal hypoxemia improve, the fetus may respond with a compensatory tachycardia.
One should not proceed directly to cesarean delivery unless the fetal heart rate abnormality is persistent with no signs of recovery. This may be evidence of abruption and should increase your suspicion for disseminated intravascular coagulopathy. At this point, the patient has had recurrent seizures, so let's go ahead and give her another bolus of two to four grams of magnesium sulfate over five minutes.
Can we also recheck her blood pressure to see if she needs another dose of levadolol? Most eclamptic seizures are self-resolving. However, for persistent convulsions defined as two or more seizures or seizure ongoing for 20 minutes after initiation of magnesium sulfate, another two to four gram bolus of magnesium sulfate should be given. Consider consultation with a neurologist for patients who have persistent or recurrent seizures, concern raised for status epilepticus, and those with neurologic deficits. It looks like her blood pressure responded well to that labetalol dose we gave.
Let's think about what we should consider next. How soon do we need to move to delivery? Should I let an OR know that we're coming for a C-section?
Not necessarily. The definitive treatment for eclampsia is delivery, but the mode of delivery, induction of labor, or... or cesarean section depends on multiple factors. Unless fetal bradycardia is persistent or fetal death is imminent, we should not move immediately to delivery.
The most important factor is maternal stability and her coagulation status. Her clot tube is normal. Her magnesium is running. Fetal heart tracing looks reassuring.
Let's go ahead and check her cervix and see what her Bishop score is so we can determine a mode of delivery. After maternal stability and coagulation status has been determined, other factors to consider when determining the mode of delivery include gestational age, fetal condition, presentation and position, patient cervical exam and bishop score, and whether or not the patient is in labor. She's 35 and 3, the baby is vertex, her bishop score is 7. I think she has a pretty good chance of having a successful induction of labor, especially since she's had several vaginal deliveries before. I agree. Once she's delivered, we'll continue the magnesium sulfate for 24 hours postpartum and continue to monitor her blood pressure and then treat acutely as needed.
Of all eclampsia cases, one-third will present in the postpartum period, usually within two days to six weeks postpartum. 79% of postpartum eclampsia cases present more than 48 hours after delivery, and most patients, about 66%, will not have a prior history of hypertension in the antecedent pregnancy. Headache is the most common prodromal symptom preceding postpartum eclampsia, but patients may also have prodromal symptoms of dyspnea, visual changes, and GI symptoms.
For patients presenting with a postpartum headache, an MRI of the head should be ordered to rule out alternative diagnoses.