|LETTER TO THE EDITOR
|Year : 2017 | Volume
| Issue : 1 | Page : 63-64
The clinical conundrum of atypical eclampsia
Department of Anaesthesiology and Critical Care, Deen Dayal Upadhyay Hospital, New Delhi, India
|Date of Web Publication||1-Jun-2017|
Department of Anaesthesiology and Critical Care, Deen Dayal Upadhyay Hospital, New Delhi
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Aggarwal R. The clinical conundrum of atypical eclampsia. J Obstet Anaesth Crit Care 2017;7:63-4
A 30-year-old female presented at 35 weeks and 5 days gestation with vomiting, headache, and decreased perception of fetal movements. She had a history of two previous cesarean sections [lower segment cesarean section (LSCS)]. The first LSCS was done at full term gestation for fetal distress. The second LSCS was done at 6-month of gestation when the patient developed high blood pressure and seizures (eclampsia). The new-born baby died on the third day due to complications of prematurity. At present, the patient was conscious but disoriented with a heart rate (HR) of 90 beats/min, blood pressure (BP) 110/60 mmHg, and peripheral oxygen saturation (SpO2) of 98%. She had mild pedal edema and petechae all over the body and face. Her ultrasound abdomen suggested a 35 weeks live fetus with hydronephrosis. Suddenly she had a generalized tonic–clonic seizure, for which she was given diazepam 0.1 mg/kg IV and nursed in in lateral decubitus position. Oxygen by ventimask and injection magnesium sulphate 4 g IV over 20 min followed by 1 g/h IV infusion were administered. She was drowsy with a HR of 110 beats/min, BP of 90/60 mmHg, and SpO2 of 97% on ventimask. Arterial blood gas analysis showed mild metabolic acidosis corrected with standard IV dose of sodium bicarbonate. Her fundoscopy showed no hypertensive changes or papilledema. There was trace proteinuria but blood investigations and cerebrospinal fluid biochemistry were normal. Prothrombin time was normal with International normalized ratio of 1.5.
The patient underwent emergency LSCS under general anesthesia using the standard protocol of rapid sequence intubation. Two units of fresh frozen plasma were transfused. The new-born baby required bag and mask ventilation for respiratory depression. Patient's trachea was extubated 2 hours later in the intensive care unit. She was conscious and oriented with stable vitals but suffered another seizure despite continuing magnesium sulfate infusion. Injection diazepam and magnesium sulphate bolus were repeated. Patient was closely monitored and given supportive treatment. Computed tomography (CT) of the head was normal. Proteinuria and petechiae subsided the next day and she was discharged on the 5 postoperative day.
This case report highlights the fact that eclampsia may have abrupt onset and may not be a progression of severe preeclampsia. Eclampsia not preceded by hypertension and/or proteinuria, occurring before 20 weeks of gestation and 48 hours after delivery, or despite patients receiving magnesium sulphate is termed as atypical eclampsia. In a series of 399 women with eclampsia reported by Matter and Sibai, hypertension was absent in 16%, proteinuria in 14% and edema in 26% cases. Katz et al. analyzed 53 eclamptic pregnancies and found that seizures were the first signs of preeclampsia in 60% of the cases.
Delay in initiation of appropriate treatment predisposes to increased maternal and fetal morbidity and mortality. Crucial time may be wasted in ruling out the differential diagnosis that includes epilepsy, cerebrovascular accidents or tumors, metabolic disorders, thrombocytopenic purpura, antiphospholipid syndrome, etc. However, all patients with atypical onset eclampsia should undergo a neurological evaluation to rule out the presence of neurological cases of seizures. Neuroimaging with CT scan is important as these patients could have significant and morbid central nervous system pathological conditions that could be rectified by medical means. Certain angiogenic factors such as soluble Flt-1, soluble endoglins, vascular endothelial growth factor, and placental growth factor are being studied for early laboratory detection of preeclampsia. Their usefulness in detection of atypical preeclampsia–eclampsia cases needs to be investigated as well.
Thus, anesthesiologists and gynecologists must be aware of this atypical variation. Constant vigilance with a high level of suspicion is required for a more positive maternal and fetal outcome.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Sibai BM, Stella CL. Diagnosis and management of atypical preeclampsia-eclampsia. Am J Obstet Gynecol 2009;200:481.
Matter F, Sibai BM. Eclampsia. VIII. Risk factors for maternal morbidity. Am J Obstet Gynecol 2000; 182:307-12.
Katz VL, Farmer R, Kuller J. Preeclampsia into eclampsia: Toward a new paradigm. Am J Obstet Gynecol 2000;182:1389-96.
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