A 31 year old female, G2P1 at 33 weeks presents to the emergency department via ambulance for seizures. Per EMS the patient was picked up from an OB clinic due to hypertension and headache. The patient was initially stable during the transport. However, 10 minutes later, she let out a cry and started convulsing. She has no medical problems and there is no history of seizures. The paramedic was able to obtain IV access and administered a total of 2 mg of lorazepam. They report that the patient has been seizing for approximately 5 minutes. The rest of history is limited given patient condition.
Physical Exam:
VS: BP 164/98, HR 110, RR 20, 98% NRB, T 37.8C
General: Ongoing, generalized tonic clonic seizure
Eyes: Deviated to the right bilaterally, 4mm and reactive bilaterally
Pulm: Bilateral BS present
CV: Tachycardic, regular rhythm, no murmurs
Abdomen: soft and non-distended
Neuro: Actively seizing, extremities stiff and in extended position
What is the diagnosis? What do you do?
Preeclampsia is a syndrome that involves a hypertensive pregnant patient that is >20 weeks gestation with proteinuria or any end organ dysfunction.
On the severe end of the preeclampsia spectrum involves syndromes such as HELLP and eclampsia. The criteria for eclampsia is met when a patient with preeclampsia begins seizing.
Overall, the incidence of eclampsia has been decreasing over the past two decades with rates of around 2 per 10,000 deliveries according to a Finnish study.
Management:
Protect the airway! Provide supplemental O2 to avoid hypoxia, have patient on end tidal CO2 monitoring, and suction to avoid aspiration.
Magnesium – and lots of it
Eclampsia seizures are generally short lived. Magnesium has been shown to prevent recurrent seizures in those with eclampsia compared to diazepam.
Dosing: 6 gm IV over 15-20 minutes loading dose with 2 gm/hour maintenance dose
Side effects:
vasodilation, nausea, vomiting, pulmonary edema
Toxic levels of serum magnesium
Loss of DTR
Arrhythmias >15,
Cardiac arrest >25
Antidote is IV calcium gluconate
Ongoing seizures should be aggressively treated as any patient in status
Benzodiazepines
Intubate and sedate (propofol being the common agent here)
Check for other causes (fingerstick, chem, CTH, etc)
Antihypertensives
Labetalol IV being one of the more commonly used agents
Resuscitate and give a call out to OB!
Definitive treatment is delivery.
Wei Li, MD is a current second year resident at Stony Brook Emergency Medicine.
References:
ACOG Practice Bulletin No. 202: Gestational Hypertension and Preeclampsia. Obstet Gynecol. 2019;133(1):e1-e25. doi:10.1097/AOG.0000000000003018
Jaatinen N, Ekholm E. Eclampsia in Finland; 2006 to 2010. Acta Obstet Gynecol Scand. 2016;95(7):787-792. doi:10.1111/aogs.12882
Jaatinen N, Ekholm E. Eclampsia in Finland; 2006 to 2010. Acta Obstet Gynecol Scand. 2016;95(7):787-792. doi:10.1111/aogs.12882
Sibai BM. Magnesium sulfate prophylaxis in preeclampsia: Lessons learned from recent trials. Am J Obstet Gynecol. 2004;190(6):1520-1526. doi:10.1016/j.ajog.2003.12.057
Edited by Bassam Zahid, MD