Obgyn · Year 3 · from Obgyn

Case 2: Eclampsia

Patient Demographics

  • Age: 22 years
  • Sex: Female
  • Occupation: Student

Chief Complaint

The patient is seizing in the labor and delivery unit.

History of Present Illness

The patient is G1P0 at 38 weeks gestation admitted for labor. She had mild preeclampsia diagnosed at 36 weeks managed as outpatient with close monitoring. Her blood pressure has been 145-150/90-95 mmHg at prenatal visits. She presented in early labor 2 hours ago. While being monitored, she suddenly developed a generalized tonic-clonic seizure witnessed by the nurse.

Pre-Seizure Status

  • Blood pressure: 162/104 mmHg (had been 148/92 on admission)
  • Complained of sudden severe headache just before seizure
  • Not yet on magnesium sulfate (was being assessed for induction)

Seizure Description

  • Generalized tonic-clonic seizure
  • Duration approximately 90 seconds
  • Postictal confusion
  • No prior history of seizure disorder

Immediate Management (ABCDE Approach)

A - Airway:

  • Positioned patient on left side (recovery position)
  • Suction available, airway maintained
  • Oxygen via face mask at 10 L/min

B - Breathing:

  • Spontaneous respirations resumed after seizure
  • SpO2 95% on oxygen

C - Circulation:

  • IV access confirmed
  • Blood pressure post-seizure: 180/115 mmHg

D - Disability:

  • Postictal state, not responding to commands initially
  • Improving mental status over 5 minutes

E - Exposure:

  • Fetal heart rate: Initial bradycardia (80 bpm) during seizure
  • Recovering to baseline 140 bpm after 5 minutes

Diagnosis

Eclampsia (new-onset seizure in setting of preeclampsia)

Pharmacologic Management

Magnesium Sulfate:

  • Loading dose: 6 g IV over 20 minutes (higher dose for eclampsia)
  • Maintenance: 2 g/hour IV continuous
  • If seizure recurs: additional 2 g bolus

Blood Pressure Control:

  • IV Labetalol 20 mg, then 40 mg
  • Blood pressure reduced to 148/94 mmHg
  • Goal: <160/110 to prevent stroke

Do NOT Give:

  • Benzodiazepines (unless magnesium fails)
  • Phenytoin (magnesium is superior in eclampsia)

Fetal Assessment

  • Fetal heart rate returned to baseline after 5 minutes
  • Transient bradycardia during seizure is expected and usually self-limited
  • Do NOT rush to cesarean during or immediately after seizure unless prolonged abnormality

Delivery Decision

  • Eclampsia is an indication for delivery after maternal stabilization
  • Patient's cervix: 4 cm, 80% effaced, 0 station
  • Decision: Continue labor with close monitoring
  • If fetal heart rate abnormalities persist or maternal status deteriorates: cesarean delivery

Clinical Course

Post-Seizure Recovery:

  • Mental status returned to baseline within 15 minutes
  • No recurrent seizures on magnesium
  • Blood pressure controlled
  • Labor progressed

Delivery:

  • Vaginal delivery 6 hours after eclamptic seizure
  • Male infant, 3,150 grams, Apgar 8/9
  • Estimated blood loss 400 mL

Postpartum:

  • Magnesium continued for 24 hours after delivery
  • No further seizures
  • Blood pressure gradually improved
  • MRI brain obtained (to rule out posterior reversible encephalopathy syndrome - PRES): normal
  • Discharged on postpartum day 3

Differential Diagnosis of Seizures in Pregnancy

  • Eclampsia (most likely in this setting)
  • Epilepsy
  • Cerebrovascular event (hemorrhagic or ischemic stroke)
  • Cerebral venous thrombosis
  • Posterior reversible encephalopathy syndrome (PRES)
  • Metabolic (hypoglycemia, hyponatremia)
  • Infection (meningitis/encephalitis)

Clinical Image

Image Description: Emergency management algorithm for eclampsia showing immediate stabilization steps, magnesium sulfate protocol, and decision-making for timing of delivery.

Attribution: Educational illustration. Adapted from ACOG guidelines.

All cases for this lecture as Markdown