Medicine for Africa - Medical Information Service

REECLAMPSIA / CLAMPSIA

Definition:

Eclampsia – per definition, consists of convulsions (seizures) which occur in association with pregnancy-associated high blood pressure.

Thus, eclampsia is a disorder that is unique to pregnant women.

Eclampsia is often preceded by a state called ‘preeclampsia’, but this does not always occur.  Eclampsia originating convulsions can appear at any time before, during or shortly after labor (up to six weeks post-partum); the earliest cases of preeclampsia have been reported after just 20 weeks of pregnancy (gestation).  Early onset preeclampsia is defined as the occurrence of preeclampsia prior to the 32nd week of gestation.  Eclampsia is the final, most severe and often life-threatening result of a stage of untreated and/or undiagnosed preeclampsia.

Preeclampsia is a medical condition, consisting of pregnancy induced hypertension, and associated with a significant amount of protein excretion in the patient’s urine.   Preeclampsia, per se, does not describe any causative factors; it is rather a set of symptoms as the result of different causes.  It is believed that one or more substances from the placenta itself may cause endothelial dysfunctions in the maternal blood vessel system of certain susceptible women, as well as in the endothelium of the mother’s liver and kidneys.

The precise cause/s of preeclampsia and eclampsia are still not known, although research has connected these syndromes with poor nutrition, high body fat, or insufficient blood flow to the fetus-bearing uterus.

Preeclampsia and eclampsia are also often referred to as ‘toxemia’.

Preeclampsia occurs in up to 10% of all pregnancies, typically in first-time pregnancies (‘primipara women’), especially in young, teenage women, and in women (primipara or multipara) who are pregnant at over 40 years of age.  Additional risk factors may include:

• Previous history of chronic high blood pressure, prior to the present pregnancy;
• Previous history of preeclampsia (the single most important risk factor!);
• A family history of preeclampsia in one’s mother or sister;
• First pregnancy after age 35;
• Obesity, prior to the current pregnancy;
• Multiparity, i.e. women who had several children previously;
• Being of African ancestry;
• Past medical history of diabetes, kidney disease, rheumatoid arthritis, or
• Autoimmune diseases such as systemic lupus erythematosus.

Preeclampsia is one of the leading causes of premature birth, with all its accompanying and subsequent problems such as epilepsy, cerebral palsy, learning disabilities, as well as hearing and vision problems.  It can also result in smaller than normal babies, due to insufficient blood supply to the fetus via the placenta.

Hypoxia (insufficient oxygen supply) is also considered to be a major cause for the damages to the maternal endothelium, subsequently limiting the growth of the placenta during the pregnancy. 

Preeclampsia and eclampsia can be confused with a series of other diseases, such as chronic hypertension, chronic renal disease, primary seizure disorders, pancreatic and gallbladder diseases, as well as blood-borne diseases such as thrombotic thrombocytic purpura (TTP), antiphospholid syndrome or the hemolytic-uremic syndrome.

Other severe yet rare complications of (pre-) eclampsia include cerebral hemorrhage as a complication of severe hypertension, and the more often occurring adult respiratory syndrome.

Preeclampsia may also be associated with a variety of placental abnormalities, such as a placenta that is too large, or too small for the accompanying fetus, how the placenta is attached to the wall of the uterus, or in so-called hydatidiform mole pregnancies (grapelike vesicles within the placenta with no fetus, or an anomalous fetal growth).

Symptoms:

Preeclampsia and eclampsia may develop into severe and life-threatening conditions for the fetus and the mother alike.

The most common symptom and ‘hallmark’ of preeclampsia is high blood pressure (HBP – above 160/110 mm Hg), which may be the first and only symptom present; while the hallmark of eclampsia is seizures.  

Secondly, the kidneys may become unable to efficiently filter the blood, resulting in the presence of protein in urine (proteinuria), an important early symptom of the potential development of preeclampsia/eclampsia. 
 
Changes of the nervous system may include blurred vision, severe headaches, and ultimately, convulsions and even blindness. Any of these symptoms constitute of a medical emergency and require immediate medical attention!

Symptoms associated with the liver may include pain in the right upper part of the abdomen, which is often confused with gallbladder related diseases.

The unborn baby may be affected via an insufficient maternal blood flow to the placenta with subsequent insufficient delivery of essential nutrients to the fetus. This may result in a smaller than expected baby (growth), the baby may appear sluggish and express poor frequency and intensity of movements.

Some of the severe symptoms are expressed in the acronym HELLP:

• Hemolytic anemia;
• Elevated Liver enzymes, and
• Low Platelet count.

Other symptoms may include:

• Seizures;
• Severe agitation;
• Unconsciousness;
• Muscle aches and pains;
• Headaches, vision problems, and
• Stomach pains.

Systemic imbalances in the course of (pre-) eclampsia may include:

• Cardiovascular problems – increased peripheral vascular resistance, decreased central venous pressure and pulmonary wedge pressure;
• Hematologic complications – decreased plasma volume, increased blood viscosity, hemoconcentration, coagulopathy;
• Renal syndromes – decreased glomerular filtration rate, plasma flow rate and uric acid clearance;
• Central nervous system (CNS) – cerebral edema, hemorrhage, and tonic-clonic seizure activity.

Other less specific symptoms may include:

• Rapid weight gain, caused by a significant increase of water retention;
• Diffuse abdominal pains;
• Decrease in the baby’s movements – an alarming sign, which requires immediate medical attention!
• Changes in reflexes;
• Reduced output of urine or no urine output at all (anuria);
• Blood in the urine;
• Unusual bruising or bleeding;
• Vaginal bleeding or cramping;
• Dizziness;
• Excessive vomiting and nausea.

Eclamptic convulsions, the only ‘true’ sign of eclampsia are subdivided into four stages:

1. Premonitory stage – the woman rolls her eyes with a concomitant slight twitch of her facial and hand muscles; this stage is often missed.
2. Tonic stage – the twitching turns into clenching; the woman may bite her tongue, while her arms and legs turn rigid. Spasm of the respiratory muscles may cause cessation of breathing and cyanosis. This stage lasts up to 30 seconds.
3. Clonic stage – as the spasm ceases, the muscles begin to jerk violently. Frothy, blood-tinged saliva appears in the mouth and on the lips, and can sometimes be aspirated. After about two minutes, the convulsions stop leading into a temporary state of unconsciousness.
4. Comatose stage – the woman falls into a deep state of unconsciousness, requiring respiratory assistance. This state may last just a few minutes or persist for many hours.

 
Diagnosis:

After a thorough physical examination, including taking the woman’s blood pressure, pulse and breathing rate, blood tests will consist of a complete blood count, including platelets (a low platelet count – thrombocytopenia – occurs in up to 20% of cases), as well as blood tests for determining serum electrolytes as well as liver (creatinine) and kidney functions (uric acid). A urine sample for urinalysis will be collected and the vital signs of the unborn baby will be closely monitored.

The baby’s well-being can be determined by way of an ultrasound, a fetal monitoring device, as well as by conducting a non-stress test and a biophysical profile.

An increased blood pressure (BP) at two separately taken readings of 140/90 (systolic/diastolic) mm Hg or more, combined with proteinuria of at least 300 mg of protein in a 24-hour urine sample is diagnostic of preeclampsia!  

A rise of the BP baseline of 30 mm HG systolic or 15 mm Hg diastolic is considered a warning sign of a potential development of preeclampsia.

Women who develop high blood pressure but without proteinuria, are diagnosed as having ‘gestational hypertension’, also called ‘pregnancy-induced hypertension – PIH’.  Both PIH and preeclampsia are serious conditions threatening the well-being of both mother and child, and thus require careful monitoring throughout the pregnancy.  Regression of these symptoms after delivery of the baby confirms the previously made diagnosis of preeclampsia.

 
Treatment:

The only treatment for eclampsia consists of the delivery of the baby, if preeclampsia or eclampsia occur prior to delivery.

However, eclampsia can also occur up to 24 hours postpartum (following delivery), and, albeit rarely, even within one week postpartum, while preeclampsia can occur up to six weeks postpartum.

There is no cure for eclampsia!

Supportive treatment consists of intravenous (i.v.) solutions of magnesium sulfate (MgSo4), which will decrease the chance of recurring seizures. Other, less effective treatments include sodium amobarbital, diazepam or phenytoin.  Antihypertensive drugs such as hydralazine may be given for severe high blood pressure.

If eclampsia occurs around the time of delivery, the mother has to be stabilized prior to inducing vaginal delivery (via oxytocin), or performing a Cesarean section. The latter path has to be chosen, if there are any signs of fetal distress, such as a decreased heart rate (fetal bradycarida).

In severe preeclampsia, delivery should occur within 24 hours of onset of symptoms, while in overt eclampsia, delivery should be completed within 12 hours of first signs of convulsions. If the mother’s symptoms become severe at a time when the baby may not yet be mature enough to survive (before week 24), an abortion may have to be performed in order to save the mother’s life.

Prevention:

Just as there is no cure for eclampsia, there are no tests that can predict preeclampsia or eclampsia.

In just a small number of women who experienced (pre-) eclampsia in a previous pregnancy, it may recur in a subsequent pregnancy (about 2%).

One of the most important preventive measurements is routine prenatal care for the pregnant woman throughout her pregnancy – this will assure early diagnosis and allow aggressive management as soon as possible.

Patient education is another important aspect of preventing (pre-) eclampsia and other pregnancy-related diseases and problems. Healthcare education regarding the physiological changes and challenges throughout a pregnancy increases the woman’s awareness of arising problems at an early point in time, thus, allowing for quick and effective medical intervention and increases the chance of therapeutic success considerably.

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