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11/1/2015

Postpartum Eclampsia

Eclampsia is defined as preeclampsia related new onset generalized tonic-clonic seizures and can result in significant morbidity and death. Postpartum eclampsia accounts for 10 to 44% of all cases of eclampsia. The differential diagnosis of postpartum seizures includes hypertensive encephalopathy, cerebrovascular accident, cerebral venous thrombosis, infection, metabolic abnormalities, and drug intoxication or withdrawal. Most patients with postpartum eclampsia present within a week of delivery. Early hospital discharge is the norm, so postpartum hypertensive disorders can go unrecognized, impairing the ability to prevent eclampsia.

Although the majority of women with postpartum eclampsia recall one or more prodromal symptoms, it is important to remain vigilant as not all women experience symptoms. Headache is the most common symptom, preceding seizure by hours to days. Discharge instructions may lack information about the signs, symptoms, and possibility of postpartum preeclampsia and eclampsia. As a result, only one third of patients with postpartum eclampsia seek medical care after discharge. When sought, it is often from primary or emergency department health care providers who may be not be adequately familiar with hypertensive disorders of pregnancy.

Eclampsia is diagnosed clinically based on generalized tonic-clonic seizures, which are sometimes accompanied by visual disturbances, headaches, epigastric or right upper quadrant pain, and altered mental status. Hyper-reflexia and non-dependent edema may be present. Laboratory abnormalities may include elevated liver transaminases, thrombocytopenia, proteinuria, hypoalbuminemia, and hyperuricemia. Laboratory values may be normal or only minimally abnormal. Overt proteinuria and severe range blood pressures are less prevalent in late onset postpartum eclampsia (2 to 6 weeks postpartum), which also may confound the diagnosis. Electroencephalogram has limited value in distinguishing seizures due to eclampsia from other causes. MRI can support the diagnosis and rule out other causes of new onset convulsions. The classic finding is symmetric, extensive vasogenic edema in the parieto-occipital region described as reversible posterior leukoencephalopathy. The posterior cerebral edema is best treated by normalizing blood pressures, diuresis, and administering magnesium sulfate. Treatment with magnesium sulfate should be immediately initiated upon diagnosis of eclampsia, and  should be continued at least 24 to 48 hours after the last seizure.

Improved awareness and heightened surveillance are important measures to identify women with increased risk. Improved patient education with verbal counseling and written discharge information including danger signs and symptoms may impact the incidence of this condition. After delivery, patients may need an extended inpatient stay for further monitoring. Early follow up after discharge within 3-10 days is advised and based on the severity of the hypertension. Collaborative efforts to improve symptom recognition among primary care providers may promote early intervention.

Further Reading:

American College of Obstetricians and Gynecologists.  ACOG Practice Bulletin No. 202: Gestational Hypertension and Preeclampsia. Obstet Gynecol. 2019 Jan;133(1):e1-e25. doi: 10.1097/AOG.0000000000003018.

American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 736: Optimizing Postpartum Care. Obstet Gynecol. 2018 May;131(5):e140-e150. doi: 10.1097/AOG.0000000000002633.

Initial Approval November 2015; Revised July 2018; Reaffirmed January 2020; Revised September 2021. Minor Revision July 2023

 

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