Eclampsia: A Critical Obstetric Emergency
Eclampsia is a severe and potentially life-threatening complication of pregnancy characterized by the onset of generalized tonic-clonic seizures in a woman with pre-eclampsia, in the absence of other neurological conditions such as epilepsy. Though relatively rare in modern obstetrics due to improved antenatal care, eclampsia continues to contribute significantly to maternal and perinatal morbidity and mortality worldwide, particularly in low-resource settings. It represents the extreme end of the spectrum of hypertensive disorders of pregnancy and requires urgent medical attention.
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Defining Eclampsia and Preeclampsia: A Clinical Spectrum
Eclampsia is a life-threatening complication of hypertensive disorders in pregnancy, marking the most severe point on a spectrum of disease that includes gestational hypertension and preeclampsia. Preeclampsia is defined as a sudden spike in blood pressure, typically occurring after 20 weeks of gestation, often accompanied by proteinuria. This hypertensive state can compromise the mother’s health and reduce the blood supply to the fetus, potentially leading to a lack of oxygen and nutrients.
Eclampsia, however, is the catastrophic progression of preeclampsia, defined by the new onset of seizures or coma in a pregnant or postpartum woman. These seizures must occur in the absence of other underlying neurological causes, such as epilepsy or cerebrovascular events. The condition is a critical medical emergency. Although eclampsia most commonly follows a diagnosis of preeclampsia, it is important to note that it can also manifest suddenly without any prior warning signs of hypertension or proteinuria. The condition can occur at any point after 20 weeks of pregnancy and up to six weeks postpartum, with the highest risk of occurrence within the first postpartum week.
Learn about pre-eclampsia: What is Pre-eclampsia?
Table Comparing Pre-eclampsia and Eclampsia
| Feature | Pre-eclampsia | Eclampsia |
|---|---|---|
| Definition | A pregnancy-related hypertensive disorder characterized by high blood pressure and proteinuria after 20 weeks of gestation. | A severe complication of pre-eclampsia marked by the onset of seizures (convulsions) in a woman with pre-eclampsia. |
| Blood Pressure | ≥140/90 mmHg on two occasions at least 4 hours apart | Same as pre-eclampsia, often more elevated |
| Proteinuria | ≥300 mg/24 hr or protein/creatinine ratio ≥0.3 | Usually present, but may be absent in some cases |
| Neurological Symptoms | May include headache, visual disturbances, and hyperreflexia | Seizures (tonic-clonic), loss of consciousness, possible coma |
| Other Organ Involvement | May involve liver (elevated enzymes), kidneys (renal dysfunction), and platelets (thrombocytopenia) | Same as pre-eclampsia, but more severe and acute due to seizures |
| Management | Monitor BP, fetal well-being, magnesium sulfate for seizure prophylaxis, antihypertensives, and plan for delivery | Immediate seizure control (magnesium sulfate), stabilization, urgent delivery if maternal/fetal condition worsens |
| Prognosis | Good with early detection and management | Higher maternal and fetal morbidity/mortality if not managed emergently |
Additional Articles:
Intrauterine Growth Restriction
Global Prevalence and Mortality
Preeclampsia is a common complication, affecting 2-8% of pregnancies worldwide. However, its burden is far from uniform. It is a leading cause of maternal and perinatal morbidity and mortality, responsible for approximately 46,000-50,000 maternal deaths and over 500,000 fetal or newborn deaths annually. The disproportionate mortality rate is particularly evident in low-resource settings, where preeclampsia and eclampsia account for approximately 10% of maternal deaths in Asia and Africa and 25% in Latin America.
Etiology: Causes and Risk Factors for Eclampsia
Eclampsia arises as a severe progression of pre-eclampsia, a hypertensive disorder of pregnancy, but the exact cause of both conditions remains multifactorial and not completely understood. It is believed to result from a complex interplay between abnormal placental development, maternal vascular dysfunction, immune maladaptation, and genetic susceptibility.
Abnormal Placentation
One of the earliest events in the development of pre-eclampsia and eclampsia is abnormal placental implantation. In a healthy pregnancy, trophoblast cells from the embryo invade the maternal spiral arteries, remodeling them into low-resistance vessels that can deliver adequate blood to the growing fetus. In pre-eclampsia, this remodeling is incomplete or defective, leading to placental hypoperfusion and ischemia. This hypoxic placenta releases antiangiogenic and pro-inflammatory factors into the maternal circulation.
Endothelial Dysfunction
The factors released by the ischemic placenta damage the maternal endothelium, triggering widespread endothelial dysfunction. This leads to vasoconstriction, increased vascular permeability, and a hypercoagulable state. These vascular abnormalities are responsible for the clinical manifestations of pre-eclampsia, including hypertension, proteinuria, and organ dysfunction. In eclampsia, these changes are more severe and progress to neurological involvement.
Risk Factors For Developing Eclampsia
While the exact cause of eclampsia is unknown, several risk factors increase a woman's likelihood of developing this condition.
1. Pre-eclampsia: Eclampsia is most commonly associated with pre-eclampsia, a condition characterized by high blood pressure and proteinuria during pregnancy. Women with pre-eclampsia have a higher risk of developing eclampsia, particularly if the condition is severe or if it is not managed properly.
2. First pregnancy: Women who are pregnant for the first time are at a higher risk of developing eclampsia, possibly due to a lack of prior exposure to the factors that contribute to the condition.
3. Age: Women who are over the age of 35 or under the age of 20 are at a higher risk of developing eclampsia, possibly due to hormonal imbalances or other factors related to pregnancy.
4. Multiple pregnancies: Women who are carrying twins, triplets, or other multiples are at a higher risk of developing eclampsia, possibly due to the increased strain on the body during pregnancy.
5. Chronic hypertension: Women who have pre-existing high blood pressure or other cardiovascular conditions are at a higher risk of developing eclampsia, particularly if their condition is not well-controlled during pregnancy.
6. Diabetes: Women with pre-existing diabetes or gestational diabetes are at a higher risk of developing eclampsia, possibly due to the effects of insulin resistance on the body during pregnancy.
7. Obesity: Women who are obese or overweight before pregnancy are at a higher risk of developing eclampsia, possibly due to the increased strain on the body and the effects of excess body fat on blood pressure and other cardiovascular factors.
8. Family history: Women with a family history of eclampsia or other hypertensive disorders during pregnancy are at a higher risk of developing the condition themselves.
Despite these known risk factors, eclampsia can sometimes occur in women with no obvious risk, making vigilance essential in all pregnancies.
Pathophysiology of Eclampsia
The progression from pre-eclampsia to eclampsia involves further deterioration of maternal homeostasis, with key involvement of the central nervous system (CNS).
The pathophysiology can be understood through several mechanisms:
Cerebral Vasospasm and Ischemia
Endothelial dysfunction results in vasoconstriction of cerebral blood vessels, which reduces cerebral perfusion and may lead to ischemia. Hypoperfusion and fluctuating blood pressure can predispose to loss of cerebral autoregulation, contributing to both ischemic and hemorrhagic injuries in the brain.
Cerebral Edema
One of the hallmark features in eclampsia is vasogenic cerebral edema—a condition where fluid leaks into the brain due to breakdown of the blood-brain barrier. This edema primarily affects the posterior brain regions, especially the occipital lobes, and is the reason why many patients experience visual disturbances and seizures. This pattern is often consistent with a condition called posterior reversible encephalopathy syndrome (PRES), which is commonly observed in eclamptic patients on neuroimaging.
Oxidative Stress and Inflammation
The imbalance between pro-angiogenic and anti-angiogenic factors, such as increased levels of sFlt-1 (soluble fms-like tyrosine kinase-1) and endoglin, leads to endothelial injury and systemic inflammation. The maternal immune response may also play a role, with exaggerated inflammatory activation worsening the vascular damage and contributing to multi-organ involvement.
Seizure Generation
The exact cause of seizures in eclampsia is not fully known, but it is likely multifactorial:
✔ Cerebral edema increases intracranial pressure.
✔ Ischemia and metabolic disturbances impair neuronal function.
✔ Endothelial injury and capillary leakage disrupt normal neurochemical homeostasis.
These changes together lower the seizure threshold and precipitate generalized tonic-clonic convulsions.
Signs and Symptoms of Eclampsia
Eclampsia is a severe complication of pre-eclampsia characterized primarily by the onset of seizures in a pregnant woman, usually after 20 weeks of gestation, during labor, or postpartum. In addition to seizures, eclampsia presents with a range of signs and symptoms affecting multiple organ systems:
1. Seizures or Convulsions
The hallmark feature of eclampsia is new-onset generalized tonic-clonic seizures. These are sudden, involuntary episodes of stiffening (tonic phase) followed by rhythmic jerking (clonic phase) of the muscles. Seizures may occur without prior warning and can lead to loss of consciousness, hypoxia, and physical injury.
2. High Blood Pressure
Severe hypertension often accompanies eclampsia. It is typically defined as:
✔ Systolic ≥160 mmHg or
✔ Diastolic ≥110 mmHg
This elevation increases the risk of stroke, organ failure, and poor fetal outcomes. Blood pressure elevation is often resistant to standard therapy.
3. Proteinuria
Proteinuria (≥300 mg/24 hr or a protein/creatinine ratio ≥0.3) indicates renal involvement. It is common in pre-eclampsia and typically worsens in eclampsia. It reflects glomerular endothelial damage, a key pathological feature.
4. Headaches
Severe, persistent frontal or occipital headaches are common and may precede seizures. These headaches may be a sign of cerebral edema, hypertension-induced intracranial pressure changes, or impending eclamptic seizure.
5. Vision Changes
Vision changes can be a symptom of severe preeclampsia and eclampsia. This can include blurry vision, double vision, seeing spots or flashing lights, and even temporary vision loss. These symptoms occur as a result of swelling and damage to the blood vessels in the retina, which can lead to a condition called hypertensive retinopathy. If left untreated, this can cause permanent damage to the vision.
6. Decreased Urine Output (Oliguria)
Decreased urine output (urine output <500 mL/day) is also a common symptom of severe preeclampsia and eclampsia. This occurs when the kidneys are not functioning properly due to high blood pressure and damage to the blood vessels. The kidneys are responsible for filtering waste products and excess fluid from the body, and when they are not working properly, the body is unable to get rid of these waste products, leading to a buildup of toxins in the bloodstream. This can lead to further complications, such as liver and lung failure, and can be life-threatening for both the mother and the fetus.
7. Nausea and Vomiting
These symptoms are nonspecific but may be present due to hepatic congestion, gastric irritation, or increased intracranial pressure.
8. Epigastric or Right Upper Quadrant Pain
Epigastric or RUQ pain is often caused by hepatic involvement, such as:
✔ Liver swelling
✔ Stretching of the Glisson capsule
✔ Associated with HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets)
8. Shortness of Breath
Dyspnea may indicate pulmonary edema, a life-threatening complication resulting from:
✔ Capillary leak
✔ Reduced renal function
✔ Fluid overload
It is important to note that not all women with pre-eclampsia will develop eclampsia, and some women may develop eclampsia without any warning signs or symptoms. Therefore, it is important for women with pre-eclampsia to receive close medical monitoring and to report any new or worsening symptoms to their healthcare provider immediately.
Complications of Eclampsia
Eclampsia is a serious obstetric emergency that can lead to multiple life-threatening complications for both the mother and the fetus. It typically arises as a progression of pre-eclampsia and is characterized by seizures that occur during pregnancy, labor, or postpartum. Prompt diagnosis and management are essential to reduce the risk of morbidity and mortality.
A. Maternal Complications
1. Neurological Complications
Eclampsia primarily affects the central nervous system. The seizures may cause cerebral hypoxia, edema, and even intracerebral hemorrhage. In severe cases, this can lead to coma, persistent neurological deficits, or cerebral venous thrombosis. Recurrent seizures without adequate oxygenation may result in long-term cognitive impairment or death.
2. HELLP Syndrome
Eclampsia significantly increases the risk of HELLP syndrome (Hemolysis, Elevated Liver enzymes, and Low Platelet count). This life-threatening condition affects liver function and blood clotting, and may present with right upper quadrant pain, nausea, and systemic symptoms. It increases the risk of liver rupture and disseminated intravascular coagulation (DIC).
3. Pulmonary Edema
Due to fluid overload, endothelial dysfunction, and capillary leakage, eclampsia may result in pulmonary edema. This leads to acute respiratory distress and hypoxia, requiring immediate respiratory support. If untreated, it can quickly become fatal.
4. Acute Renal Failure
The kidneys are particularly vulnerable to the effects of vasospasm and endothelial injury in eclampsia. This can result in acute kidney injury (AKI), presenting as oliguria or anuria, and may require dialysis if not reversible.
5. Liver Injury
Liver dysfunction in eclampsia may range from mild enzyme elevation to hepatic hemorrhage or subcapsular hematoma. In rare cases, liver rupture may occur, especially when associated with HELLP syndrome, and can be fatal without emergency surgery.
6. Cardiovascular Complications
Severe hypertension in eclampsia puts the mother at risk of stroke, myocardial infarction, and heart failure. These complications can occur suddenly and may result in permanent damage or death if not rapidly managed.
7. Placental Abruption
Eclampsia increases the risk of placental abruption, where the placenta prematurely detaches from the uterine wall. This leads to massive vaginal bleeding, severe abdominal pain, and can compromise both maternal and fetal survival.
8. Disseminated Intravascular Coagulation (DIC)
DIC is a rare but severe complication in which widespread clotting in small vessels consumes clotting factors and platelets, leading to uncontrolled bleeding. It can result from severe eclampsia, placental abruption, or HELLP syndrome.
9. Maternal Death
In low-resource settings or delayed treatment scenarios, maternal mortality remains a major concern. The combination of seizures, stroke, multi-organ failure, and hemorrhage can be rapidly fatal.
B. Fetal Complications
1. Intrauterine Growth Restriction (IUGR)
Due to impaired placental perfusion from maternal vascular dysfunction, fetuses may suffer from IUGR, resulting in low birth weight and developmental delays. This occurs because the placenta cannot deliver adequate oxygen and nutrients.
2. Prematurity
Management of eclampsia often requires early delivery, especially if maternal or fetal conditions deteriorate. As a result, many babies are born prematurely, with associated risks such as respiratory distress syndrome, intraventricular hemorrhage, and feeding difficulties.
3. Fetal Hypoxia and Distress
Seizures and high maternal blood pressure can reduce uteroplacental blood flow, leading to fetal hypoxia, acidosis, and signs of distress on fetal monitoring (e.g., bradycardia or reduced variability). If not promptly managed, this may necessitate emergency cesarean delivery.
4. Stillbirth
In severe, untreated cases, especially with placental abruption or prolonged fetal hypoxia, intrauterine fetal death (IUFD) or stillbirth may occur. The risk increases with delayed recognition or lack of access to obstetric care.
5. Neonatal Intensive Care Unit (NICU) Admission
Due to prematurity, low birth weight, or complications at birth, many neonates born to mothers with eclampsia require NICU care. They may need respiratory support, feeding assistance, or treatment for infections and other complications.
6. Long-Term Developmental Issues
Infants who experience IUGR, asphyxia, or prematurity due to eclampsia-related complications may be at risk for long-term neurodevelopmental delays, learning difficulties, and chronic health issues.
Eclampsia carries serious risks for both the mother and the fetus. Early recognition, hospital-based management, seizure control, and timely delivery are critical to minimizing complications. Maternal and fetal outcomes have improved with modern obstetric care, but eclampsia remains a leading cause of maternal and perinatal mortality in many parts of the world, particularly in areas with limited access to healthcare.(alert-passed)
Diagnosis of Eclampsia
Eclampsia is diagnosed based on clinical presentation rather than laboratory tests alone, as it is a clinical emergency characterized by new-onset seizures in a pregnant or postpartum woman with preeclampsia. It requires immediate recognition and treatment to reduce the risk of maternal and fetal complications. Since no definitive test confirms eclampsia, diagnosis relies on a combination of history, physical examination, and supportive investigations.
1. Clinical Criteria
The hallmark of eclampsia is the occurrence of generalized tonic-clonic seizures in a pregnant woman, usually after 20 weeks of gestation, during labor, or in the postpartum period, in the absence of other neurologic conditions such as epilepsy, brain tumor, or meningitis.
Seizures typically begin with a period of facial twitching or eye-rolling, followed by tonic (rigid) and then clonic (jerking) movements. The patient may lose consciousness and have postictal confusion or sleepiness afterward. The seizure usually lasts less than a minute.
Eclampsia is typically preceded by signs and symptoms of severe preeclampsia, such as:
✔ Severe hypertension (≥160/110 mmHg)
✔ Persistent headache
✔ Visual disturbances (blurred vision, flashes of light)
✔ Right upper quadrant or epigastric pain
✔ Nausea and vomiting
✔ Shortness of breath
✔ Decreased urine output
However, it is important to note that up to 20–40% of women may not have classic signs of preeclampsia prior to seizure onset, making vigilance critical even in women with mild or unrecognized hypertension.
2. Physical Examination
On examination, the patient may show signs of:
✔ Hypertension (blood pressure ≥140/90 mmHg)
✔ Edema (especially facial or hand swelling)
✔ Neurological signs such as hyperreflexia, clonus, or altered mental status
✔ Proteinuria on dipstick or urinalysis
The presence of seizures in a hypertensive pregnant woman with proteinuria or other signs of organ dysfunction (such as elevated liver enzymes or low platelets) strongly suggests eclampsia.
3. Supportive Laboratory Tests
While no specific laboratory test confirms eclampsia, tests help assess the severity and organ involvement and exclude other differential diagnoses. Useful investigations include:
✔ Urinalysis: To detect proteinuria, supporting a diagnosis of preeclampsia.
✔ Complete blood count (CBC): To check for thrombocytopenia (low platelets).
✔ Liver function tests (LFTs): Elevated AST/ALT may indicate liver involvement or HELLP syndrome.
✔ Renal function tests: Elevated serum creatinine and urea indicate kidney impairment.
✔ Coagulation profile: Important if HELLP syndrome or disseminated intravascular coagulation (DIC) is suspected.
✔ Serum electrolytes: To monitor for abnormalities, especially in those requiring intravenous fluids or magnesium sulfate.
4. Imaging (If Indicated)
Neuroimaging is not routinely required for the diagnosis of eclampsia but may be considered if:
✔ The seizures are focal or prolonged
✔ The patient has no prior history of hypertension or preeclampsia
✔ Postictal recovery is delayed
✔ There is suspicion of intracranial pathology (e.g., hemorrhage, stroke, tumor)
MRI of the brain is more sensitive than CT and may show signs of posterior reversible encephalopathy syndrome (PRES), a condition often seen in eclamptic patients characterized by vasogenic edema, especially in the parieto-occipital lobes.
5. Differential Diagnosis
The diagnosis of eclampsia requires ruling out other causes of seizures in pregnancy, including:
✔ Epilepsy
✔ Cerebral venous thrombosis
✔ Intracranial hemorrhage
✔ Infection (e.g., meningitis, encephalitis)
✔ Metabolic disturbances (e.g., hypoglycemia, hyponatremia)
In cases of uncertainty, detailed history, imaging, and laboratory workup help to differentiate eclampsia from other neurologic or medical causes of seizures.
The diagnosis of eclampsia is largely clinical, centered on identifying new-onset seizures in a pregnant or recently postpartum woman, typically with features of preeclampsia. Because eclampsia can present suddenly and progress rapidly, early recognition and a high index of suspicion are essential for prompt treatment and improved outcomes for both the mother and the fetus.(alert-passed)
Management of Eclampsia
Eclampsia is a life-threatening obstetric emergency that requires prompt and coordinated medical intervention. The goals of management are to stabilize the mother, prevent further seizures, control blood pressure, and initiate the timely delivery of the fetus. Multidisciplinary care involving obstetricians, anesthetists, and intensive care specialists is often necessary to ensure optimal outcomes.
A. Acute Phase Management and Resuscitation
The acute management of eclampsia is a medical emergency that requires rapid, coordinated intervention. The initial steps involve standard resuscitation protocols (ABCDE assessment) to secure the patient’s airway and ensure adequate breathing.
1. Airway: Position the patient in the left lateral decubitus position to reduce the risk of aspiration and improve venous return. Suction may be needed to clear secretions or vomitus.
2. Breathing: Administer oxygen via a face mask (8–10 L/min) to maintain adequate oxygenation.
3. Circulation: Establish intravenous access with large-bore cannulas and start isotonic fluids carefully to avoid fluid overload.
4. Monitoring: Continuous monitoring of blood pressure, oxygen saturation, respiratory rate, level of consciousness, and urine output is essential. A Foley catheter is often inserted to measure hourly urine output, which also helps assess renal function.
B. Seizure Control: The Role of Magnesium Sulfate
In the management of eclampsia, the prevention and management of seizures are crucial parts of the treatment plan. Seizures are a major complication of eclampsia and can lead to serious maternal and fetal consequences, including maternal brain damage, placental abruption, and fetal distress.
Magnesium sulfate is the first-line treatment for the acute management and prevention of recurrent seizures in eclampsia, as it has been shown to be superior to other anticonvulsants such as phenytoin and diazepam. While its mechanism of action is not fully understood, it is known to have neuroprotective effects by acting on receptors and calcium channels in the central nervous system, helping to prevent cerebral edema.
The standard administration protocol involves an initial loading dose of 4-6 grams IV over 15-30 minutes, followed by a maintenance dose of 1-2 grams per hour via a continuous IV infusion. This treatment is continued for 24 hours after either the last seizure or delivery, whichever is more recent. In settings where IV access is not immediately available, a loading dose of 10 grams intramuscularly can be used as an alternative regimen. Due to the risk of magnesium toxicity (hypermagnesemia), which can lead to areflexia and respiratory paralysis, careful monitoring of the patient is essential during administration.
C. Blood Pressure Control Using Antihypertensives
Severe hypertension (≥160/110 mmHg) must be managed promptly to reduce the risk of stroke, placental abruption, and cardiac complications.
Target BP: Maintain systolic BP between 140–160 mmHg and diastolic between 90–105 mmHg.
First-line antihypertensives:
✔ Labetalol (IV): Initial dose of 20 mg, repeated every 10 minutes as needed.
✔ Hydralazine (IV): 5–10 mg every 20 minutes.
✔ Nifedipine (oral): 10 mg orally, can be repeated if needed.
Regular monitoring of BP and fetal status is essential during this phase.
D. Monitoring of Patient
Women with eclampsia require close monitoring of vital signs, urine output, and fetal well-being. This monitoring helps to identify any changes or complications that may occur and allows for a prompt intervention to prevent further harm.
Continuous fetal heart rate monitoring is typically used to monitor fetal well-being in women with eclampsia. This involves placing a device on the abdomen to measure the fetal heart rate and detect any changes or abnormalities. This allows for prompt intervention if fetal distress is detected.
Frequent blood pressure checks are also necessary to monitor blood pressure levels and ensure that they remain within safe limits. Women with eclampsia may require blood pressure checks every few hours to ensure that their blood pressure is well-controlled.
Regular blood tests are also needed to monitor organ function and detect any abnormalities. This may include tests to monitor kidney function, liver function, and blood clotting function. These tests help to identify any complications that may arise and allow for prompt intervention to prevent further harm.
Urine output is also closely monitored in women with eclampsia. Decreased urine output can be a sign of kidney damage, which is a common complication of eclampsia. Women with eclampsia may require a catheter to measure their urine output and ensure that it remains within safe limits.
In severe cases of eclampsia, admission to the intensive care unit may be necessary for more intensive monitoring and management. In the ICU, women with eclampsia may receive continuous monitoring of vital signs, frequent blood tests, and more intensive management of their condition.
E. The Definitive Treatment: Delivery of the Placenta
The only known definitive cure for eclampsia is the delivery of the baby and the placenta. However, stabilization of the mother is more urgent than immediate delivery.
✔ Timing: Delivery should occur after stabilization, typically within 12 hours of the last seizure.
✔ Gestational age and fetal status influence the mode and urgency of delivery.
✔ If the patient is at term (≥37 weeks) or if the fetus or mother is unstable, immediate delivery is indicated.
✔ In preterm gestations (<34 weeks), delivery is still usually pursued but may be delayed briefly to allow corticosteroid administration for fetal lung maturity (if feasible and safe).
F. Mode of Delivery
The timing and mode of delivery (vaginal or Caesarean section) are determined by the gestational age of the fetus and the overall condition of both the mother and the fetus.
✔ Vaginal delivery is preferred if the cervix is favorable and the patient is in labor or can be induced safely.
✔ Cesarean section may be required in cases of:
- Fetal distress
- Failed induction
- Unfavorable cervix
- Refractory seizures or maternal instability
G. Postpartum Care in Eclampsia
Postpartum management is a critical component in the overall care of women with eclampsia. Even after delivery, these patients remain at risk for seizure recurrence, hypertensive complications, and organ dysfunction, particularly in the first few days after childbirth. Close monitoring and supportive management during this period are essential to prevent maternal morbidity and mortality.
1. Seizure Monitoring and Magnesium Sulfate Continuation
Seizures in eclamptic patients may occur up to 48–72 hours postpartum, particularly in women who had poorly controlled preeclampsia or experienced seizures during labor. For this reason, magnesium sulfate therapy is continued for at least 24 hours after the last seizure or after delivery, whichever comes later. This anticonvulsant regimen helps reduce the risk of postpartum seizures. During this period, regular monitoring for magnesium toxicity is required, including assessments of respiratory rate, deep tendon reflexes, and urine output. If signs of toxicity develop, magnesium sulfate should be stopped immediately and calcium gluconate administered as an antidote.
2. Monitoring for Maternal Complications
Eclampsia can lead to several life-threatening postpartum complications. Women should be closely observed in a high-dependency or intensive care setting for early detection and management of the following:
🔹 Pulmonary Edema: Fluid overload or cardiac dysfunction may lead to pulmonary edema. Signs include shortness of breath, crackles on auscultation, and hypoxia. Careful fluid balance and diuretic therapy may be needed.
🔹 Acute Kidney Injury (AKI): Reduced renal perfusion or direct injury from severe preeclampsia/eclampsia can cause AKI. Oliguria or anuria and elevated serum creatinine levels necessitate nephrology consultation and possible dialysis.
🔹 HELLP Syndrome: This severe form of preeclampsia may present or worsen postpartum. It is characterized by Hemolysis, Elevated Liver enzymes, and Low Platelet count. Patients may experience right upper quadrant pain, nausea, and bleeding tendencies. Prompt supportive treatment, corticosteroids, and sometimes plasma exchange are required.
🔹 Postpartum Hemorrhage (PPH): Women with eclampsia are at higher risk of PPH due to uterine atony or coagulopathy. Active management of the third stage of labor and vigilant monitoring of bleeding are essential. Blood transfusion and uterotonic agents may be needed.
2. Antihypertensive Therapy
Many women continue to have elevated blood pressure in the postpartum period, requiring ongoing antihypertensive treatment. Oral medications such as labetalol, nifedipine, or methyldopa are commonly used. Blood pressure should be monitored frequently, and the dose adjusted accordingly. Long-term follow-up with a primary care provider or cardiologist may be necessary, especially for women who remain hypertensive beyond six weeks postpartum.
3. Patient Counseling and Future Risk Management
Before discharge, comprehensive counseling should be provided. Women who have experienced eclampsia are at increased risk of:
🔹 Recurrence in future pregnancies (particularly if eclampsia occurred early in gestation).
🔹 Chronic hypertension, cardiovascular disease, and renal disease later in life.
Patients should be encouraged to seek preconception counseling before planning future pregnancies. In subsequent pregnancies, early and frequent prenatal care is essential to monitor for early signs of preeclampsia, allowing for preventive strategies such as low-dose aspirin from 12 weeks' gestation, tight blood pressure control, and close fetal monitoring.
H. Neonatal Management
Babies born to mothers with eclampsia may require:
✔ Resuscitation at birth due to preterm delivery or fetal distress.
✔ NICU care for complications like prematurity, low birth weight, or intrauterine growth restriction (IUGR).
The management of eclampsia involves rapid stabilization, seizure control with magnesium sulfate, blood pressure management, and timely delivery. Postpartum monitoring is essential to prevent delayed complications. With prompt and appropriate management, maternal and fetal outcomes can be significantly improved, although the condition remains a major contributor to maternal mortality in many parts of the world.(alert-passed)
Prevention of Eclampsia
Eclampsia, characterized by the onset of seizures in a woman with preeclampsia, remains a major cause of maternal and fetal morbidity and mortality, particularly in low-resource settings. Prevention strategies are centered around early identification and management of preeclampsia, as well as minimizing risk factors through lifestyle, pharmacologic, and monitoring interventions.
1. Early Identification and Risk Assessment
One of the most important steps in preventing eclampsia is the early detection of preeclampsia. Pregnant women should undergo a thorough risk assessment during their first antenatal visit, especially those with known risk factors such as:
✔ First pregnancy
✔ Multiple gestation
✔ Chronic hypertension
✔ Diabetes mellitus
✔ Renal disease
✔ History of preeclampsia or eclampsia
✔ Autoimmune disorders (e.g., lupus, antiphospholipid syndrome)
High-risk women should be flagged for close monitoring throughout pregnancy, including more frequent prenatal visits, blood pressure checks, and urine protein assessments.
2. Antenatal Monitoring and Surveillance
Routine antenatal care plays a vital role in detecting preeclampsia early. Monitoring includes:
✔ Regular blood pressure measurements
✔ Urinalysis for proteinuria
✔ Fetal growth assessment via ultrasound
✔ Maternal blood tests (renal and liver function, platelet count)
Detecting preeclampsia in its early stages allows for prompt initiation of management strategies to control blood pressure and prevent seizure progression.
3. Low-Dose Aspirin Prophylaxis
For women at high risk of developing preeclampsia, low-dose aspirin (75–150 mg daily) initiated between 12 and 16 weeks of gestation and continued until 36 weeks or delivery has been shown to significantly reduce the incidence of preeclampsia and therefore the risk of eclampsia. This is especially recommended for women with previous preeclampsia, chronic hypertension, renal disease, or multiple gestation.
4. Calcium Supplementation
In populations with low dietary calcium intake, calcium supplementation (1.5–2 g per day) during pregnancy is recommended by the World Health Organization (WHO) to reduce the risk of preeclampsia and eclampsia. Calcium appears to decrease vascular smooth muscle excitability and lower blood pressure, thereby offering a protective effect.
5. Antihypertensive Therapy for Severe Hypertension
In women with severe chronic or gestational hypertension (≥160/110 mmHg), timely initiation of antihypertensive medications such as labetalol, nifedipine, or hydralazine is critical. Effective blood pressure control helps prevent complications like cerebral hemorrhage and seizures, key features of eclampsia.
6. Magnesium Sulfate for Preeclampsia with Severe Features
Magnesium sulfate is the gold standard for seizure prophylaxis in women with preeclampsia with severe features (e.g., very high blood pressure, severe headaches, visual disturbances, epigastric pain, or abnormal laboratory findings). It is usually given intravenously and continued for at least 24 hours postpartum or after delivery. Studies have shown that magnesium sulfate significantly reduces the risk of progression to eclampsia.
7. Timely Delivery
For women with worsening preeclampsia or signs of maternal or fetal distress, timely delivery—often via induction or cesarean section—is necessary to prevent the development of eclampsia. Delivery is the only definitive cure for preeclampsia. However, timing must balance maternal stability and fetal maturity, especially in preterm pregnancies.
8. Patient Education and Symptom Awareness
Educating pregnant women on the warning signs of preeclampsia—such as persistent headaches, visual changes, swelling, abdominal pain, and decreased fetal movement—can lead to earlier medical attention and intervention. Awareness empowers women to seek care promptly, reducing delays that can lead to seizures or other complications.
9. Preconception Counseling
Women with a history of preeclampsia or eclampsia should receive preconception counseling before planning future pregnancies. This includes optimizing control of chronic medical conditions, initiating preventive measures like aspirin or calcium supplementation, and planning for early and frequent antenatal care in subsequent pregnancies.
Prognosis of Eclampsia
Eclampsia remains one of the most severe complications of pregnancy, contributing significantly to maternal and perinatal morbidity and mortality, especially in low- and middle-income countries. The overall prognosis depends on factors such as the timing of diagnosis, the quality of medical care, the severity of organ involvement, and gestational age at the time of onset.
Maternal Prognosis
The maternal prognosis in eclampsia varies depending on how early the condition is detected and treated. With modern obstetric care—including close monitoring, antihypertensive therapy, and seizure control—most women recover fully. However, maternal complications can be significant, especially in cases with delayed diagnosis or inadequate medical intervention.
Key maternal complications include:
🔹 Seizure-related injuries, such as tongue biting, head trauma, or aspiration pneumonia
🔹 Cerebral hemorrhage or stroke, particularly in patients with very high blood pressure
🔹 Acute kidney injury (AKI) due to renal vasoconstriction or thrombotic microangiopathy
🔹 Pulmonary edema, which may result from fluid overload or cardiac dysfunction
🔹 HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelet count)
🔹 Liver rupture or subcapsular hematoma in severe cases
🔹 Disseminated intravascular coagulation (DIC), leading to bleeding complications
Early and aggressive management improves outcomes, but some women may have residual neurological deficits or long-term renal impairment, particularly after severe or prolonged seizures.
Maternal Morbidity and Mortality
Globally, eclampsia accounts for 10–15% of maternal deaths, making it one of the top five direct causes of maternal mortality. In low-resource settings, mortality rates may reach 10–15% or higher due to lack of access to emergency obstetric care, medications (e.g., magnesium sulfate), and intensive monitoring.
Even in high-resource settings, maternal morbidity remains high due to complications like ICU admission, need for mechanical ventilation, and emergency cesarean delivery. The risk of recurrent eclampsia in future pregnancies is approximately 2–5%, although the recurrence of preeclampsia may be much higher (15–20%).
Fetal and Neonatal Prognosis
Fetal and neonatal outcomes in eclampsia are heavily influenced by gestational age at onset, severity of placental dysfunction, and timing of delivery. Common complications include:
🔹 Preterm birth due to the need for early delivery
🔹 Intrauterine growth restriction (IUGR) due to poor placental perfusion
🔹 Hypoxia and acidosis, leading to low Apgar scores or neonatal encephalopathy
🔹 Stillbirth, especially in cases where placental abruption occurs
🔹 Neonatal intensive care unit (NICU) admission is common
Perinatal mortality in eclampsia ranges from 5% to 20%, with much higher rates in developing countries. However, with access to timely obstetric and neonatal care, many infants can survive and thrive.
Long-Term Prognosis for the Mother
Eclampsia is not just a pregnancy complication—it is also a marker of long-term cardiovascular and renal risk. Women who have experienced eclampsia or severe preeclampsia are at higher risk for:
🔹 Chronic hypertension
🔹 Ischemic heart disease and stroke
🔹 Chronic kidney disease (CKD)
🔹 Recurrence in future pregnancies
For this reason, long-term follow-up is recommended, including lifestyle modification, cardiovascular risk screening, and preconception counseling before future pregnancies.
Eclampsia remains a serious obstetric emergency with potentially life-threatening consequences. While the prognosis has improved dramatically in well-equipped healthcare settings, maternal and fetal outcomes are still poor where access to care is limited. Prompt recognition, timely delivery, and intensive postpartum monitoring are key to improving survival. Additionally, women with a history of eclampsia require long-term follow-up for cardiovascular and renal health.(alert-passed)
