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The occurrence of seizures defines eclampsia It is a manifestation of severe central nervous system involvement The other abnormal findings of severe preeclampsia are also observed with eclampsia
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Preeclampsia-eclampsia can mimic and be confused with many other diseases, including chronic hypertension, chronic renal disease, primary seizure disorders, gallbladder and pancreatic disease, immune or thrombotic thrombocytopenic purpura, and hemolytic-uremic syndrome It must always be considered a possibility in any pregnant woman beyond 20 weeks of gestation It is particularly difficult to diagnose when preexisting disease such as hypertension is present Uric acid values can be quite helpful in such situations, since hyperuricemia is uncommon in pregnancy except with gout, renal failure, or preeclampsia-eclampsia
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Early recognition is the key to treatment This requires careful attention to the details of prenatal care especially subtle changes in blood pressure and weight The objectives are to prolong pregnancy if possible, to allow fetal lung maturity while preventing progression to severe disease and eclampsia The critical factors are the gestational age of the fetus, fetal pulmonary maturity status, and the severity of maternal disease Preeclampsia-eclampsia at 36 weeks or more of gestation is managed by delivery regardless of how mild the disease is judged to be Prior to 36 weeks, severe preeclampsia-eclampsia requires delivery except in unusual circumstances associated with extreme fetal prematurity, in which case prolongation of pregnancy may be attempted Epigastric pain, thrombocytopenia, and visual disturbances are strong indications for delivery of the fetus For mild to moderate preeclampsia-eclampsia, bed rest is the cornerstone of therapy This increases central blood flow to the kidneys, heart, brain, liver, and
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1 Emergency care If the patient is convulsing, she is turned on her side to prevent aspiration and to improve blood flow to the placenta Fluid or food is aspirated from the glottis or trachea The seizure may be stopped by giving an intravenous bolus of either magnesium sulfate, 4 g, or diazepam, 5 10 mg, over 4 minutes or until the seizure stops A continuous intravenous infusion of magnesium sulfate is then started at a rate of 2 3 g/h unless the patient is known to have significantly reduced renal function Magnesium blood levels are then checked every 4 6 hours and the infusion rate adjusted to maintain a therapeutic blood level (4 6 mEq/L) Urinary output is checked hourly and the patient assessed for signs of possible magnesium toxicity such as loss of deep tendon
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reflexes or decrease in respiratory rate and depth, which can be reversed with calcium gluconate 2 General care The occurrence of eclampsia necessitates delivery once the patient is stabilized It is important, however, that assessment of the status of the patient and fetus take place first Continuous fetal monitoring must be performed and blood typed and cross-matched quickly A urinary catheter is inserted to monitor urinary output, and blood is sent for complete blood count, platelets, liver enzymes, uric acid, creatinine or urea nitrogen, and electrolytes If hypertension is present with diastolic values over 110 mm Hg, antihypertensive medications should be administered to reduce the diastolic blood pressure to 90 100 mm Hg Lower blood pressures than this may induce placental insufficiency through reduced perfusion Hydralazine given in 5- to 10-mg increments intravenously every 20 minutes is frequently used to lower blood pressure Nifedipine, 10 mg sublingually or orally, or labetalol, 10 20 mg intravenously, both every 20 minutes, can also be used 3 Delivery Except in unusual circumstances, delivery is mandated once eclampsia has occurred Vaginal delivery may be attempted if the patient has already been in active labor or the cervix is quite favorable and the patient is clinically stable The rapidity with which delivery must be achieved depends on the fetal and maternal status following the seizure and the availability of laboratory data on the patient Oxytocin may be used to induce or augment labor Regional analgesia or anesthesia is acceptable Cesarean section is used for the usual obstetric indications or when rapid delivery is necessary for maternal or fetal indications 4 Postpartum Magnesium sulfate infusion (2 3 g/h) should be continued until preeclampsia-eclampsia has begun to resolve postpartum (which may take 1 7 days), but in any case for at least 24 hours The most reliable indicator of this resolution is the onset of diuresis with urinary output of over 100 200 mL/h When this occurs, magnesium sulfate can be discontinued Late-onset preeclampsia-eclampsia can occur during the postpartum period It is usually manifested by either hypertension or seizures Treatment is the same as prior to delivery ie, with magnesium sulfate although other antiseizure medications can be used since the fetus is no longer present
Levine R et al Soluble endoglin and other circulating antiangiogenic factors in preeclampsia N Engl J Med 2006 Sep 7;355(10):992 1005 [PMID: 16957146] Sibai BM Diagnosis, prevention, and management of eclampsia Obstet Gynecol 2005 Feb;105(2):402 10 [PMID: 15684172]
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