A 32-year-old woman, gravida 2 para 1, at 37 weeks gestation is undergoing a prolonged induction of labor for a twin pregnancy. During the induction, the patient abruptly loses consciousness, has stiffness of the arms and legs, and then begins to have muscle jerking. She is unresponsive for several minutes, but slowly regains consciousness. The patient has been receiving an oxytocin infusion for the last 8 hours, and epidural analgesia was placed several hours ago after spontaneous rupture of membranes. She has no chronic medical conditions and takes no daily medications. Temperature is 37.2 C (99 F), blood pressure is 158/98 mm Hg, pulse is 118/min, and respirations are 24/min. The patient is alert but disoriented. The neck is supple. Heart sounds are regular, and the lungs are clear to auscultation bilaterally. Patellar deep tendon reflexes are 3+, and there are no focal neurologic deficits. Laboratory results are as follows:
| Complete blood count | |
| Hemoglobin | 10 g/dL |
| Platelets | 90,000/mm3 |
| Leukocytes | 14,000/mm3 |
| Serum chemistry | |
| Sodium | 134 mEq/L |
| Potassium | 3.6 mEq/L |
| Chloride | 104 mEq/L |
| Bicarbonate | 20 mEq/L |
| Creatinine | 0.7 mg/dL |
| Glucose | 80 mg/dL |
Which of the following is the best next step in management of this patient?
Eclampsia (preeclampsia + new-onset seizure) | |
Clinical features |
|
Diagnosis |
|
Management |
|
DBP = diastolic blood pressure; SBP = systolic blood pressure. | |
This laboring patient with tonic-clonic seizure likely has eclampsia. Eclampsia is the presumptive diagnosis in pregnant patients with new-onset seizure and preeclampsia with severe features, as in this patient with hypertension (ie, systolic ≥140 or diastolic ≥90 mm Hg in pregnancy) and thrombocytopenia (platelet count <100,000/mm3). Preeclampsia likely occurs due to an abnormal placenta that releases antiangiogenic factors, causing maternal endothelial dysfunction in the brain (eg, brain ischemia, seizure) and other end organs.
Eclampsia is classically preceded by severe headache or visual disturbances (eg, blurred vision, scotomata). However, not all patients have preceding neurologic symptoms. Eclamptic seizures are typically tonic-clonic, generalized, and brief, lasting up to a few minutes and followed by a postictal phase. During the postictal phase (typically lasting 10-20 min), the patient may be unresponsive, confused/disoriented, or drowsy. There are typically no associated focal neurologic deficits.
Eclampsia is a clinical diagnosis; however, brain imaging (eg, CT scan of the head) can be performed to exclude other causes of seizure. Because of the risk of seizure recurrence and maternal complications (eg, stroke), patients with eclampsia require prompt delivery because removal of the placenta is typically curative. Patients also require magnesium sulfate infusion to reduce the risk of seizure recurrence.
(Choice A) Oxytocin and antidiuretic hormone share a similar structure; therefore, prolonged or excessive oxytocin administration (eg, labor induction) can cause severe hyponatremia, leading to cerebral edema and seizure. This patient's only mild hyponatremia makes this diagnosis unlikely.
(Choice B) This patient with preeclampsia and new-onset seizure most likely has eclampsia and requires urgent delivery; however, if she continues to have seizures postpartum and brain imaging is normal, an electroencephalogram may be indicated to evaluate for other causes of seizure.
(Choice C) Emergency intubation is indicated for inadequate oxygenation (eg, pulmonary edema), ventilation, or airway protection (eg, high spinal anesthesia). In contrast, this patient is conscious with normal respirations and lung examination.
(Choice D) Epidural removal is indicated for local anesthetic systemic toxicity (LAST), which can present with generalized tonic-clonic seizures. However, LAST is typically associated with cardiovascular collapse (eg, hypotension), not hypertension.
Educational objective:
Patients with preeclampsia with severe features and new-onset seizure likely have eclampsia. Eclamptic seizures are typically tonic-clonic and generalized, last several minutes, and are associated with a postictal phase; there are usually no associated focal neurologic deficits. Treatment is with prompt delivery and magnesium sulfate infusion.