Hx: A previously healthy 15 yo female presents by EMS for a generalized seizure. The patient is post-ictal and unable to give any history on arrival. The paramedics state they were called to the scene for a seizure and found the patient post-ictal on arrival. Minimal history was obtained from family on scene but there is no history of prior seizures. The patient had a second seizure in route to the ED and received a single dose of diazepam 5mg IV with termination. When the patient’s mother arrives later she confirms the patient has no past medical history.
PMHx: none
SocHx: none
Exam:
- Vitals: Pulse 100, BP 160/100, RR 20, Temp 98.9F, O2Sat 100% with a NRB mask
- General: obese female, appears 15 yo, post-ictal, poorly arousable
- HEENT: normal head, atraumatic, TM’s clear, pharynx clear, normal tongue, gag reflex present
- Resp: clear to auscultation, adequate respirations, good air movement
- Cardiovascular: tachycardic, regular, no murmurs, symmetrical pulses x 4 extremities
- Abdomen: obese, no masses, soft, no pain response with palpation
- Extremities: no deformity, warm
- Neuro: withdraws to pain, pupils 4mm bilaterally, eyes midline, no rigidity, no spontaneous movement
Differential:
- toxic ingestion
- illicit drug use (cocaine, amphetamines)
- intracranial mass
- intracranial hemorrhage
- arrhythmia (hypkalemia)
- head injury, trauma
- CVA
- withdrawal seizure (alcohol, benzodiazepine)
- pregnancy
ED Course:
- IV access, monitor, pulse oximtery, IV fluid bolus, interview of family is conducted.
- Patient has a generalized tonic clonic seizure shortly after arrival and receives 1 mg lorazepam IV with termination.
- Patient is taken for CT of the head and has a second seizure where she is given another 1 mg lorazepam dose with termination.
- When patient is returned to the room, she is post-ictal, but has not awakened between seizures. Discussion with family regarding differential.
- Patient has a third seizure and final lorazepam 1mg dose IV is given with plans for RSI and propofol infusion.
- Prior to RSI, mom alerts staff that patient appears to be passing something vaginally.
- Immediate examination reveals patient is delivering a baby, appears to be 20-22 weeks gestation.
- Neonatal team is alerted as baby is delivered but shows obvious signs of intra-uterine demise. A brief resuscitation of the baby is attempted with intubation and IV epi without success.
- Meanwhile, the patient is intubated with RSI and placed on propofol infusion while 4 gram bolus of Magnesium is initiated IV for eclampsia.
- Labetalol is given IV for BP control (20 mg boluses)
- Family was unaware of patient’s pregnancy or sexual activity.
Hospital Course:
- The patient is admitted to the ICU where EEG shows no further seizure activity.
- After 24 hours of magnesium infusion and continued labetalol for BP management the patient is extubated.
- She survives to discharge, neurologically intact.
Diagnosis: Eclampsia
Discussion: Eclampsia is a pregnancy related condition consisting of generalized tonic-clonic seizures and coma that occur after a period of pre-eclampsia. Seizures are often preceded by: (see references)
- hypertension (75%) – with almost half being only mild hypertension.
- headache (66%)
- visual disturbances (27%)
- right upper quadrant or epigastric pain (25%)
- asymptomatic (25%)
Although ecplampsia is often discussed as occurring during pregnancy, up to 21% of cases occur post-partum, with 20% intrapartum, and 59% antepartum.
Treatment of eclampsia is focused on prevention of recurrent seizures, treatment of hypertension, supportive care, and delivery of baby if pregnant:
- Magnesium sulfate is given as a bolus of 4-6 grams over 15min followed by an infusion of 2 grams/hour and typically continued for 24-48 hours post delivery. Magnesium is given to prevent further seizures and has been proven to be far more effective than traditional anti-epileptic medications in this scenario. If it does not result in prompt resolution of seizures, second line agents include benzodiazepines and a pathway similar to status epileptics. At this point, imaging and neurology consultation for EEG is suggested to guide management.
- Labetalol or other IV agents are given to manage blood pressure and reduce systolic below 160 and diastolic below 105
- Prompt delivery of the baby is required as expectant management has been shown to fail, despite adequate medical therapy.
Women with eclampsia are at increased risk of developing pre-eclampsia with subsequent pregnancies.
References:
