A woman in her third trimester is brought into the emergency department for a "scary fall." Unfortunately, no one knows her and she has not been receiving prenatal care. She is an African American teenager who is clearly in the third trimester of pregnancy, but dating is unknown. Bystanders witnessed her falling with brief flexion of her arms, upward deviated eyes, extension of the back, arms, and legs, and crying out. This was followed by brief, violent muscle contractions, cyanosis, foamy salivation at the mouth, and loss of bladder control. All of this resolved by itself within one minute. Currently, she is confused, complaining about sore muscles and a headache. She is hypertensive. A urinalysis shows proteinuria.
Challenge: What's the diagnosis?
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eclampsia
Patient clearly has Ecclampsia.. Symptoms suggestive of Imminent Ecclampsia are Epigastric Pain (due to hepatic sub-capsular hemorrhage), blurring of vision, headache..
Ecclampsia may be treated using Pritchard Regimen (MgSO4)given as a loading dose intravenously (4mg) and intramuscularly (5mg over each gluteus- 10 mg)- therefore the total loading dose is 14mg. Thereafter, 5mg MgSO4 is given 4th hourly (in alternating glutei) for a total duration of 24 hours from the last seizure or the loading dose whichever comes later.
Monitor for toxicity of MgSO4 - Respiratory rate should not drop below 12/min, patellar reflex should remain ellicitable, urine formation should be maintained above 30 ml/hr.
Use I.V. bolus hydralazine to control the blood pressure (maintain diastolic below 90mm of Hg) while using Nifedipine or Methyl Dopa for longer control of B.P.
eclampsia, help syndrome
nice job! yes, it's eclampsia...not quite hellp yet (hemolytic anemia, elevated LFTs, thrombocytopenia). very useful about the MgSO4 and watching for toxicity, and yes, the ob/gyns like hydralazine. definitive treatment (like most things) is delivery of fetus.
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Shining Forth
In Greek, eclampsia means "shining forth" and is generalized seizures or coma in the setting of preeclampsia anytime from the second trimester to the puerperium.
Sources: UpToDate, Wikipedia.
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