Pioneer Medical Journal Vol. 3, No.

5, JANUARY - JUNE, 2013



Department Of Obstetrics and Gynaecology,
Federal Medical Centre, Umuahia.
Correspondence to:

Occurrence of Eclampsia before 20 weeks gestation, after 48 hours postpartum or in absence of
typical signs of hypertension and /or proteinuria is termed Atypical Eclampsia. We report a case
of a 27 year old booked para2
nurse with 2 living children who developed Eclampsia on the 6

postpartum day without preceding pre-eclampsia. Problems of atypical Eclampsia lie in its
unpredictable onset. A high index of suspicion and close follow-up will help in the early
detection of this condition. This is crucial especiallyin developing countries where Eclampsia is
a major cause of maternal mortality and facilities for timely diagnosis and management of these
cases are inadequate.
Key Words: Atypical Eclampsia, Management, Umuahia.

Eclampsia is defined as the development of convulsions and/or unexplained coma during
pregnancy or postpartum in patients with signs and symptoms of preeclampsia after 20 weeks
prepartum and before 48 hours postpartum

Occurrence of Eclampsia before 20 weeks, after 48 hours postpartum or in absence of typical
signs of hypertension and/or proteinuria is known as Atypical Eclampsia
.Eclampsia, as well as
Atypical Eclampsia, is an important cause of maternal mortality and morbidity
. Correct and
timely diagnosis and management of these cases is challenging for obstetricians.

Pioneer Medical Journal Vol. 3, No. 5, JANUARY - JUNE, 2013

We report a case of Atypical Eclampsia occurring on 6
postpartum day without prior history of

Mrs. U.O., a 27 year old Nurse, a booked para2
with 2 living children, who had elective lower
segment caesarean section at 39 weeks gestation on account of breech presentation with previous
caesarean section, with an outcome of a live female neonate with good Apgar scores and birth
weight of 3.6kg.

She had emergency lower segment caesarean section due to cephalopelvic disproportion in
labour in her previous pregnancy two year before. Her family history was unremarkable.
During this index pregnancy, her antenatal period was uneventful and she remained
normotensive. Her post-operative course was uneventful and she was discharged home on the 5

postoperative day.

On the 6
post operative day, however, she developed severe occipital and frontal headaches. On
the next day, she was managed in a peripheral hospital for a generalized tonic-clonic seizure and
had eight episodes of similar seizures, treated with 10mg of intravenous diazepam before being
transferred to our emergency department.

On admission in our facility, her Glasgow Coma Scale (GCS) score was 6, blood pressure
180/110 mmHg, pulse 120 beats/minute, respiratory rate 24 breaths/minute, and temperature
C. Her neck was supple and non-tender, and her pupils were equal and reactive to light.
Cardiovascular, respiratory, and abdominal examination findings revealed no abnormalities. The
ophthalmologic examination and laboratory results (full blood count serum electrolyte, urea,
creatinine, uric acid and calcium; liver function test; random blood sugar; coagulation profile;
cerebro-spinal fluid examination) were normal except urinalysis that revealed proteinuria of 1

Consultant Obstetrician and the anesthesiology team were immediately alerted and invited.
Immediate resuscitation measures were commenced, ensuring airway patency, breathing and
circulatory maintenance and monitoring of urinary output via an indwelling urethral catheter
Pioneer Medical Journal Vol. 3, No. 5, JANUARY - JUNE, 2013

connected to a uribag. MgSO
seizure prophylaxiswas commenced using Pritchard’s regimen.
Broad spectrum antibiotics and anti-malarial treatments were started. She had two further
episodes of similar seizures while being resuscitated necessitating intubation by
anaesthesiologists who were already on ground. She was immediately transferred to Intensive
Care Unit. (ICU) on mechanical ventilation. While on admission, neurology team and
cardiology team opinions were sought. Neurological examination findings were normal; though
Computed Tomography Scan (CT), Magnetic Resonance Imagining (MRI) and Electro
Encephalogram (EEG) requested were not done because of financial constraint. Cardiologists
excluded any cardiac cause. Patient was transferred to the ward from the ICU after 24 hours
when her condition was adjudged stable. Her condition remained stable for the next one week
and she was discharged home with a blood pressure of 100/60 mmHg, and a follow-up
appointment in clinic given. At follow-up visit, here blood pressure was 110/70 mmHg,
urinalysis was negative for protein and glucose and her wound had healed well. She was
referred to the family planning clinic for contraceptive counseling and told to book early in a
tertiary hospital in her future pregnancy.

Pre-eclampsia is a multisystem disorder. It usually warns about occurrence of Eclampsia
beforehand. However, hypertension is only one of the signs and is not always present in
preeclamptic patents developing Eclampsia
. It is difficult to predict which organ system will
predominantly be involved.

Eclampsia, a rare but serious complication of pre-eclampsia, becomes more problematic when it
develops without prior preeclamptic signs and symptoms
. Our patient remained free of signs
and symptoms throughout antenatal period and post-operative period until the 6
day when she developed neurological symptom (headache). Our diagnosis of Eclampsia was
based on the clinical presentation, biochemical findings and the exclusion of other underlying

Our differential diagnostic considerations included cerebral vein thrombosis, subarachnoid
haemorrhage from an aneurysm, hypertensive encephalopathy,previously undiagnosed brain
Pioneer Medical Journal Vol. 3, No. 5, JANUARY - JUNE, 2013

tumours. These differentials were ruled out on cardiac and neurological evaluation in our
patient. CT Scan, MRI and EEG requested to rule out these differentials were not done because
of financial constraints. Infectious disorders were unlikely because of the clinical course and
negative findings on cerebrospinal fluid study. Biochemical investigations ruled out metabolic
causes like hypoglycaemia and hypocalcaemia.

By definition, our patient had atypical Eclampsia since she developed seizure on the 6
operative/post-partum day without prior signs of pre-eclampsia (hypertension and proteinuria).
She only complained of headache a day before seizure manifestation, and this highlights the fact
that such prodromal symptom in post-partum women even in the absence of preceding
proteinuria and hypertension should cast suspicion on impending Eclampsia. Adie reported
162 cases of Eclampsia in a period of two years of which 8% (13) had features of atypical
eclampsia with normal blood pressure and without preeclampsia prodromi. In their study, post-
partum convulsions had occurred in 31% of patients
.In another study, Katz 53
cases of Eclampsia in the absence of pre-eclamptic signs. In their patients, seizures were the
main manifestation of disease in 60% of cases
, as observed in our patient. The most common
cause of convulsions in association with hypertension or proteinuria during pregnancy or
immediate post-partum is Eclampsia. However, late post-partum eclampsia is defined as
Eclampsia that occurs more than 48 hours, but less than four weeks, after delivery
. All
Eclamptic patientsin developing countries are at higher risk of maternal death
, mainly
because of poor utilization of maternity services and lack of intensive care facilities and man
power needed to manage the maternal complications from eclampsia
This however, was not
the case in our patient who had supervised pregnancy and delivery, and benefited from expert
management and intensive care facilities when atypical eclampsia developed. Low incidence of
eclampsia in developed countries is probably related to seizure prophylaxis in patients with
classic presentation of severe preeclampsia.

Current management schemes designed to prevent eclampsia are based on early detection of
preeclampsia and subsequent use of preventive therapy in such women. This management
schemes assume that the clinical course in the development of eclampsia is characterized by a
gradual process that begins with progressive weight gain followed by hypertension and
Pioneer Medical Journal Vol. 3, No. 5, JANUARY - JUNE, 2013

proteinuria, which is followed by the onset of premonitory symptoms, and ends with the onset of
generalized convulsions or coma

Most women who develop eclampsia do have prior history of pre-eclampsia. However, as
shown in the patient reported on as well as in other studies
,the onset of convulsions does not
necessarily follow the presumed progression from pre-eclampsia to eclampsia.

Eclampsia may be an unusual presenting scenario in atypical cases before detection of overt
hypertension or proteinuria. Even minor clues in diagnosis, such as a marginally elevated blood
pressure or trace proteinuria, may be critical for appropriate and timely management.
Obstetricians should be aware of atypical presentations, maintain a high level of suspicion, and
be ready to take immediate live-saving steps.

Pioneer Medical Journal Vol. 3, No. 5, JANUARY - JUNE, 2013

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