ECLAMPSIA

Supervised by :
dr. Ismu Setyo Djatmiko, Sp.OG

Muhamad Faisal Khishotul Hayati Agnes Widiartika

INTRODUCTION
Background
Definition

Eclampsia refers to the occurrence of new-onset,

generalized, tonic-clonic seizures or coma in a
woman with preeclampsia.
It typically occurs during or after the 20th week of
gestation or in the postpartum period.
Epidemiology

10% About 2% of women

with eclampsia develop
of all pregnancies are eclampsia with future
complicated by hypertension. pregnancies.

5 % of patients with hypertension

develop severe preeclampsia

Most cases of eclampsia present in the 3rd trimester of pregnancy, with about 80% of
eclamptic seizures occurring intrapartum or within the first 48 hours following delivery.
Course of Eclamptic Seizures
Facial
Eclampsia manifests as 1 twitching Distortion
seizure or more, with each
Protrusion
seizure generally lasting 60 Foaming
-75 seconds.
Respiration
Phase 1 lasts 15-20 seconds and begins ceases
with facial twitching. The body becomes
rigid, leading to generalized muscular
contractions.

Phase 2 lasts about 60 seconds. It starts in

Rigid
the jaw, moves to the muscles of the face
and eyelids, and then spreads throughout
the body.
The muscles begin alternating between
contracting and relaxing in rapid sequence.
A coma or period of unconsciousness,
lasting for a variable period, follows
phase 2.
After the coma phase, the patient may
regain some consciousness.
Principles of Therapy
Resucitation
Airway
Breathing
Circulation

Anticonvulsan
MgSO4

Anti Hypertension
Nifedifine
Methyl dopha

Termination
CASE
Patient’s Identity
Name : Mrs. F
Date of birth / Age : January 30th 1998 / 20 years old
Nationality : Indonesian
Address : Kec. Cireunghas, kab.Sukabumi
Marital status : Married
Occupation : House wife
Religion : Moslem
Date of admission : Desember 13th, 2018
Date of examination : Desember 13th, 2018
Anamnesis
P1A0 known to be Seizure by the patient's family
10 minutes before admitted to the hospital. Seizures
occured in Ruang Tanjung RS. Syamsudin twice and
repeated twice in the Emergency Units. The duration of
seizures was 1-2 minutes with the characteristic was
protrusion of the eyes, the head turned to the right side,
facial twitching followed body rigidity, leading to generalized
muscular contractions.
The muscles began alternating between contracting and
relaxing in rapid sequence. After the seizure the patient
was unconscious for several minutes. When she regained
consciousness, the patient did not remember what
happened at all.
 Patients claimed to have given birth to her first
child at the Puskesmas 5 days before being hospitalized. A
history of hypertension in pregnancy was recognized at
8 months with the highest blood pressure of 170/100 mmHg.
Patients had severe headache and blurred vision 1 day
before labor. Epigastric pain was denied.
 History of Past Illness
History of fever : Denied
History of seizure : Denied
History of hypertension : Denied
History of diabetes melitus : Denied
History of trauma : Denied
History of TBC : Denied
History of surgery : Denied
History of TORCH : Denied
 Menstrual History
a. Menarche : 13 years old
b. Menstrual cycle : regular, 28 days, with duration of 7 days,
dysmenorrhea (-)
c. Total pads : 3 pads/day
Anamnesis
Marital History
Married once, been married for 5 years now, when her
husband was 14 years old

Medication History
Patient used Vitamins and Anti hypertensive therapy
during pregnancy, but patient doesn’t know the drugs
name.
Anamnesis
Obstetric History
P1A0
1st day of last menstrual cycle : Februari 2018
Contraception : Injection Contraception/month (2015-2017)

Antenatal Care History

Patient had antenatal care with a midwife 5 times.

Gestational History
No Years Gestational age Labour history Sex Birth weight
1 2018 39 weeks Pervaginam female 2000 grams
General Examination
General Condition : Moderately Ill
Consciosusness : Compos Mentis
GCS : E4M6V5 (compos mentis)
Vital Sign
Blood Pressure : 140/110 mmHg
Heart Rate : 98 BPM
Respiratory Rate : 21x/minute
Temperature : 36,70 C
Nutritional Status
Weight : 50 Kg
Height : 150 Cm
BMI : 21
 Physical Examination

1. Head : Normocephal
2. Eyes : Anemic Conjuctiva -/- , Icteric Sclera -/-
3. Mouth : Wet oral mucosa membrane
4. Neck : Thyroid enlargement (-), KGB (-)
5. Thorax
a. Heart : regular 1st and 2nd heart sounds, murmur -, gallop –
b. Lung
 Inspection : symmetric chest expansion in both static and dynamic
 Percussion : sonor on both lungs
 Auscultation: vesicular breath sounds left = right, rhonchi -/- , wheezing -/-
Abdomen
a. Inspection : flat
b. Palpation : soft, fundal height 2 fingers above symphysis-pubic
c. Auscultation : bowel sound (+), 6 x/minute
Extremities : warm, edema -/-/-/-
a. Physiological reflex ++/++/++/++
b. Pathological reflex -/-
c. Nuchal rigidity (-)
Gynecological Examination
External exam :
 Groin and pubic
Inguinal region :
- Inspection :
Erythema (-), Erosion (-), Ulcer (-), Papules (-), Vesicle (-),
Fissure (-) Warts (-)
- Palpation :
Mass (-) Limphadenopathy (-)
 Genital externa
1. Pubic hair : Lice (-)
2. Clitoris : Edema (-)
3. Urethra paraurethra gland : Erythema (-) , Edema (-), Lession (-)
4. Urethra discharge : (-)
5. Vulva and vaginal opening : Edema (-) , Erythema (-), Erosion (-), Ulcer (-),
Papules (-), Vesicle (-), Fissure (-), Warts (-)
1. Vaginal discharge : (-)
2. Perineum : Lacerations (-), STD lesions (-), Rashes (-)
3. Bartholin gland : Edema (-)
Inspekulo :
- Vulva normal
- Perineum found sutured wound with minimal bleeding
- Vaginal wall normal
- Portio closed
- Blood (+) from OUI, fluor (-), odor (-)
Vaginal toucher :
- Vulva/vagina normal
- Vaginal wall normal
- Portio soft
- Right and left adnexa normal
- Cavum douglas normal
- Fluxus (+), fluor (-)
Laboratory Examination
13-12-18 Reference Value Unit
Hb 14,2 12-14 g/dL
Leukocyte 12,100 4.000-10.000 /µL
Hematocrit 42 37-47 %
Erythrocyte 4,5 3.8-5.2 million/µL
MCV 92 80-100 fL
MCH 32 26-34 Pg
MCHC 34 32-36 g/dL
Thrombocyte 220.000 150.000-450.000 /µL
Blood Glucose 93 <140 mg/dL
SGOT 80 <31 U/l
SGPT 61 <32 U/l
Ureum 13 15-36 mg/dL
Creatinin 0,42 0,52-1,04 mg/dL
Natrium (Na) 142 137-150 mmol/L
Potassium (K) 3,2 3,5-5,5 mmol/L
Calsium 9,4 8-10,4 mmol/L
Chloride (Cl) 101 94-108 mmol/L
Urinalisis Results Unit Reference Value
Colour Yellow yellow
Appearance Clear Clear
pH 1.010 4,6-8,0
Specific Gravity 1,020 1,005-1,003
Leukocyte Negative cell/µL Negative
Nitrite Negative mg/dL Negative
Protein Negative mg/dL Negative
Ketones Negative mg/dL Negative
Urobilinogen Normal mg/dL <1
Bilirubin Negative Negative
Eritrocyte Negative cell/µL Negative
Microscopic
Leukocyte 1-3 LPB <6
Erythrocyte 0-1 LPB <3
Epithel Positive LPK 1~15
Cylinder Negative LPB Negative
Crystal Negative LPB Negative
Bacteria Negative LPK Negative
Working Diagnosis
P1A0 Partus maturus (5 days) in Primary Health Care, Post partum eclampsia.

MANAGEMENT
Oxygen 5-6 lpmnasal canule
MgSO4 20% 4 gr RL 100cc  MgSO4 20% 10 gr RL 500 cc
Nifedipine 10 mg oral/30 minutes (max 120 mg/24 hours) Nifedipine 3x10 mg/oral
Ceftriaxone 2x1 gr
ICU care
Consult anaesthesiologist and neurologist
Vital sign observation
What is the diagnosis based on history taking,
PE and additional exam?

P1A0 Partus Maturus (5 days)

in Primary Health Care with
Post Partum Eclampsia.
Based on History taking :
Convulsed 10 minutes before admitted to the hospital. Seizures
occured 2 times and repeated twice.
Muscles began alternating between contracting and relaxing in
rapid sequence. After the seizure the patient was unconscious
for several minutes.
After labor 5 days.
A history of hypertension in pregnancy: on 8 months with the
highest blood pressure of 170/100 mmHg
Severe headache
Blurred vision
Physical Examination:
Level of consciousness : Compos mentis
Blood Pressure 150/90 mmHg

Laboratory examination:
SGOT : 80 U/I
SGPT : 61 U/I
Ureum : 13 mg/dL
Creatinin : 0.42 mg/dL
Definition of Eclampsia
Convulsion and or loss of consciousness in
a woman with preeclampsia that cannot be attributed
to another cause.
• Severe headache
• Blurred vision
• Epigastric pain

Physical Examination:
• Level of consiousness: somnolent – coma
• Blood Pressure >140/90 mmHg
 Depending on convolution appears,
eclampsia divided into:

• Antepartum eclampsia: before labor

• Intrapartum eclampsia: during labor
• Postpartum eclampsia: after labor. Postpartum eclampsia
can occur immediately (early postpartum, 24 hours until 7
days after labor) or later (late post partum, more than 7 days
during the puerperium. Late post partum eclampsia is rare.
What the risk factor of the patient?

Primigravida / Primiparitas
Risk Factor of Eclampsia

• Poor outcome of previous

pregnancy, including
History of intrauterine growth retardation,
Nulliparity PRIMIGRAVIDA Pre/eclampsia
abruptio placentae, or fetal
death.

• Multifetal gestations,
Teen Lower hydatid mole, fetal hydrops,
Pregnancy > 35 years old socioeconomic primigravida
status
How to exclude the differential
diagnosis of the other seizures?
Epilepsy

• At least two unprovoked (or reflex) seizures occurring >24 h apart;

• one unprovoked (or reflex) seizure and a probability of further seizures
similar to the general recurrence risk (at least 60%) after two unprovoked
seizures, occurring over the next 10 years;
• Diagnosis of an epilepsy syndrome.

In this patient:
Seizure occur 4 times in 24 hours, and no seizures occurring >24 h apart.
History of seizures denied.
Meningitis

• Fever
• Severe headache
• Nuchal rigidity

In this patient:
o No history of fever, chronic cough.
o Neurological examination within normal limits.
Head injury:
In this patient: no history of trauma.

Cerebrovascular disease:
No history of stroke, deep vein thrombosis, TIA, aneurysm,
and other disease.
ECG: within normal limit

Metabolic disorder:
Laboratory examination within normal limit
 What is the management
for the patient appropiate?
• Resusitation
Oxygen 15 lpm simple maskNRM

• Control and preventing recurrent convultions

MgSO4 20% 4 gr RL 100cc  MgSO4 20% 10 gr RL 500 cc

• Management of hypertension
Nifedipine 10 mg oral/30 minutes (max 120 mg/24 hours) 
Nifedipine 3x10 mg/oral
Resusitation

• Call for help

• Don't leave the patient
• Prevent trauma (wide bed, fix enough)
• If the patient has a seizure:
• Prepare seizure equipment (suction, Oxygen mask, tongue spatel, etc.)
• Left tilt position
• Oxygen 4-6 lpm
• Anti convultant: MgSO4
 Control and preventing recurrent convultions

• Using an intravenously administered loading dose of magnesium

sulfate that is followed by a maintenance dose, usually IV,
of magnesium sulfate
• INITIAL DOSAGE - 4 g of MgSO4 in 100 cc RL (given in 15-20
minutes)
• MAINTENANCE DOSAGE - 10 g in 500 cc RL with rates 1-2 g /
hour (20-30 tpm)
• RECURRENT CONVULTION - 2 g MgSO4 bolus IV
Terms MgSO4 administration:
• Patellar reflex (+)
• Breath Frequency > 16x / minute
• Minimum urine production of 0.5 cc / kg / hour or 25
cc / hour (last 4 hours)
• Available antidote  Ca Glukonas 10%

If there is a sign of intoxication  STOP MgSO4! 

Give antidote
Management of Hypertension

Dangerous hypertension can cause cerebrovascular hemorrhage and

hypertensive encephalopathy, and it can trigger eclamptic convulsions
in women with preeclampsia. Other complications include hypertensive
afterload congestive heart failure and placental abruption. Because of
these sequelae, the National High Blood pressure Education Program
Working Group (2000) and the 2013 Task Force

Antihypertensive recommendations in pregnancy:

• Systolic ≥ 160 mmHg or
• Diastolic ≥ 110 mmHg
Essential Antihypertensive:

• Nifedipine: recommend a 10-mg initial oral dose to be repeated in 30

minutes if necessary
• Methyldopa
• Hidralazin: intravenously with a 5-mg initial dose, and this is followed
by 5- to 10-mg doses at 15- to 20-minute intervals until a satisfactory
response is achieved. limit the total dose to 30 mg per treatment cycle
• Labetalol: we give 10 mg intravenously initially. If the blood pressure
has not decreased to the desirable level in 10 minutes, then 20 mg is
given. The next 10-minute incremental dose is 40 mg and is followed
by another 40 mg if needed. If a salutary response is not achieved,
then an 80-mg dose is given. maximum dose of 220 mg per treatment
cycle.
The target of decreasing BLOOD PRESSURE is 20% from MAP [(1S + 2D) / 3]

If blood pressure is 140-159 / 90-109 mmHg:

Started: calcium channel blocker group (nifedipine)
Continued: methyldopa or other beta blockers (propanolol, acebutolol, etc.)

For cases of postpartum and breastfeeding:

Methyldopa, nifedipine, captopril
Termination of pregnancy

• All cases of eclampsia are terminated without regard to gestational age.

• Termination is carried out after stabilization of the mother's condition.
• Eclampsia is not an indication of SC.
• Principles of labor: 1 and 2 Phase accelerated
• The treatment of eclampsia patients is multidisciplinary with intensive care
• Maintain BP <160/110 mmHg during labor
Pospartum Care

• Anticonvulsants are continued until 24 hours

post-partum / from the last seizure
• Antihypertension is still given
• Monitoring fluid
 Conclusion

• Diagnosis of this patient is correctly made

• The risk factor of this patient is primipara
• Differential diagnosis of this patient is excluded
• Management in this is correctly made
Thank you