Management of eclampsia in the prehospital setting

Eclampsia is an uncommon and serious condition, particularly in the pre-hospital setting. Immediate treatment is required and should include airway control, administration of oxygen, anti-epileptics and magnesium, hypertension control, and urgent delivery of the baby.

CASE REPORTS
Case 1
A call was received to a 34-year-old unconscious pregnant woman. On arrival the patient was found to be conscious, with normal heart and lung sounds, a blood pressure of 130/90 mm Hg and a pregnancy of 28 weeks duration. The husband reported hearing loud snoring when he and his wife were sleeping, and he was unable to wake her. The pregnancy was problem-free except for a small bleed during the early stage. During questioning, the patient developed a generalised tonic–clonic seizure. Diazepam 5 mg was administered and she was taken to hospital with a diagnosis of eclampsia without complications.

Case 2

A 25-year-old pregnant woman’s family called for assistance when the patient suffered seizures. On arrival the woman appeared to be 34 weeks pregnant and presented with hypertension but did not otherwise fulfil the criteria of pre-eclampsia. The family said that she had undergone an episode of strange movements that had lasted 2 min. The patient was conscious but exhibited a tendency to sleep. The blood pressure was 140/90 mm Hg and there were no other abnormal findings. During the transfer to hospital, the patient suffered a generalised tonic–clonic seizure lasting 30 s. She was treated with 3.5 g of magnesium sulfate diluted in 250 ml of crystalloid. The transfer was completed without additional complications.

DISCUSSION

The hypertensive disorders of pregnancy include hypertension before pregnancy, chronic hypertension, and gestational hypertension. When gestational hypertension is accompanied by proteinuria, the disorder is termed pre-eclampsia. Eclampsia is defined as the occurrence of seizures in women with pre-eclampsia. Eclampsia affects 1 in 2000 pregnancies in the UK with a mortality rate of 1.8%. In the last two decades, it has been recognised that pre-eclampsia and eclampsia are part of a multisystemic syndrome characterised by vasoconstriction, metabolic changes, endothelial dysfunction, activation of the coagulation cascade, and increased inflammatory response.

The clinical signs and symptoms of severe disease in patients with pre-eclampsia include blood pressure >160 mm Hg systolic or >110 mm Hg diastolic, or an increase of 30/15 mm Hg from baseline (as in case 1); proteinuria > 5g/24 h; elevated serum creatinine >1.2 mg/dl (106 µmol/l); grand mal seizures (eclampsia); pulmonary oedema; oliguria <500 ml/24 h; microangiopathic haemolysis; thrombocytopenia, platelet count <100 000; elevated hepatic enzymes; oligohydramnios; and symptoms suggesting end-organ involvement such as headache, visual disturbances, and epigastric pain. The HELLP syndrome is a variant of pre-eclampsia, and is characterised by haemolytic anaemia (H), elevated hepatic enzymes (EL), and low platelets (LP). Outside of hospital some of this information may be obtained form patient-held clinical records.