Chapter 3

Case analyisis
Problems :
1. How to diagnosed this patient ?
2. What are the management of this patient ?

How to diagnosed this patient?

a. Anamnesis
b. Physical Examination
c. Laboratory Examination

Theory
Anamnesis
Seizure (100%)
Headache (80%),

Case
usually

frontal
Generalized edema (50%)
Vision disturbance (40%),
such as blurred vision and

photophobia
Right
upper

quadrant

abdominal pain with nausea

(20%)
Amnesia and other mental

status changes
A coma or unconsciousness

Risk Factors:
Nulliparity
Family history of
preeclampsia, previous
preeclampsia and eclampsia
Poor outcome of previous
pregnancy,

She was seizures 4 times

She admitted headache, vision
disturbance such as blurred
vision and diplopa
She has abdominal pain
She was unconsciousness
during in emergency after
seizure
First pregnancy
Patients age 33 years old

Physical exam:

High blood pressure (160/100

mmHg)
Tachycardia (106 bpm)
Tachypnea (32x/min)
epigastric
abdominal
tenderness

including intrauterine
growth retardation, abruptio
placentae, or fetal death
Multifetal
gestations, hydatid mole,
fetal hydrops, primigravida
Teen pregnancy
Primigravida
Patient older than 35 years

Lab finding:

Protein

Pos++
Creatinine

0.73 mg/dL

Physical exam:

Sustained systolic BP greater

than 160 mm Hg or diastolic

BP greater than 110 mm Hg

Tachycardia
Tachypnea
Hyperreflexia
Papilledema
Oliguria or anuria
Localizing
neurologic

deficits
Right upper quadrant or
epigastric

abdominal

tenderness
Generalized edema
Small fundal height for the
estimated gestational age

Lab finding:
Proteinuria
Elevated creatinine level

Diagnosis
The frequency of prenatal visits is increased during the third trimester, and this aids early
detection of preeclampsia. The diagnostic criteria of the disease have been revised over the past
decade, such that edema is no longer required and even proteinuria without a worsening
creatinine level may be less of a concern than previously suspected. The progression of the

disease state is highly variable. It may worsen from a mild to severe state, or to eclampsia,
without warning, or it may be severe at the time of diagnosis.
Preeclampsia can quickly develop into eclampsia. The natural progression of the disease is from
symptomatic severe preeclampsia (differentiated from preeclampsia by specific vital signs,
symptoms, and laboratory abnormalities) to seizures.
Features of eclampsia include the following:

Seizure (100%)

Headache (80%), usually frontal

Generalized edema (50%)

Vision disturbance (40%), such as blurred vision and photophobia

Right upper quadrant abdominal pain with nausea (20%)

Amnesia and other mental status changes

A coma or unconsciousness
Outpatient surveillance is continued unless overt hypertension, proteinuria, headache,
visual disturbances, or epigastric discomfort supervene. Depending on whether convulsions
appear before, during, or after labor, eclampsia is designated as antepartum, intrapartum, or
postpartum. A coma or period of unconsciousness, lasting for a variable period. After the coma
phase, the patient may regain some consciousness, and she may become combative and very
agitated. However, the patient will have no recollection of the seizure. Eclampsia is most
common in the last trimester and becomes increasingly frequent as term approaches. Importantly,
other diagnoses should be considered in women with convulsions more than 48 hours postpartum
or in women with focal neurological deficits, prolonged coma, or atypical eclampsia.
Physical findings
Most patients with eclampsia present with hypertension and seizures, along with some
combination of proteinuria and edema. Findings at physical examination may include the
following:

Sustained systolic BP greater than 160 mm Hg or diastolic BP greater than 110 mm Hg

Tachycardia

Tachypnea

Mental status changes

Hyperreflexia

Papilledema

Oliguria or anuria

Localizing neurologic deficits

Right upper quadrant or epigastric abdominal tenderness

Generalized edema

Small fundal height for the estimated gestational age

Respirations after an eclamptic convulsion are usually increased in rate and may reach
50 or more per minute in response to hypercarbia, lactic acidemia, and transient hypoxia.
Cyanosis may be observed in severe cases. High fever is a grave sign as it likely emanates from
cerebrovascular hemorrhage. Proteinuria is usually, but not always. An increase in urinary output
after delivery is usually an early sign of improvement. If there is renal dysfunction, serum
creatinine levels should be monitored. In antepartum eclampsia, labor may begin spontaneously
shortly after convulsions ensue and may progress rapidly. If the convulsions occur during labor,
contractions may increase in frequency and intensity, and the duration of labor may be shortened.
Because of maternal hypoxemia and lactic acidemia caused by convulsions, it is not unusual for
fetal bradycardia to follow a seizure
Management of eclampsia
1. Magnesium Sulfate to Control Convulsions
It has been long recognized that magnesium sulfate is highly effective in preventing
convulsions in women with preeclampsia and in stopping them in those with eclampsia.
Magnesium sulfate administered parenterally is an effective anticonvulsant that avoids
producing central nervous
system depression in either the mother or the infant. It may be given intravenously by
continuous infusion or intramuscularly by intermittent injection Maintenance magnesium
sulfate therapy is continued for 24 hours after delivery. For eclampsia that develops
postpartum, magnesium sulfate is administered for 24 hours after the onset of
convulsions.

Initial dose
4g MgSO4 (10 cc MgSO4 40%) dissolved to ringer lactate 100cc in 15-20 minutes
Maintenance dose
10g to ringer lactate 500cc, given in 1-2g/hours
Benzodiazepines or phenytoin can be used for seizures that are not responsive to
magnesium sulfate. Avoid the use of multiple agents to abate eclamptic seizures, unless
necessary.

2. Control hypertension
The goal is to maintain systolic BP between 140 and 160 mm Hg and diastolic BP
between 90 and 110 mm Hg. Nifedipine : 10 mg per oral can repeat every 30 minutes up
to 120mg/24 hours, Nikardipine : given if the blood pressure > 180/110 mmHg with dose
1 ampul
3. Fluid Therapy
Lactated Ringer solution is administered routinely at the rate of 60 mL to no more
than 125 mL per hour unless there is unusual fluid loss from vomiting, diarrhea, or
diaphoresis, or, more likely, excessive blood loss with delivery. Oliguria is common with
severe preeclampsia. Diuretics are used only in the setting of pulmonary edema.
4. Steroids
A dose of antenatal steroids may be administered in anticipation of emergent
delivery when gestational age is less than 32 weeks. Betamethasone (12 mg IM q24h 2
doses) or dexamethasone (6 mg IM q12h 4 doses) is recommended.