Postpartum eclampsia

A clinical study

LOKENATH BHOSE, M.B.B.S., D.G.O., M.R.C.0.G

Calcutta, India

I N R E c E N T years a decrease in the in- tion by age group and parity between pa-
cidence of convulsive toxemia of pregnancy tients with postpartum eclampsia and those
has occurred all over the world, mainly be- with antepartum eclampsia. But either type
cause of greater and better antenatal care. of eclampsia, compared with nonconvulsive
Simultaneously, a relative increase in the toxemia, was more common in younger
proportion of postpartum eclampsia has also women and in primiparas.
been reported.‘, 3 This factor, as well as the Mode of delivery. The high incidence of
significance of the condition for explanation operative vaginal delivery and abdominal
of the etiology of toxemia of pregnancy, to- delivery in antepartum eclampsia, compared
gether with the problems in the diagnosis, with both postpartum eclampsia and non-
prognosis, and treatment justify a clinical convulsive toxemia, was the result of the
study. rigid adoption of the policy of shortening
the second stage of labor by easy forceps
Material and incidence delivery as soon as possible. It may be noted
In the Chittaranjan Seva Sadan College here that none of the women with noncon-
Hospital, from September, 1956, to Decem- vulsive toxemia developed convulsion after
ber, 1960, among 35,020 pregnant women abdominal delivery.
admitted to the hospital beyond 28 weeks of Severity and number of convulsions. In
gestation, nonconvulsive toxemia was diag- the classification of 62 cases according to
nosed in 3,980 ( 11 .-l per cent) and convul- Eden’s criterion” (excluding prolonged
sive toxemia in 292 (0.8 per cent) (Table I). coma), it was found that 22 cases (35.5 pet
Of 3,980 patients with nonconvulsive tox- cent) were the severe type and 40 (64.5 per
emia, 30 ( 1 .Ol per cent) had antepartum cent ) were the mild type of eclampsia
eclampsia and 3 1 (0.78 per cent) had post- (Table IV). The total number of convul-
partum eclampsia. In 1 more patients with- sions was between 1 and 5 in 41 cases (66.1
out toxemia the convulsions started after the per cent) and above 10 in 17 (27.4 per
delivery. This paper presents a clinical study cent) of 62 cases of postpartum eclampsia.
of 35 patients with postpartum eclampsia, Toxemic condition before onset of con-
together with 27 patients (Table II) who vulsion. This was assessed on admission in
were admitted with postpartum eclampsia, 35 patients with postpartum eclampsia who
and who were delivered outside the hospital. were delivered in the hospital (Table VI.
Pre-eclampsia was noted in 30 (85.7 per
Clinical analysis cent) of 35 patients, 21 of which had a
Age and parity. Table III shows that blood pressure of 160/90 mm. Hg or more.
there was not much difference in distribu- Only hypertension (156/100 mm. Hg) was
present in 1 patient. The blood pressure was
less than 140/90 mm. Hg in the remaining
From the Department of Obstetrics 3 patients in whom edema and albuminuria
and Gynecology, the Chittaranjan Sew
Sadan College Hospital. were also absent; in 3 of these 4 patients,
Volume 89 Postpartum eclampsia 899
Number 7

however, hypertension and albuminuria de- per cent) of 62 patients of this series. The
veloped soon after delivery. interval was 20 hours and 15 days in the
Interval between delivery and first con- remaining 2 patients. The first convulsion
vulsion. Table VI shows that the first con- occurred within 3 hours in 33 (53.2 per
vulsion occurred within 12 hours in 60 (96.8 cent) patients and within 6 hours in -47
(75.8 per cent) patients.

Table I. Incidence of convulsive and non- Treatment

convulsive toxemias among obstetrical The routine medicinal treatment, also

patients in the Chittaranjan Seva Sadan reported previously’, ’ for all cases of
College Hospital (September, 1956, to eclampsia, consisted of the administration
December, 1960) of 12.5 mg. each of chlorpromazine hydro-
chloride and promethazine hydrochloride in
Cases 1 No. 1 %
25 ml. of 25 per cent glucose solution as a
Nonconvulsive toxemia 3,980 11.4 stat intravenous dose, followed by intra-
Convulsive toxemia 292 0.8
Nontoxemic 30,748 87.8 venous drip infusion of 540 ml. of 10 per
Total 35,020 100.0 cent glucose solution containing 50 mg. each
of the same two drggs. The drip infusion
was continued until the blood pressure br-
came stabilized at about the level of 130/90
Table II. Distribution of postpartum and
antepartum eclampsia mm. Hg, the convulsion ceased, and t!le
patient became restful. Next, intramuscular
injections of the same drugs were given in
doses of 25 mg. every 4 to 6 hours. A chlor-
promazine hydrochloride tablet of 25 mg.
Post- 27 9.2 35 46.7 62 16.9 was given orally twice daily for 7 days after
partum
the acute phase was over.
Ante- 265 90.8 40 53.3 305 83.1
partum* The rate of administration of the drip
Total 292 100.0 75 100.0 367 100.0 infusion was adjusted and controlled chiefly
*Includes intrapartum eclampsia. by the level of the blood pressure. When

Table III. Distribution of cases of nonconvulsive toxemia and anteparum and

postpartum eclampsia accordin g to age, parity, and mode of delivery

Eclampsia

Nonconuulsiue toxemia Antepartum Postpartum

No. 1 9% No. 1 7~ / No. 1 %

14 to 25 years 2,309 58.0 277 90.8 53 85.5

26 to 35 years 1,441 36.2 24 79 8 12.9
Above 35 years 230 5.8 4 1 .s 1 1.6

Parity
Primipara 1,500 37.7 239 78.4 45 72.6
Multipara 2,480 62.3 66 21.6 17 27.4

Delivery*
Spontaneous 3,665 92.3 126 42.8 34 94.4
vaginal
Forceps 241 6.1 122 41.5 f 5.6
Cesarean section 47 1.2 7 2.4 N 1 0.0
Others 19 0.4 39 13.3 Nil 0.0
*Confinement in hospital only.
 Table IV. Distribution of cases of Table VIII. Death and therapeutic
postpartum and antepartum eclampsia response in postpartum eclampsia
according to severity and the number of
convulsions I No. I cr,
Maternal death I 1.6
Fetal wastage
Stillbirth 0 n.n
Early neonatal death* i 13.9

Severity
Mild eclampsia 40 64.5 111 38.5
Control
Recurrence
of

Nonrecurrence
conmdsion
33
29
53.2
,-l6.8
Severe eclampsia 22 35.5 177 61.5
Control of hypertension
Total conLulsiofls Satisfactory 11 68.3
1 to5 41 66.1 80 27.8 Unsatisfactory 19 31.7
6tolO 4 6.5 79 27.4. “Death within 10 days of delivag among 36 infant\
Above 10 17 27.4 129 44.8 inclodinq rnn~ set of twins.

Table V. Presenting toxemia before onset of the patient remained restless or the convul-
convulsion sions continued, even after satisfactory con-
1 No. 1 % trol of the blood pressure was achievrtl,
Pre-eclampsia 30 85.7 sedatives like meperidine hydrochloride in
Chronic hypertension 1 2.9 usual doses. were administered in addition
None 4 11.4 to the usual routine. Table VII shows the
Total 35 100.0 additional drugs which were used in 26 of
62 patients.

Table VI. Delivery-onset of convulsion Results

interval There was 1 maternal death. ‘I’his patient
Interrd (hr.) 1 No. / %
was admitted in very poor condition with
pulmonary edema 3 hours after an unaided
Upto 33 53.2
3 to 6 14 22.6 spontaneous vaginal delivery in her homrx.
6to12 13 21.0 There were 14 convulsions which started
12to24 1 1.6
soon after deliL,ery; the last one occurred
Above 24 1 1.6
in the hospital before the routine treatment
Total 62 100.0
could be started. Autopsy was not don?.
Of 36 infants (including one set of twins)
Table VII. Drugs administered in addition delivered in the hospital, neonatal death
within 10 days of delivery occurred in 5
to the routine treatment with
(13.9 per cent1 cases. There was no still-
chlorpromazine hydrochloride and
birth (Table VIII).
promethazine hydrochloride
Symptomatic effects of therapy. Since the
No. treatment of eclampsia is essentially sympto-
Additional drugs cases
matic, amelioration of the main features,
Meperidine hydrochloride (intramuscular convulsion and hypertension. should also br
or intravenous”) 18
With magnesium sulfate (intramuscular) 1 recognized in the assessment of results.
With paraldehyde (intramuscular or In 29 (46.8 per cent) of 62 patients there
rectal”) 4 was no recurrence of convulsion after the
With thiopental sodium (intravenous) 2
With magnesium sulfate (intramuscular) treatment was started. The convulsions were
and paraldehyde (intramuscular) 1 controlled within 6 hours in 45 (72.6 per
Total 26 cent) patients, and within 13 hours in 56
TWO cases. (90.3 per cent) patients.
 Postpartum eclampsia 901

A satisfactory control of hypertension was nosis, and moist rales at the bases of the
achieved in 41 (68.3 per cent) of 60 pa- lungs. Typical eclamptic convulsions con-
tients. In these patients the blood pressure tinued for 12 hours and 45 minutes befort>
was reduced below 130/90 mm. Hg within the patient recovered. Convulsions recurred
2 hours and the low level was maintained eighteen times in the hospital. With tht%
throllghout the acute phase: with the ex- investigations usually performed, eclampsia
ception of one or two short-lasting rises. as the cause of these convulsions could not
In the remaining 19 (31.7 per cent) patients be ruled out.
the control was considered unsatisfactory. Comparative study of postpartum and
Initial hypotension, before the treatment antepartum eclampsia during the period 01
was started, occurred in 2 patients. review revealed that while there was not
much difference in respect to age and parit)
Comment distribution, other factors related to thr
Although there has been a reduction in severity of the disease and its control
the incidence of eclampsia in the Chit- showed some contrast.
taranjan Seva Sadan Hospital from 4 pe1 It was found that mild eclampsia oc-
cent of all confinements from 1931 to 1935, curred more frequently in postpartunl
to 1 .l per cent from 1956 to 1960, the pro- eclampsia (64.5 per cent) than in ante-
portion of postpartum eclampsia has re- partum eclampsia (38.5 per cent). The in-
mained more or less the same (19.0 and cidence of cases in which the total number
15.8 per cent, respectively). This indicates of convulsions did net exceed 5 was 66.1
a simultaneous decrease in number of both per cent in postpartum eclampsia, bu; onI)
the types of convulsive toxemia among 27.8 per cent in antepartum eclampsia. Con-
women, most of whom did not have ade- vulsions did not recur after the treatment
quate antenatal treatment. Rut during the was started in 46.8 per cent of the cases
period of review, among 75 women who of postpartum eclampsia and 33.6 per cent
developed eclampsia after the institutional of the cases of antepartum eclampsia. In
treatment was started, the onset of post- 68.3 per cent of the cases of postpartunl
partum convulsion occurred in 35 (46.7 eclampsia a satisfactory control of blood
per cpnt ) . pressure was obtained. The corresponding
In this series the convulsion started within figure of antepartum type was 49.6 per
12 hours of delivery in 96.8 per cent of cent.
cases. This experience is in agreement with The fetal results, a!> expected, showed a
that of other authors.‘, ‘, ‘-’ remarkable difference. While in postpartuni
The study of literature showed a marked cases, all infants delil.ered in the hospital
difference in opinion about the limitation were liveborn, the stillbirth rate with ante-
of the delivery-convulsion interval in post- partum eclampsia was 32.9 per cent. Early
partum eclampsia that has varied at 24 neonatal death in postpartum and ante-
hours” 30 hours,S 4 days,:‘. ’ and 7 days.” partum eclampsia occurred in 13.9 per cent
I>oubt has been raised regarding the pos- and 22.8 per cent of cases, respectively.
sibility of the disease occurring beyond these The study of birth weight of infants de-
limits and it has been said that in these livered in the hospital showed a prematurity
type of cases some other causes such as rate of 38.9 per cent in postpartum and
epilepsy, cerebral venous thrombosis, and 75.9 per cent in antepartum cases. The
cerebral hemorrhage are often present.‘, ‘, ” general prematurity late of the hospital
But in 1 patient of this series, the convul- was 40 per cent in 1959. The maternal
sion started 15 days after the delivery at her mortality rate was 1.6 per cent in 62 pa-
home. She had 5 convulsions within 6 hours. tients with postpartum eclampsia whereas
after which she was admitted to the hospital it was 4.3 per cent among 305 patients with
with features of severe pre-eclampsia, cya- antepartum eclampsia.
902 Bhose August 1, 1964
Am. .I. Ohst. & Gyncc.

Summary and conclusions those of antepartum eclampsia which oc-

Some clinical aspects of 62 consecutive curred during the period of survey revealed
patients with postpartum eclampsia who that the severity of the disease was less in
were treated mainly with chlorpromazine cases of postpartum eclampsia and these
hydrochloride and promethazine hydro- were more amenable to treatment.
chloride, have been analyzed. The maternal
mortality rate was 1.6 per cent. In all but This work was done under the direct super-
1 case the convulsion started within 24 vision of the late Dr Subodh Mitra. We would
hours of delivery. like to thank Dr. B. Sengupta for his kind per-
The comparison between these cases and mission to publish the hospital records.

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