Clinical Query:

We have a patient who has been having seizures since childhood and also has had recurrent status-epilepticus during each of her 3 pregnancies( the last one when she was with us was at 32 weeks). However her laboratory parameters never revealed any evidence of pre eclampsia( Her BP , urine protein, serum uric acid, liver enzymes, platelet counts were normal). Her seizures did not subside with all variety of anticonvulsants in full dosage that we tried last time but did subside soon after the delivery of the baby. Her CT head was normal. How common is eclampsia without pre eclampsia? Rakesh Biswas, Manipal teaching hospital, Nepal
 
Responses:
 
1)From the details provided she seems to have
a neurological disorder of some sort that was aggragvated somehow by
pregnancy, rather than preeclampsia and eclampsia.

Williams Obstetrics (21st edition 2001, McGraw Hill) answers your
question in one sentence (page 596): "Almost without exception,
preeclamsia precedes the onset of ecclamptic convulsions.".

Sincerely,

Philip F. Hall, MD BScMed FRCSC
Director, Fetal Assessment, Provincial Obstetric Outreach and
Maternal-Fetal Medicine Programs
Vice President, Medical Staff
St.Boniface General Hospital, 409 Tache Avenue D2044
Winnipeg, Manitoba, Canada R2H 2A6
 
2)Why do you think thiis is eclampsia? Is she on anticonv.? Serum levels?
Regards
Amos D Korczyn, MD, MSc
Sieratzki Professorr of Neurology
Tel Aviv University, Israel
 
3)Rakesh - Is this question of any use in any  way, besides satisfying your curiosity ?? Does it help in the actual Tx , the ability to 'predict'  and perhaps prevent or prepare or mitigate  Looking for chaos vs random-ness ? Can you  keep the  woman 'safe', and also her newborn (obviously you did, and the 2 other 'attendings' did before you) during delivery and post? What's the intent ?? Maybe it's Vishnu  or the Haitian  =quivalent, Herzulie Freda, that is pissed off  with the woman's husband - or some other 'logic' or etiology that no current coulter counter  or CT can measure.....Curious George, your Eternal Hair Shirt, June Levinshohn
 
4) dEAR Rakesh
I do not know about the how.
But I had a similar patient while doing my internship in gyne
With regards
Ravi

5) Dear Rakesh,

It is a known fact that eclampsia can occur without any earlier
indications.  I would not be able to tell you the percentage.

B M Hegde (VC-MAHE)
 
6)Dear Rakesh,
it is common to have this kind of presentation .I have seen several cases in India. Did you know that you can have seizures post natal without any preceding features of PET/E or CVT.Look for HELPP.All the best
Pratap John Philip, Consultant Medicine, Sydney, Australia

7)this is not eclampsia -- try mri brain it should reveal some focus
cecil
 
Dear  Rakesh,
Explanations/answers of your queries are as follow:
7                    We planned for termination of pregnancy because that was the only way to cure Eclampsia.  No other measures eg. Anticonvulsive or antihypertensive therapy work satisfactorily, not only because long term effect of these drugs on fetus is not yet fully evaluated, but also because Preeclampsia is a multi-system disorder, where occurrence of convulsion (Eclampsia) carries significant risk of several lethal complications eg ARF, DIC, hepatic dysfunction or pulmonary edema. At an initial stage, all these problems are completely reversed, shortly after delivery. We don't know the exact cause of preeclampsia; thus specific preventive or therapeutic approach of this unique obstetric problem remained undetermined.
7                    The past history of several episodes of fits, together with a near normal BP on admission and absence of proteinuria misled us to a diagnosis of epilepsy in pregnancy. As I documented earlier, eclampsia in a normotensive individual is not a rare entity and there are reports of nonproteinuric hypertension also, but eclampsia, on the back ground of both normal BP and urine protein content, at least in my opinion, is really rare.  [I do not know what the world literature says].On further questioning  (very difficult to get exact history from an unconscious patient)we came to know that all past attacks of fits occurred only when she was pregnant and, more importantly, her condition improved every time following delivery /termination of pregnancy. In fact, if we believe this history, the diagnosis can not be anything other than eclampsia. Retrospectively, the diagnosis of eclampsia was confirmed again when the patient started improving rapidly following delivery.
Do you have any thing else to clarify?
I will provide you with necessary references if you want them.
Adrija Dutta, Asst Prof,O & G, Manipal teaching hospital, Nepal
 P.S.

Dear Rakesh
I failed to get the journal you want.
I, however can supply some other important informations in this regard.
Quoting from Turnbull's Obstetrics :
"A UK survey reported that almost 40% of cases (eclampsia)occured before hypertension or protienuria was documented. (1) "
"Eclpmpsia is usually accompanied by hypertension, although not always severe and proteinuria is absent in 20-40% (2). "
Ref: 1. Douglas & Redman; Eclampsia in UK(1994): BMJ 309: 1395-1400 [SEE ATTACHED FILE]
Ref:2. Villar & Sibai ;Eclampsia (1988) :Ob. & Gy Clinic of North Am 15:377-377

Thanks to summarise: We thought about eclampsia because the patient's seizures recovered only after her delivery. She has unfortunately suffered a lot of residual anoxic cerebral damage and is nearly in a vegetative state at the moment and its sad to see her baby sucking from her breast while she lies mute with a vacant stare into space. We concluded that it was in all probability a pregnancy aggravated seizure(either because of reduced blood levels which can be due to increased hepatic microsomal induction during pregnancy or hemodilution) and the drug levels may have normalised after delivery.However there is a substantial population of physicians who do believe eclampsia can occur without pre eclampsia.

Rakesh Biswas