ECLAMPSIA

(Case Study)

Submitted by: Edison P. Luna

Definition:

Eclampsia (Greek, "shining forth"), an acute and life-threatening complication of pregnancy, is characterized by the appearance of tonic-clonic seizures, usually in a patient who had developed pre-eclampsia. (Preeclampsia and eclampsia are collectively called Hypertensive disorder of pregnancy and toxemia of pregnancy.) Eclampsia includes seizures and coma that happen during pregnancy but are not due to preexisting or organic brain disorders. Key warning signs of eclampsia in a woman diagnosed with preeclampsia may be severe headaches, blurred or double vision, or seeing spots. Toxemia is a common name used to describe preeclampsia and eclampsia. There has never been any evidence suggesting an orderly progression of disease beginning with mild preeclampsia progressing to severe preeclampsia and then on to eclampsia. The disease process can begin mild and stay mild, or can be initially diagnosed as eclampsia without prior warning.

Causes:

No one knows what exactly causes preeclampsia or eclampsia. Since we don't know what causes preeclampsia or eclampsia, we don't have any effective tests to predict when preeclampsia or eclampsia will occur, or treatments to prevent preeclampsia or eclampsia from occurring (or recurring). Preeclampsia usually occurs with first pregnancies. However, preeclampsia may be seen with twins (or multiple pregnancies), in women older than 35 years, in women with high blood pressure before pregnancy, in women with diabetes, and in women with other medical problems (such as connective tissue disease and kidney disease). For unknown reasons, African American women are more likely to develop eclampsia and preeclampsia than white women. Preeclampsia may run in families, although the reason for this is unknown. Preeclampsia is also associated with problems with the placenta, such as too much placenta, too little placenta, or how the placenta attaches to the wall of the uterus. Preeclampsia is also associated with

hydatidiform mole pregnancies, in which no normal placenta and no normal baby are present.

There is nothing that any woman can do to prevent preeclampsia or eclampsia from occurring. Therefore, it is both unhealthy and not helpful to assign blame and to review and rehash events that occurred either just prior to pregnancy or during early pregnancy that may have contributed to the development of preeclampsia.

Patients History Jocelyn Gamiel Lavarez, a 33 year old patient who resides in Ragay, Camarines Sur was admitted last September 8, 2011 at around 11:40 am.

Signs and Symptoms The hallmark of eclampsia is seizures. Similar to preeclampsia, other changes and symptoms may be present and vary according to the organ system or systems that are affected. These changes can affect the mother only, baby only, or more commonly affect both mother and baby. Some of these symptoms give the woman warning signs, but most do not.

The most common symptom and hallmark of preeclampsia is high blood pressure. This may be the first or only symptom. Blood pressure may be only minimally elevated initially or can be dangerously high; symptoms may or may not be present. However, the degree of blood pressure elevation varies from woman to woman, and also varies during the development and resolution of the disease process. There are also some women who never have significant blood pressure elevation (including approximately 20% of women with eclampsia). A common belief is that the risk of eclampsia rises as blood pressure increases above 160/110 mm Hg. The kidneys are unable to efficiently filter the blood (as they normally do). This may cause an increase in protein to be present in the urine. The first sign of excess protein is commonly seen on a urine sample obtained in your provider's office. Rarely does a woman note any changes or symptoms associated with excess protein in the urine. In extreme cases affecting the kidneys, the amount of urine produced decreases greatly.

Nervous system changes can include blurred vision, seeing spots, severe headaches, convulsions, and even occasionally blindness. Any of these symptoms require immediate medical attention. Changes that affect the liver can cause pain in the upper part of the abdomen and may be confused with indigestion or gallbladder disease. Other more subtle changes that affect the liver can affect the ability of the platelets to cause blood to clot; these changes may be seen as excessive bruising. Changes that can affect your baby can result from problems with blood flow to the placenta and therefore result in your baby not getting proper nutrients. As a result, the baby may not grow properly and may be smaller than expected, or worse the baby will appear sluggish or seem to decrease the frequency and intensity of its movements. You should call your doctor immediately if you notice your baby's movements slow down.

Anatomy and Physiology The Circulatory System is designed to deliver oxygen and nutrients to all parts of the body and pick up waste materials and toxins for elimination. This system is made up of the heart, the veins, the arteries, and the capillaries. Circulation is achieved by a continuous one-way movement of blood throughout the body. The network of blood vessels that flow through the body is so extensive that blood flows within close proximity to almost every cell. Heart The heart is a muscular pump that propels blood throughout the body. The heart is located between the lungs, slightly to the left of center in the chest. The heart is broken down into four chambers including:

The right atrium, which is a chamber which receives oxygen- poor blood from the veins. The right ventricle which pumps the oxygen-poor blood from the right atrium to the lungs. The left atrium which receives the now oxygen-rich blood that is returning from the lungs. The left ventricle, which pumps the oxygenated blood through the arteries to the rest of the body.

This process occurs about 72 times per minute, every day of our lives.

Blood Vessels Blood vessels are broken down into three groups: the arteries which carry blood out of the heart to the capillaries, the veins which transport oxygenpoor blood back to the heart, and the capillaries which transfer oxygen and other nutrients into the cells and removes carbon dioxide and other metabolic waste from these body tissues. Blood Pressure Blood pressure is the force exerted by the blood against the walls of the blood vessels. The output or direct pumping of the heart and the resistance to blood flow in the vessels determines blood pressure. Resistance is determined by blood viscosity and by friction between the blood and the wall of the blood vessel. Blood pressure = blood flow x resistance.

Pathophysiology: While multiple theories have been proposed to explain preeclampsia and eclampsia, it occurs only in the presence of a placenta and is resolved by its removal. Dr.Mayank suggested that placental hypoperfusion is a key feature of the process. It is accompanied by increased sensitivity of the maternal vasculature to pressor agents leading to vasospasm and hypoperfusion of multiple organs. Further, an activation of the coagulation cascade leads to microthrombi formation and aggravates the perfusion problem. Loss of plasma from the vascular tree with the resulting edema additionally compromises the situation. These events lead to signs and symptoms of toxemia including hypertension, renal, pulmonary, and hepatic dysfunction, and - in eclampsia specifically - cerebral dysfunction. Preclinical markers of the disease process are signs of increased platelet and endothelial activation Placental hypoperfusion is linked to abnormal modeling of the fetal-maternal interface that may be immunologically mediated The invasion of the trophoblast appears to be incomplete. Adrenomedullin, a potent vasodilator, is produced in diminished quantities by the placenta in preeclampsia (and thus eclampsia). Other vasoactive agents are at play including prostacyclin, thromboxane A2, nitric oxide, and endothelins leading to vasoconstriction. Many studies have suggested the importance of a woman's immunological tolerance to her baby's father, whose genes are present in the young fetus and its placenta and which may pose a challenge to her immune system. Eclampsia is seen as a form of hypertensive encephalopathy in the context of those pathological events that lead to preeclampsia. It is thought that cerebral vascular resistance is reduced, leading to increased blood flow to the brain. In addition to abnormal function of the endothelium, this leads to

cerebral edema. Typically an eclamptic seizure will not lead to lasting brain damage; however, intracranial hemorrhage may occur.

Risk Factors Eclampsia, like preeclampsia, tends to occur more commonly in first pregnancies and young mothers where it is thought that novel exposure to paternal antigens is involved. Further, women with preexisting vascular diseases (hypertension, diabetes, and nephropathy) or thrombophilic diseases such as the antiphospholipid syndrome are at higher risk to develop preeclampsia and eclampsia. Having a large placenta (multiple gestation, hydatiform mole) also predisposes women to toxemia. Further, there is a genetic component; patients whose mother or sister had the condition are at higher risk. Patients who've experienced eclampsia are at increased risk for preeclampsia/eclampsia in a later pregnancy.