Beyond the Basics: Preeclampsia and Eclampsia

     Most women who develop preeclampsia can deliver a healthy baby. However, the more severe the preeclampsia and the earlier it occurs in the pregnancy, the greater the risk for both patient and fetus. Complications associated with preeclampsia include eclampsia, HELLP syndrome, placental hypoperfusion and abruptio placentae.

     Eclamptic seizures, which represent the hallmark progression from preeclampsia to eclampsia, are also not well understood. These are seizures that occur without any evidence of other underlying metabolic or structural conditions. It is thought that the seizures result from the same pathology as what is occurring in the placenta. Cerebral vasospasm, edema, ischemia, infarction, hemorrhage and ionic shifts are thought to incite seizure activity. If a seizure occurs in the first trimester or well into the postpartum period, you should suspect and assess for other central nervous system causes.

     Although the relationship is not clearly understood, approximately 10% of preeclamptic and 30%–50% of eclamptic patients develop HELLP—a syndrome associated with hemolysis, elevated liver enzymes and a low platelet count. Patients with both conditions develop liver dysfunction, which is associated with a higher mortality rate. In addition, the low platelet count can be problematic because it can increase the risk of bleeding into the brain, especially when it exists in eclamptic hypertension.

     Constriction of the uteroplacental arteries creates a hypoperfused placenta. The reduced blood flow delivers less oxygen and nutrients to the fetus, which may retard fetal growth or precipitate low-birth-weight babies, preterm birth or stillbirth.

     Another complication of preeclampsia is an increased risk of abruptio placentae, when the placenta prematurely separates from the uterine wall. Depending on the degree of separation, this puts the pregnant patient at great risk for severe hemorrhage. Separation of the placenta may also significantly reduce fetal blood flow and increase the risk of fetal mortality.

     Mild to moderate preeclampsia may go unnoticed by the patient, since it remains relatively asymptomatic. This is especially true of the pregnant patient often seen in the prehospital environment who has had no prenatal care or very inconsistent or sporadic prenatal care. Routine prenatal screening would be necessary to identify patients with mild to moderate preeclampsia. Thus, if a patient presents with a more severe case of preeclampsia or eclampsia and does not report any past medical history of such, she may have not been aware that she actually had a milder form of the condition if prenatal care was inconsistent or absent. Most often, you will be responding for a patient who is experiencing a more severe form of preeclampsia and has end-organ effects that are producing abnormal signs and symptoms that are recognized by the patient. In the most severe cases, the patient may be seizing. It is then important to determine if she has a preexisting medical condition that makes her prone to seizures, if the seizure is a manifestation of eclampsia, or if she is experiencing some other central nervous system pathology, such as a hemorrhagic stroke, that is causing her to seize. Pregnant patients who seize due to a preexisting condition would not typically present with hypertension and some of the following complaints upon assessment. History is very important in making a differential field diagnosis in this case.

     Common signs and symptoms of preeclampsia are: