Via Research Recognition Day Program VCOM-Carolinas 2025

Case Reports

Clinical Case Report: Abnormal Progression to Eclampsia After Normal Prenatal Course Camden Pereira OMS III, Brooke Bennett OMS III, Steven Lewis M.D. Edward Via College of Osteopathic Medicine, Spartanburg, SC

Abstract

Case Presentation

Discussion

A 19 year-old G1P0 female with an uncomplicated prenatal course presented to clinic for routine prenatal visit at 38w4d and was sent to labor and delivery due to elevated blood pressures (142-147/94-98). Patient was asymptomatic during this time. Patient was admitted for induction of labor secondary to preeclampsia without severe features, as evidenced by hypertension + proteinuria. After starting Pitocin and Cervidil, the patient rapidly progressed to C/C/+3 and the fetal monitor showed prolonged decelerations with fetal descent. The delivery of the fetal head was assisted by a modified Ritgen maneuver and the patient then stopped pushing despite repeated requests to do so. Maneuvers to resolve a functional shoulder dystocia were employed and a viable male infant was delivered via vaginal spontaneous delivery. After delivery, the patient was poorly communicative and quiet, but followed simple commands. She began to show evidence of nystagmus and progressed into a full tonic-clonic seizure of 3 minutes duration. She was given Valium 5 mg IV and magnesium 4 gram bolus and was intubated for airway protection and transferred to the ICU for further care. A CT of the head without contrast showed white matter changes suggesting an area of possible remote ischemia vs. encephalomalacia (Figure 1). Follow up MRI was recommended which revealed a region of postictal gyral edema without a specific etiology focus (Figure 2). These findings were stable and consistent with the CT findings earlier in the day. The patient was extubated once stabilized and experienced no recurrent seizure activity on EEG. Patient was then stable for discharge home. Diagnosis : The final diagnosis was preeclampsia without severe features presenting in the third trimester, followed by eclamptic seizure.

Background Eclampsia is a hypertensive disease of pregnancy that occurs in less than one percent of live deliveries. Despite its low prevalence, eclampsia carries a mortality rate of up to fifteen percent. Of those who experience eclamptic seizure, one in four develop sequelae from the event. In many cases of eclampsia, the patient often exhibits non specific premonitory signs such as headache, visual disturbances, and gastrointestinal symptoms with labs often pointing towards end-organ damage. This case report reflects the instance of a 19-year-old nulliparous woman who experienced a postpartum eclamptic tonic-clonic seizure after presenting with an uncomplicated prenatal course. While eclampsia is often thought to follow preeclampsia with severe features, this case exemplifies that this pattern is not as linear as many clinicians are led to believe. This case report highlights the need for continued research to inform guidelines for hypertensive disorders of pregnancy. ● Eclampsia is defined by new onset seizures or unexplained altered mental status in a pregnant or postpartum patient in the absence of other causative etiologies. ● Pathogenesis is debated, but most researchers agree that eclampsia is a result of cytotoxic cerebral edema caused by vascular injury or endothelial dysfunction, most commonly uteroplacental insufficiency. ● Historically, eclampsia has been regarded primarily as a severe progression of preeclampsia, where severe features such as visual disturbance and headache are present prior to onset of seizures. ● Treatment should not be delayed while waiting for labs or imaging. If diagnostic modalities are however utilized, the following could be observed: elevated transaminases, elevated protein:creatinine ratio, proteinuria, thrombocytopenia, evidence of cerebral edema on CT/MRI, slow waves and spikes on EEG. ● Definitive treatment of antepartum eclampsia is emergent delivery, treatment and subsequent prophylaxis of seizures, and supportive care ● Complications include ischemic and hemorrhagic stroke, coma, heart failure, venous thrombosis, renal failure, disseminated intravascular coagulation, and fetal or maternal demise.

Conclusion This case highlights the need to continuously reexamine the paradigm surrounding monitoring and treating preeclampsia without severe features in the late third trimester. This patient is a rare case in which new onset moderate hypertension escalated into eclampsia without first meeting criteria for prophylactic seizure treatment. We know that those exhibiting preeclampsia are more likely to develop eclampsia, however, eclampsia in the absence of premonitory signs and symptoms needs to be further understood. The graphic represents the role of Magnesium Sulfate to prevent seizure in patients >37 weeks gestation admitted to Labor and Delivery as supported by ACOG. There is no current consensus regarding the use of MgSO4 in patients without severe features, as the benefit of its use has not significantly outweighed risk in retrospective cohort studies (5). *Rates may be adjusted/reduced with renal impairment

References 1. American College of Obstetricians and Gynecologists. Hypertension in pregnancy. http://www.acog.org/Resources-And-Publications/Task-Force-and-Work-Group Reports/Hypertension-in-Pregnancy. Accessed November 23, 2015.

2. Berhan Y. No Hypertensive Disorder of Pregnancy; No Preeclampsia-eclampsia; No Gestational Hypertension; No Hellp Syndrome. Vascular Disorder of Pregnancy Speaks for All. Ethiop J Health Sci. 2016 Mar;26(2):177-86. doi: 10.4314/ejhs.v26i2.12. PMID: 27222631; PMCID: PMC4864347. 3. Boushra M, Natesan SM, Koyfman A, Long B. High risk and low prevalence diseases: Eclampsia. Am J Emerg Med. 2022 Aug;58:223-228. doi: 10.1016/j.ajem.2022.06.004. Epub 2022 Jun 8. PMID: 35716535. 4. Magley M, Hinson MR. Eclampsia. [Updated 2024 Oct 6]. In: StatPearls [Internet]. Treasure Island

(FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/sites/books/NBK554392/

5. Howell, Samantha E. et al. Magnesium sulfate administration in preeclampsia without severe features and perinatal outcomes. American Journal of Obstetrics & Gynecology. Volume 230, Issue 1, S549

Figure 1. CT head without contrast showing post-seizure changes

Figure 2. MRI brain without and with contrast showing stable post-seizure changes

2025 Research Recognition Day

65