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Late onset postpartum
eclampsia can occur in nor-
motensive women with un-
complicated pregnancies, not
just in women with pre
eclampsia
References:
• Nalini Munjuluri and Marc
Lipman et.al., Postaprtum
eclampsia of late onset,
November 2005
• Jamie M. Nuwer, MD and
Shervin Eshaghani, Hospi-
tal Physician: Late Postpar-
tum Eclampsia with Poste-
rior Reversibl Encephalopa-
thy Syndrome, June 2007
S.M. Pinpin
INITIAL PRESENTATION AND HISTORY
A
25 year old woman gravida 3, para 3 was
transferred from a Government Hospital.
She was presented to the Emergency De-
partment with complaints of persistent increase in
blood pressure and episodes of seizure. She gave
birth to a healthy baby by normal vaginal deliv-
ery. The postpartum was uneventful until the 13th
day, when she reported having a peripheral
edema and exertional dyspnea. She was immedi-
ately brought to a public hospital and during hos-
pitalization the patient had episodes of seizures
and headache. She was diagnosed with HYPER-
TENSIVE ENCEPHALOPATHY VS. POSTPAR-
TUM ECLAMPSIA. After 5days, the patient was referred to and transferred at
a private hospital for further observation and management.
Physical Examination
U
pon admission to the ED, the patient was febrile to 38.6ºC , had a heart
rate of 109 and a blood pressure up to 150/100 mmHg. The patient was
with ET at the level of 21cm, with NGT for feeding and medications and
Indwelling catheter draining well to HCB with an
output of 930cc. She had an IVF of D5W 500cc at
KVO with a side drip of Hydralazine drip. The
physical examination was normal, including full
neurologic exam, the seizure was not noted except
for trace of bipedal edema.
Page 2
LABORATORY EVALUATION, X-RAY AND COMPUTED
TOMOGRAPHY

T
he results of a CT scan of the head were normal. CBC revealed a
slightly elevated white blood cell count (15.1 x 10³/µL [normal: 4.5 – 11
x 10³/µL]) . A chemistry panel showed hypernatremia (147 mEq/L
[normal: 135 – 145 mEq/L] ) and hypokalemia (3.4 mEq/L [3.4 – 5.5 mEq/L).
Urine dipstick showed 2+ protein and 2+ blood. Chest X-ray result shows
pneumonia on the left lower lobe of the lung. ETA GS/CS reveals a very few
colony of Klebsiella Oxytoca. ABG result reveals Respiratory Alkalosis, uncom-
pensated.
During evaluation at the ED, the patient had a persistent high blood
pressure and a minimal amount of urine output upon admission. She was
treated with 40 mg of Furosemide IV and Lanoxin 0.25mg/tablet. Her blood
pressure was controlled with hydralazine, metoprolol and aldactone.

FURTHER HOSPITALIZATION AND HOSPITAL COURSE

T
he patient was ad-
mitted to the medical
intensive care unit
and her blood pressure was
stabilized on metoprolol and
aldactone. Ceftazidime,
third-generation cepha-
losporin antibiotic was given
every 8hours it has broad spectrum activity
against Gram-positive and Gram-negative bacteria
as a broad spectrum antibiotic as a treatment for
the presence of infections. Combivent nebulization
were also administered that served as bronchodila-
tors that relax muscles in the airways and increase
air flow to the lungs.
tored. Because the patient’s hemoglobin count
decreased, a 1 unit of PRBC was transfused to
stabilize the patient’s hemoglobin count. The pa-
tient also manifested signs of altered mental
status where in she became restless and combat-
a ive. The patient was also diagnosed with Hypo-
thyroidism and was treated with Euthyrox, a
replacement for a hormone that is normally pro-
duced by the thyroid gland to regulate the body's
energy and metabolism. It is also used to treat or
prevent goiter (enlarged thyroid gland), which
can be caused by hormone imbalances, radiation
treatment, surgery, or cancer.

D
uring hospitalization the patient
manifested hematuira (blood in
the urine) and decreased urine
output as evidenced by a huge difference
between the patient’s intake and output of
less that 30 cc per hour for two consecutive
hours. Furosemida (Lasix) 40mg was given
as an immediate order and the patient’s in-
take and output was continuously moni-
 Page 3

The patient’s bipedal edema continuously subsided

and no cerebral deterioration was noted. But due to
financial constraints, the family of the patient was
unable to provide further support for hospital ex-
penses. After 6days of hospitalization, regardless of
the patient’s condition, the family with the full
knowledge of the patient consented for Home
Against Medical Advice (HAMA) with the full
education from the attending physician of the possible consequences of their refusal for
further hospitalization.

Discussion

T
his case illustrates the edema. dromal symptoms before the
complexity that is usu- onset of eclampsia. My patient

T
ally encountered in rec- he previously contro- had most of these symptoms.
ognizing and diagnosing Late versial existence of a

E
Postpartum Eclampsia. When the delayed postpartum clampsia should be
patients manifested some classi- variant of eclampsia is now ac- considered in any
cal symptoms of imminent knowledged by most experts. postpartum woman
eclampsia such as headache, hy- Convulsions with initial presen- who develops any of these
pertension, bipedal edema and tation more that 48 hours but prodromal symptoms. Further
nausea the diagnosis went unrec- less than four weeks after deliv- indicators include convulsions
ognized and the patient end up ery are commonly referred as up to four weeks after deliv-
seizing. The etiology remained postpartum eclampsia. ery, hypertension or proteinu-
unclear until other common con- ria. This is important as

P
ditions in the differential had ostpartum eclampsia eclampsia is amenable to treat-
been ruled out. can present with a vari- ment with magnesium sulfate.
ety of clinical and neu-

E
clampsia is a poorly un- rological symptoms and signs.
derstood multisystem Lubrasky and Chames reported
complication of preg- that 44% to 79% of their respec-
nancy that substantially contrib- tive patients with late onset
utes to maternal morbidity and postpartum eclampsia had not
mortality. If the symptoms that been identified as having pree-
the patient presented were dur- clampsia before seizure onset.
ing antepartum when suspicion They reported that severe and
of eclampsia is high, the diagno- persistent headache, visual
sis would have been made easily symptoms, epigastric or right
in women who already have hy- upper quadrant pain and hy-
pertension, proteinuria and pertension can present as pro-
Page 4

EVALUATION AND DIAGNOSIS

T
he work-up for LPE should include serial blood pressure measure-
ments because in many cases blood pressure was elevated only inter-
mittently. A basic metabolic panel, CBC, urine toxicology screen, lum-
bar puncture and cerebral imaging help to differentiate LPE from other possi-
ble diagnosis.

TREATMENT

M
agnesium Sulfate remains the drug of choice for preventing and treating
eclamptic seizure. If such seizures are not treated appropriately, grave
complications such as intracerebral hemorrhage and death can occur. In
this case study, the patient was at a different hospital while the episodes of seizure was
present. After the transfer, seizing was not noted all
throughout the hospitalization.

S
evere hypertension should be controlled to
keep blood pressure within a safe range while
maintaining cerebral perfusion pressure,
which can be difficult with fluctuating blood pres-
sure. In the case of my patient, Hydralazine drip was
on hold and antihypertensive drugs such as Metro-
polol, Losartan and Aldactone was given to maintain the patient’s BP. When blood pres-
sure becomes severely elevated (SBP>160 mmHg or DBP >110mmHg) intravenous dose of
hydralazine was resumed. Sibai recommends treating to a SBP between 140 and 160
mmHg and a DBP between 90 and 110 mm Hg.

CONCLUSION

Late onset postpartum eclampsia can occur in normotensive uncomplicated postpartum women as
well as in women in preeclampsia. The presence of prodromal symptoms should be thoroughly
investigated, even in the absence of antecedent pre-eclampsia. Counseling should discuss the warn-
ing signs of severe persistent headache, nausea/vomiting, visual changes and generalized or focal
neurologic deficits. Seizures usually prompt after Emergencu department admissions. Such com-
plaints up to 1month after delivery should be worked up for the Late Postpartum Eclampsia pro-
drome with the goal of preventing seizures in imminent eclampsia (severe headache, blurred vision
or epigastric pain) and promptly managing eclampsia should it occur. If seizures and blood pres-
sure are not appropriately controlled, permanent neurologis deficits and even death can occur.