3/22/2019 Management of atypical eclampsia with intraventricular hemorrhage: A rare experience and learning!

Anesth Essays Res. 2015 May-Aug; 9(2): 257–259. PMCID: PMC4563978

doi: 10.4103/0259-1162.153768 PMID: 26417139

Management of atypical eclampsia with intraventricular hemorrhage: A

rare experience and learning!
Kewal Krishan Gupta and Lajya Devi Goyal1

Department of Anesthesia and ICU, G.G.S. Medical College and Hospital, Faridkot, Punjab, India
1Department of Obstetrics and Gynaecology, G.G.S. Medical College and Hospital, Faridkot, Punjab, India

Corresponding author: Dr. Kewal Krishan Gupta, House No. 204, Medical Campus, Faridkot - 151 203, Punjab,
India. E-mail: doc_krishan31@yahoo.co.in

Copyright : © Anesthesia: Essays and Researches

This is an open-access article distributed under the terms of the Creative Commons Attribution-
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Abstract
Cerebrovascular accident during hypertensive disorder of pregnancy is a rare entity, but carries high
risk of mortality and morbidity due to its unpredictable onset and late diagnosis. Here, we report an
unusual case of 20-year-old primigravida with 34 weeks gestation having no risk factor, which
developed sudden atypical eclampsia and intracranial hemorrhage within few hours. She was
successfully managed by multidisciplinary approach including emergency cesarean section and
conservative neurological treatment for intraventricular hemorrhage.

Keywords: Atypical eclampsia, intraventricular hemorrhage, prolonged coma

INTRODUCTION
Preeclampsia/eclampsia is one of the most common risk factors for stroke in pregnancy, particularly
during the postpartum period.[1] The incidence of stroke during pregnancy including cerebral venous
thrombosis ranges from 10 to 34/100,000 deliveries.[2] In some patients, this can be complicated by
atypical presentation of eclampsia, which is characterized by the occurrence of eclampsia before 20
weeks, after 48 h postpartum or in the absence of typical signs of hypertension and/or proteinuria.[3]
Clinical literature regarding anesthetic and critical care management for eclampsia with stroke is very
sparse. Only early diagnosis and management can improve the outcome in these patients. This unique
case illustrates that timely diagnosis and multidisciplinary approach for management in eclamptic
patient complicated by intracranial hemorrhage can decrease the mortality and morbidity associated
with it, especially in developing countries.

CASE REPORT
A 20-year-old primigravida of 34 weeks gestation with previous normal antenatal care, brought to the
emergency with complaint of sudden onset of headache and epigastric pain since morning. On clinical
examination, she was 34 weeks pregnant and not in the labor. Her vitals record of heart rate - 102/min,
blood pressure (BP) - 170/100 and SpO2-96% were made. On provisional diagnosis of imminent
eclampsia, supportive treatment started to control BP. She received injection labetalol 20 mg
intravenous (i.v.) stat and magnesium sulfate 5 g i.m. in each buttock along with 4 g by i.v. infusion
over 20 min. The patient was admitted to the obstetric high care unit for BP control with observation
for any complication. Blood tests were ordered for urea, electrolytes, blood sugar, uric acid, full blood
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3/22/2019 Management of atypical eclampsia with intraventricular hemorrhage: A rare experience and learning!

count, liver function and coagulation profile, which were found normal. Urine test was negative for
proteinuria. Within 4 h of admission, patient had sudden generalized tonic-clonic seizures for which
supportive treatment including oxygen with assisted ventilation and drugs, that is, midazolam,
phenytoin, magnesium sulfate were given. Emergency lower segment caesarean section planned in
view of persistent postictal drowsiness and high BP. Standard general anesthesia with rapid sequence
induction was carried out for surgery. During intraoperative period, high BP after intubation was
controlled with injection labetalol 20 mg i.v. stat again and a healthy male baby delivered with Apgar
score of 7/10 at 1 and 5 min respectively. Postoperatively patient shifted to Intensive Care Unit (ICU)
for elective ventilation due to persistent poor Glasgow Coma Scale (GCS) of 5/15. Injection
magnesium sulfate continued as per protocol with monitoring for magnesium toxicity along with
antihypertensive drugs in ICU. After 24 h of surgery, computed tomography (CT) scan of the head was
obtained in view of persisting low GCS, that is, 4/15. Scan showed intraventricular hemorrhage (IVH)
in all the ventricles with diffuse brain edema [Figure 1]. On the advice of neurosurgeon, conservative
treatment with injection manitol, lasix, steroid, and levipril started. On 4th postoperative day,
improvement in GCS was noted and weaning from the ventilator started. After the return of full
conscious level, patient extubated on 7th day and repeated CT scan of head had shown resolving IVH
with no brain edema. Patient discharged on 10th day in satisfactory condition with advice of regular
follow-up.

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Figure 1

Computed tomography head showing intraventricular hemoorhage

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3/22/2019 Management of atypical eclampsia with intraventricular hemorrhage: A rare experience and learning!

DISCUSSION
Hypertensive disorder of pregnancy is a multisystem disorder. Usually, occurrence of eclampsia is
warned by preeclampsia but sometimes patient may present with sudden onset without prior sign of
preeclampsia (i.e., hypertension and proteinuria). In our case, patient was asymptomatic till 34 weeks
of the antenatal period and suddenly develops neurological symptoms with high BP. Although the
presence of hypertension, sudden headache, seizures and negative proteinuria supported our diagnosis
of atypical eclampsia but persistent, prolonged coma directed us for considering other differential
diagnosis of this condition. The most common cause of convulsions developing in association with
hypertension and/or proteinuria during pregnancy or immediately postpartum is eclampsia. Rarely,
other etiologies like ischemic or hemorrhagic stroke, hypertensive encephalopathy, seizure disorder and
metabolic disorder may mimic eclampsia.[4] Differential diagnoses are particularly important in the
presence of focal neurologic deficits, prolonged coma, or atypical eclampsia. Cerebrovascular accident
due to hypertensive disorders of pregnancy account for 28–50% of maternal deaths.[5] In our case of
atypical eclampsia occurrence of sudden headache, seizure, and prolonged coma could be attributed to
antepartum IVH. Intracranial hemorrhage could possibly be due to rupture of blood vessels, caused by
the rapid increase in the hydrostatic forces that overwhelm autoregulatory mechanisms. One study
concluded that brain edema in patients with preeclampsia-eclampsia syndrome is primarily associated
with laboratory-based evidence of endothelial damage.[6]

Anesthetic management in unconscious eclamptic patients may present several dilemmas including
rapid sequence induction while blocking the stress responses to laryngoscopy, drug interaction between
magnesium sulfate with muscle relaxant, regarding use of internal jugular cannulation with brain
edema and the risk of laryngeal edema presenting as difficult airway.[7,8] Until now, only two cases of
successful management in eclamptic patient with intracerebral hemorrhage by craniotomy with
cesarean section had been reported.[8,9] The importance of early clinical and radiological assessment
of the central nervous system in eclampsia patient with a sudden decrease in conscious level has also
been emphasized.[10] We report the first case of eclamptic patient with IVH, which was successfully
managed by timely diagnosis and conservative treatment. Prolonged coma and prompt response to
decongestant therapy in our patient can only be explained by brain edema with intraventricluar
hemorrhage secondary to eclampsia.

CONCLUSION
As an anesthesiologist and critical care expert, we should always keep the possibility of hemorrhagic
stroke in eclamptic patient especially in atypical presentation with persistent poor conscious level and
focal neurological sign. Early diagnosis and multidisciplinary approach including anesthesiologist,
obstetrician and neurosurgeon can improve the outcome in these patients.

Footnotes
Source of Support: Nil.

Conflict of Interest: None declared.

REFERENCES
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thrombosis. Stroke. 2000;31:1274–82. [PubMed]

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3. Sibai BM, Stella CL. Diagnosis and management of atypical preeclampsia-eclampsia. Am J Obstet
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4. Sibai BM. Diagnosis, prevention, and management of eclampsia. Obstet Gynecol. 2005;105:402–10.
[PubMed]

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8. Roopa S, Hegde HV, Torgal SV, Melkundi S, Sunita TH, Mudaraddi RR, et al. Anesthetic
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