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{{Eclampsia}}
{{Eclampsia}}
{{CMG}}
'''To go back to the main page, click [[Microchapter templates|here]]'''
 
{{CMG}} {{AE}}[[User:Navneet|Navneet Kaur M.B.,B.S.]]


==Overview==
==Overview==
Seizures during pregnancy that are unrelated to [[Preeclampsia]] need to be distinguished from [[Eclampsia]].  
Seizures during pregnancy that are unrelated to [[Preeclampsia]] need to be distinguished from [[Eclampsia]]. This is essential to recognize the correct cause and provide the targeted treatment necessary in a timely manner.


==Differentiating Eclampsia from other Diseases==
==Differentiating Eclampsia from other Diseases==
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*[[Adrenal Insufficiency]] or Acute [[Adrenal crisis]]
*[[Adrenal Insufficiency]] or Acute [[Adrenal crisis]]
*[[Aneurysm]] of the brain
*[[Aneurysm]] of the brain
*Brain tumor
*[[Brain tumor]]
*[[Cerebellar Haemorrhage]]
*[[Cerebellar Haemorrhage]]
*[[Disseminated herpes simplex]]/ [[Herpes Simplex Encephalitis]]([[HSE]])
*[[Disseminated herpes simplex]]/ [[Herpes Simplex Encephalitis]] ([[HSE]])
*[[Disseminated sepsis syndromes]]
*[[Disseminated sepsis syndromes]]
*[[Drug Overdose]] syndromes
*[[Drug Overdose]] syndromes
*[[Drug Withdrawal]] syndromes
*[[Drug Withdrawal]] syndromes
*[[Encephalitis]]
*[[Encephalitis]]
*[[Fatty liver of pregnancy]]
*[[Acute Fatty liver of pregnancy]] ([[AFLP]])
*[[Hemolytic uremic syndrome]]
*[[Hemolytic uremic syndrome]] ([[HUS]])
*[[Hypertensive encephalopathy]]
*[[Hypertensive encephalopathy]]
*[[Hypoglycemia]]
*[[Hypoglycemia]]
*Medication- or drug-related seizures
*[[Medication- or drug-induced seizures]]
*[[Meningitis]]
*[[Meningitis]]
*[[Posterior reversible encephalopathy syndrome]] ([[PRES]])
*[[Posterior reversible encephalopathy syndrome]] ([[PRES]])
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| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;" |Disseminated herpes simplex/ [[Herpes Simplex Encephalitis]]([[HSE]])
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;" |Disseminated herpes simplex/ [[Herpes Simplex Encephalitis]]([[HSE]])
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* On physical exam and history [[Herpes Simplex Encephalitis]]([[HSE]]) may present with Headache, Seizures, vision abnormalities, confusion, hyperactivity also observed in eclampsia.
* On physical exam and history [[Herpes Simplex Encephalitis]]([[HSE]]) may present with Headache, Seizures( seen in 50% of cases <ref name="pmid18754956">{{cite journal| author=Misra UK, Tan CT, Kalita J| title=Viral encephalitis and epilepsy. | journal=Epilepsia | year= 2008 | volume= 49 Suppl 6 | issue=  | pages= 13-8 | pmid=18754956 | doi=10.1111/j.1528-1167.2008.01751.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18754956  }} </ref>), vision abnormalities, confusion, hyperactivity also observed in eclampsia.
| style="padding: 5px 5px; background: #F5F5F5;" |
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* On physical exam and history [[Herpes Simplex Encephalitis]]([[HSE]]) demonstrates high fever, [[stiff neck]], altered reflexes, drowsiness with [[stupor]], localised symptoms such as [[aphasia]], [[anosmia]] that distinguish it from [eclampsia]. Also, skin lesions in dermatomal distribution, immunocompromised status, [[retinitis]] points towards [[HSE]]. Detection of [[DNA]] or Zoster [[Antigen]] in [[CSF]] and [[Polymerase chain reaction]][[(PCR)]] on CSF confirms infection with [[HSV]]. Treatment with [[antivirals]]([[acyclovir]]) results in dramatic improvement.
* On physical exam and history [[Herpes Simplex Encephalitis]]([[HSE]]) demonstrates high fever, [[stiff neck]], altered reflexes, drowsiness with [[stupor]], localised symptoms such as [[aphasia]], [[anosmia]] that distinguish it from [eclampsia]. Also, skin lesions in dermatomal distribution, immunocompromised status, [[retinitis]] points towards [[HSE]]. Detection of [[DNA]] or Zoster [[Antigen]] in [[CSF]] and [[Polymerase chain reaction]][[(PCR)]] on CSF confirms infection with [[HSV]]. Treatment with [[antivirals]]([[acyclovir]]) results in dramatic improvement.
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| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;" |Disseminated Sepsis
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;" |Drug overdose/[[Drug Intoxication]]
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* On physical exam and history drug intoxication can present with Seizures, Hypertension, nausea and vomiting also observed in eclampsia. The most common drugs accountable for seizures include [[Antidepressants]], [[Diphenhydramine]], [[Stimulants]]([[Cocaine]], [[Methamphetamines]]) [[Tramadol]], and [[isoniazid]].<ref name="pmid26174744">{{cite journal| author=Chen HY, Albertson TE, Olson KR| title=Treatment of drug-induced seizures. | journal=Br J Clin Pharmacol | year= 2016 | volume= 81 | issue= 3 | pages= 412-9 | pmid=26174744 | doi=10.1111/bcp.12720 | pmc=4767205 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26174744  }} </ref>
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* Careful history and past records will indicate if the patient is taking any recreational or prescriptional medication respectively that could lead to overdose. Other symptoms of preeclampsia like proteinuria, edema are generally absent. Urine drug screening and Blood screening will confirm the diagnosis.
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| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;" |Drug Withdral Syndromes
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* [[Drug Withdral]] Symptoms are precipitated by sudden absence of a drug from one's system after development of [[physiological dependence]] on the drug. They could include Hypertesnion, tremors , seizures([[GTCS]]), agitation, nausea and vomiting, also seen in eclampsia. Common responsible agents include, [[Short acting opoids]](such as [[Heroin]], some painkillers), [[Long acting opoids]](eg.[[methadone]]), benzodiazepines(eg. [[clonazepam]], [[Xanax]]), [[Alcohol]].
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* Presence of past history of drug intake, and symptoms like [[anxiety]], [[insomnia]], [[hallucinations]], [[Psychological]] disturbances, [[Diarrhea]]([[Benzodiazepines]]), [[Delerium Tremens]]([[alcohol withdrawal]]), frequent yawning, goosebumps, body aches([[opioids]]) point towards drug withdrawal. A [[urine drug screen]] helps confirm the diagnosis.
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| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;" |Encephalitis
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* Encephalitis, inflammation of the brain, is most often caused by viral infection <ref name="pmid22946723">{{cite journal| author=Michael BD, Solomon T| title=Seizures and encephalitis: clinical features, management, and potential pathophysiologic mechanisms. | journal=Epilepsia | year= 2012 | volume= 53 Suppl 4 | issue=  | pages= 63-71 | pmid=22946723 | doi=10.1111/j.1528-1167.2012.03615.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22946723  }} </ref> , presents with seizures in 2-67% of cases <ref name="pmid18754956">{{cite journal| author=Misra UK, Tan CT, Kalita J| title=Viral encephalitis and epilepsy. | journal=Epilepsia | year= 2008 | volume= 49 Suppl 6 | issue=  | pages= 13-8 | pmid=18754956 | doi=10.1111/j.1528-1167.2008.01751.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18754956  }} </ref>, and headache also seen in eclampsia.
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* On history and physical exam a patient with Encephalitis demonstrates: [[fever]], [[stiff neck]], [[sensitivity to light]], increased [[drowsiness]], [[confusion]] and [[disorientation]], [[irritability]], anxiety and if severe: weakness, partial [[paralysis]], [[double vision]], [[impaired speech]] or hearing, [[coma]], [[psychosis]], [[hallucinations]], etc. often not seen in eclampsia.  Neuroimaging (brain MRI or CT scan), [[PCR]] or a [[lumbar puncture]] ([[spinal tap]]) is performed to check for signs of infection. Eg. if the cause is viral, the CSF will show: moderately elevated protein (60-80 mg/dL), normal glucose, and a moderate [[pleocytosis]] (up to 1000 [[leukocytes]]/µL)([[Mononuclear cells]] usually predominate). Blood, urine and stool tests to look for organisms or antibodies responsible for an infection often helps establish diagnosis.
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| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;" |Acute Fatty Liver of Pregnancy ([[AFLP]])
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* On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] also observed in [disease name].
* On history and physical exam [[AFLP]] demonstrates nausea and vomiting (seen in 50-60%), abdominal pain (50-60%), edema, mental status changes (altered sensorium, confusion, disorientation, [[psychosis]], restlessness, [[seizures]] or [[coma]]) (60–80%), [[tachycardia]] (50%) also seen in [[eclampsia]]. <ref name="pmid16432556">{{cite journal| author=Ko H, Yoshida EM| title=Acute fatty liver of pregnancy. | journal=Can J Gastroenterol | year= 2006 | volume= 20 | issue= 1 | pages= 25-30 | pmid=16432556 | doi=10.1155/2006/638131 | pmc=2538964 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16432556  }} </ref>
| style="padding: 5px 5px; background: #F5F5F5;" |
| style="padding: 5px 5px; background: #F5F5F5;" |
* On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] that distinguish it from [disease name].
* Presence of [[Disseminated intravascular coagulation]] (55% cases), [[jaundice]] (>70%), [[gastrointestinal bleeding]] ( seen in 20–60% cases), [[acute renal failure]] (seen in 50% cases), [[Oliguria]] (seen in 40–60% cases), fever(late onset) <ref name="pmid16432556">{{cite journal| author=Ko H, Yoshida EM| title=Acute fatty liver of pregnancy. | journal=Can J Gastroenterol | year= 2006 | volume= 20 | issue= 1 | pages= 25-30 | pmid=16432556 | doi=10.1155/2006/638131 | pmc=2538964 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16432556  }} </ref> and absence of hypertension, proteinuria differentiates it from eclampsia. Abdominal pain is usually right upper quadrant, midepigastric or radiating to back in AFLP(seen in 50-60% cases) <ref name="pmid16432556">{{cite journal| author=Ko H, Yoshida EM| title=Acute fatty liver of pregnancy. | journal=Can J Gastroenterol | year= 2006 | volume= 20 | issue= 1 | pages= 25-30 | pmid=16432556 | doi=10.1155/2006/638131 | pmc=2538964 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16432556  }} </ref> and mostly epigastric and non radiating in eclampsia.
* Severe coagulopathy such as disseminated intravascular coagulation is rare in pre-eclampsia but the prevalance is 55% in AFLP. <ref name="pmid16432556">{{cite journal| author=Ko H, Yoshida EM| title=Acute fatty liver of pregnancy. | journal=Can J Gastroenterol | year= 2006 | volume= 20 | issue= 1 | pages= 25-30 | pmid=16432556 | doi=10.1155/2006/638131 | pmc=2538964 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16432556  }} </ref>
* Lab tests in AFLP shows raised, [[hyperbilirubinemia]], [[hypoglycemia]], elevated [[ammonia]], [[leukocytosis]] and [[thrombocytopenia]], prolonged [[PT]] and [[hypofibrinogenemia]] if DIC is present, which differentiates it from eclampsia.
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Latest revision as of 06:52, 14 August 2021

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Navneet Kaur M.B.,B.S.

Overview

Seizures during pregnancy that are unrelated to Preeclampsia need to be distinguished from Eclampsia. This is essential to recognize the correct cause and provide the targeted treatment necessary in a timely manner.

Differentiating Eclampsia from other Diseases

Eclampsia must be differentiated from other diseases that can cause seizures during pregnancy. The differentiation can be done by obtaining a proper history, physical examination, diagnostic tests, or imaging. Such disorders include:

Usually, the presence of the signs of severe preeclampsia that precede and accompany eclampsia facilitates the diagnosis.

Differential Diagnosis Similar Features Differentiating Features
Acute exacerbation of SLE
  • Lupus flares can present with proteinuria, hypertension, deterioration in kidney function, thrombocytopenia and seizure also observed in eclampsia.
  • On urine examination, cellular casts and proteinuria can be found in SLE while only proteinuria is seen in Eclampsia. SLE is associated with decreasing levels of complement and incresing titre of anti-dsDNA. Also, a history of previous SLE and onset of symptoms before 20 weeks points towards lupus and a renal biopsy can help confirm the diagnosis although it is genereally not recommended during pregnancy.
Acute adrenal insufficiency
  • Adrenal insufficiency can present with fatigue, nausea, vomiting, increased heart rate, increased respiratory rate, loss of appetite, headache, abdominal pain, confusion, loss of consciousness, abnormal body movements, or coma, also seen in eclampsia.
  • Adrenal insufficiency will present with hypotension, whereas eclampsia is associated with high blood pressure. Also, AI patients may have a history of chronic use of steroids for diseases such as asthma, rheumatoid arthritis, etc.[1] Patients may present with symptoms only in the postpartum period as during pregnancy they may acquire cortisol transplacentally from the fetus.[2] Diagnostic tests show decreased morning basal serum cortisol, decreased salivary free cortisol, not seen in eclampsia. Further cosyntropin test and basal ACTH levels can be done. Imaging (MRI without gadolinium administration should be done in pregnant women) may show a pituitary tumor or a cranial SOL.
Brain tumor(s)
  • Brain tumor often presents with signs of raised Intracranial pressure, such as headache, nausea, vomiting and seizures, also seen in eclampsia. Commom tumors that can be found are meningiomas[3], pituitary tumors, gliomas, etc.
  • Presence of past history of convulsions and absence of hypertension and proteinuria points towards cerebral pathology. Brain tumour may present with partial or localized seizures rather than GTCS and can have localized symptoms, such as visual disturbances in pituitary adenomas, localized sensory or motor changes, etc which could differentiate it from eclampsia. Also, brain imaging such as MRI can help establish the diagnosis.
Intracranial Haemorrhage/ Ruptured Brain Aneurysm
  • On physical exam, history and diagnostic test, ICH demonstrates headache, nausea and vomiting, vision abnormalities(such as blurring, scotomas, diminished vision), seizures, loss of consciousness also observed in Eclampsia.
  • The headache in ICH is often described as the worst headache of life. Presence of symptoms such as stiffness of neck, sensitivity to light, unilateral drooping of eyelid, unilateral symptoms of stroke(sensory or motor weakness), and absence of proteinuria, oliguria, edema, gestational hypertension differentiates its from Eclampsia. Neuroimaging (CT or MRI brain) will show AV malformation, ruptured blood vessel, blood in the subarachnoid space that distinguish it from Eclampsia.
Disseminated herpes simplex/ Herpes Simplex Encephalitis(HSE)
  • On physical exam and history Herpes Simplex Encephalitis(HSE) may present with Headache, Seizures( seen in 50% of cases [4]), vision abnormalities, confusion, hyperactivity also observed in eclampsia.
Drug overdose/Drug Intoxication
  • Careful history and past records will indicate if the patient is taking any recreational or prescriptional medication respectively that could lead to overdose. Other symptoms of preeclampsia like proteinuria, edema are generally absent. Urine drug screening and Blood screening will confirm the diagnosis.
Drug Withdral Syndromes
Encephalitis
  • Encephalitis, inflammation of the brain, is most often caused by viral infection [6] , presents with seizures in 2-67% of cases [4], and headache also seen in eclampsia.
Acute Fatty Liver of Pregnancy (AFLP)
  • On history and physical exam AFLP demonstrates nausea and vomiting (seen in 50-60%), abdominal pain (50-60%), edema, mental status changes (altered sensorium, confusion, disorientation, psychosis, restlessness, seizures or coma) (60–80%), tachycardia (50%) also seen in eclampsia. [7]

References

  1. A. Chrisoulidou, C. Williamson, M. De Swiet, Assessment of adrenocortical function in women taking exogenous glucocorticoids during pregnancy. J. Obstet. Gynaecol. 23(6), 643–644 (2003)
  2. Drucker D, Shumak S, Angel A. Schmidt's syndrome presenting with intrauterine growth retardation and postpartum addisonian crisis. Am J Obstet Gynecol. 1984 May 15;149(2):229-30. doi: 10.1016/0002-9378(84)90206-0. PMID: 6720805.
  3. Hala M. Goma (April 10th 2013). Management of Brain Tumor in Pregnancy — An Anesthesia Window, Clinical Management and Evolving Novel Therapeutic Strategies for Patients with Brain Tumors, Terry Lichtor, IntechOpen, DOI: 10.5772/54250. Available from: https://www.intechopen.com/chapters/43971
  4. 4.0 4.1 Misra UK, Tan CT, Kalita J (2008). "Viral encephalitis and epilepsy". Epilepsia. 49 Suppl 6: 13–8. doi:10.1111/j.1528-1167.2008.01751.x. PMID 18754956.
  5. Chen HY, Albertson TE, Olson KR (2016). "Treatment of drug-induced seizures". Br J Clin Pharmacol. 81 (3): 412–9. doi:10.1111/bcp.12720. PMC 4767205. PMID 26174744.
  6. Michael BD, Solomon T (2012). "Seizures and encephalitis: clinical features, management, and potential pathophysiologic mechanisms". Epilepsia. 53 Suppl 4: 63–71. doi:10.1111/j.1528-1167.2012.03615.x. PMID 22946723.
  7. 7.0 7.1 7.2 7.3 Ko H, Yoshida EM (2006). "Acute fatty liver of pregnancy". Can J Gastroenterol. 20 (1): 25–30. doi:10.1155/2006/638131. PMC 2538964. PMID 16432556.

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