44 Eclampsia
Eclampsia is a puzzling hypertensive disorder affecting only women. Associated solely with pregnancy and childbirth, it is an epileptic form of convulsions that develops during the second half of pregnancy and disappears after conception.
The severity depends upon the degree and timing of the illness as well as the characteristics of the patient. Eclampsia is associated with hypertension, edema, and toxemia, and all three can cause the symptoms of the disease to vary widely. Preeclampsia refers to hypertension, abnormal edema, or proteinuria during pregnancy, whereas eclampsia is the disease’s most extreme form, manifested by severe convulsions, coma, and even death. Eclampsia is a leading cause of maternal and fetal mortality and can cause stillbirths or premature labor. Medical experts remain confused about the cause of this disorder and have no effective way to cure the disease other than to terminate pregnancy by delivering the baby. Through careful prenatal care, however, physicians can usually control the problem, and it is now relatively rare in the United States and Europe.Not only is the disease difficult to define, but also accurate records of its existence are rare, especially in Third World countries where prenatal care by a medical attendant is uncommon. Although eclampsia is one of the diseases most troubling to obstetricians, research on the illness is difficult because it is found only in human beings. Its etiology remains unknown but may be multifactorial.
Distribution and Incidence
For reasons not understood, eclampsia seems to be more common among the economically underprivileged. The typical patient is a young woman in her first pregnancy, who is of low socioeconomic status and has had little or no prenatal care. It is more common among women who (1) are diabetic; (2) have high blood pressure or suffer from renal or vascular diseases; (3) suffer from poor nutrition or hydatiform moles; (4) are on the age extremes of their childbearing years; and (5) bear twins.
It occurs more frequently in the spring and summer and in certain locations. It also evinces a familial tendency, suggesting some kind of genetic disorder.Eclampsia is less likely to occur in women who have experienced a previous case. There are few conclusive studies indicating that race is a factor, though it has been suggested that black women in the United States are more likely to suffer from eclampsia than their white counterparts because of greater tendency to develop chronic hypertension on the one hand, and less opportunity for proper maternal care on the other. The disorder occurs in 6 to 8 percent of all pregnancies. Statistics show that it is more common in urban areas, though this association may reflect only the fact that urban women who experience eclampsia or preeclampsia receive more medical assistance in giving birth than rural women, and thus the condition is more frequently noted and reported. Indeed, it is difficult to determine the frequency of eclampsia in rural areas or Third World nations because women there seldom seek, have access to, or can afford regular prenatal care and a hospital delivery. In the United States it has been estimated that the incidence of toxemia is between 5 and 7 percent of all deliveries, and that of eclampsia between 0.12 and 0.26 percent of all deliveries. On the other hand, the incidence figures from several Navajo studies soar to as high as 15.2 and.41, respectively, yet hypertension does not seem to be a predisposing factor (Slocomb and Kunitz 1977). Afro-Americans also have a much higher incidence of toxemia and eclampsia than the general U.S. population, but in this case hypertension does seem to predispose to the disease (Williams, ed. 1975).
Clinical Manifestations
Symptoms of eclampsia and preeclampsia include excessive and sudden weight gain, edema, hypertension, and proteinuria. Patients may also suffer from headache, dizziness, visual disturbances, anorexia, nausea, vomiting, upper abdominal pain, and swelling of the face and extremities.
In severe cases, women experience visual and neurological disturbances, oliguria (a deficiency of urine excretion), and, of course, convulsions. In addition, cardiac output increases and the kidneys (which seem to be the target organ for the disease) are affected. Eclampsia can lead to lethal complications affecting the liver, kidney, uterus, and brain, such as abruptio placentae, acute renal failure, cerebral hemorrhage, disseminated intravascular coagulation, and circulatory collapse. Preeclampsia does not occur before the twentieth week of pregnancy, and eclampsia rarely before the thirty-second week. Doctors carefully monitor blood pressure and weight gain to prevent its occurrence, although the disease’s progress can be rapid and sudden.History and Geography
It is difficult to determine how common or serious eclampsia was in ancient times. The writings of Egyptian, Chinese, Indian, and Greek scholars do not convincingly note cases, other than an occasional remark describing a pregnant woman’s convulsion, fit, or headache. For centuries eclampsia was commonly mistaken for epilepsy. If discussed at all, writers generally attributed the disease to uterine suffocation, believing that the uterus had wandered into the abdominal region. Therapy focused on encouraging a retrograde motion of the uterus to relieve pressure on the upper body and brain. Medieval writings only hint at the disease, but perhaps the reason for this paucity of information was that midwives had a monopoly on assisting births and did not provide written descriptions of problems they encountered. In the second century, Galen noted that epilepsy could be fatal to pregnant women, and Eucharius Rosslin in the sixteenth century stated that convulsions and unconsciousness were ominous signs in pregnant women. Jacques Guillimeau in 1612 concluded that convulsions occurred because the fetus was striving to come forth or that improper positioning extended the womb, thus fostering convulsions.
Franςois Mauriceau in 1688 was the first physician systematically to describe eclampsia, thereby indicating a new concern with the disorder as men began entering the field of obstetrics. He also was the first to note that primogravids were at greater risk that multigravids. Mauriceau suggested several causes, including excessive hot blood flowing from the uterus and malignant vapors from a dead fetus. In 1694, he recommended that two or three phlebotomies be performed routinely during pregnancy should a woman exhibit eclamptic tendencies. All early medical experts agreed that it was a dangerous disease.During the nineteenth century, speculation about the disease was widespread, and physicians considered it to be the most dreaded disorder associated with pregnancy. Doctors speculated on numerous possible causes of eclampsia, including a woman’s rapidly changing emotions, a sanguine or plethoric state, excessive hemorrhaging, blood to the brain, nutritional deficiency, excessive protein in the system, albuminuria, renal deficiency, retention of urinary constituents, nerve irritation, high blood pressure, seasonal changes, lethargy, melancholia, wealth, improper positioning of the womb, corrupt menstrual flow, a bad seed, an unstable personality, passions of the mind, and interrupted circulation.
Therapy was generally “heroic.” Solutions included warm baths, doses of opium, extensive bleeding from the jugular vein or a temporal artery, depletion to rid the body of toxins, removal of meat or milk from the diet, mustard poultices, ice or cold water on the head, snuff, clysters, emollients to dilate the cervix, and plasters to the lower body to draw the uterus downward. Doctors disagreed on whether it was wise to deliver the baby immediately. Heroic cures, especially those emphasizing depletion, doubtlessly contributed to maternal deaths.
In 1768 Thomas Denman wrote one of the earliest monographs on the disease in English. John Lever and James Young Simpson in 1843 simultaneously discovered the consistent occurrence of proteinuria in preeclamptic patients by finding albumin in their urine.
This was a major breakthrough, for the disease could now be considered a toxemia rather than one caused by mechanical pressure. Until the twentieth century, eclampsia was associated with wealthy women, probably because they used male doctors who wrote about the disorder. Not until the 1930s were poor women viewed as susceptible. Unwed mothers were also seen as vulnerable, perhaps because their infants were more likely to be primogravids. Early in the twentieth century, eclampsia was usually associated with hypertension and elevated blood pressure, though speculation as to its origin was still common.Today physicians depend upon careful monitoring of blood pressure and proteinuria during pregnancy, while watching for edema and excessive weight gain. Early detection is essential. If a woman should suffer preeclampsia, physicians recommend rest and constant monitoring. If a patient suffers from convulsions, attendants take immediate measures to prevent physical injury by suctioning her air passage, providing oxygen, and employing magnesium sulfate to control the seizures. Should the convulsions persist, in rare cases sodium amorbarbital, a barbit- uate, is administered. Seizures can cause fetal death because the convulsive woman is not breathing and thus the baby is cut off from its oxygen supply. If the baby is near term, doctors make every effort to deliver it once the convulsions have subsided and the patient is conscious. Eclampsia remains one of the greatest puzzles in the list of human diseases and fosters much debate and concern. Doctors have developed better means to manage the disease but still lack an Imderstanding of its etiology.
Sally McMillen
Bibliography
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