Case of the Week

Editor: Dr Danielle Coleman

This lady had eclamptic seizures at home. She was post-ictal on arrival to the emergency department. The history of seizures, hypertension and proteinuria is suggestive of this diagnosis. In addition, the blood results show that this lady has developed HELLP syndrome.

• Personnel: In this situation presence of senior ED staff and the obstetric registrar is mandatory. 
• High flow oxygen
• Place patient in left lateral decubitus position.
• Magnesium sulphate: An initial loading dose of 6g IV, this is followed by a maintenance infusion of 2g/hr.
• Control of hypertension: Hydralazine (5-10mg as an IV bolus) or labetelol (20-40mg as an IV bolus, every 15 mins as required) can be used. Aiming for a diastolic BP of between 90-110. Care should be taken not to decrease the BP to rapidly as this can cause hypoperfusion of the placenta and fetal distress.
• Delivery is the only cure for eclampsia.

Certain people are more prone to the condition; risk factors include, nulliparity, previous history, extremes of maternal age and renal disease.

The development of this condition can be explained in 2 stages. In the first stage there is incomplete trophoblastic invasion of spiral arterioles, which leads to decreased uteroplacental flow. (In the normal process, trophoblastic invasion causes dilatation of the arterioles, thus providing good blood flow to the placenta). To further compound this there may be atheromatous lesions in the spiral arterioles. Why this happens remains unclear, but it may be caused by altered immune responses. Stage one leads onto stage two: The decreased blood flow results in an ischaemic placenta, this triggers an inflammatory response in the mother , resulting in endothelial cell damage leading to vasoconstriction, clotting dysfunction and increased vascular permeability. It is this endothelial damage and its consequences which lead to the clinical manifestations of the condition which we see.