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Clinical Review

First seizures in adults

BMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g2470 (Published 15 April 2014) Cite this as: BMJ 2014;348:g2470

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Re: First seizures in adults

Don’t forget eclampsia

In her article ‘First seizures in adults’, Dr Angus-Leppan fails to mention eclampsia, an important cause of tonic – clonic seizure, which has a unique management pathway[1]. She rightly emphasises the importance of taking a good history in order to establish whether a seizure has happened, and lists some important diagnostic blood tests. However, health care professionals also need to think of pregnancy as a potential cause of the first seizure in order not to overlook eclampsia.

Eclampsia is defined as a convulsion in pregnancy or up to 10days postpartum in which at least 2 of the following are present within 24hours of the episode: hypertension, proteinuria of at least 0.3g per 24hours, thrombocytopenia <100 x 109/l, raised aspartate or alanine transaminase >42iu/l [2]. In the last UK survey of eclampsia there were 314 cases over a 12month period, giving a rate of 2.7 per 10,000 maternities [2]. However, in the majority ]62%] hypertension and proteinuria [as evidence of pre eclampsia] had not been detected in the days preceding eclampsia. Also the majority of eclampsia is antenatal and preterm, with the earliest cases from 19weeks’ gestation, and therefore presentation can be to non-maternity staff, including paramedical officers, General Practitioners and emergency department personnel.

Management of eclampsia is with intravenous magnesium sulphate [3], which has the additional benefit in the antenatal patient of providing fetal neuroprotection to preterm babies and thereby reducing the likelihood of cerebral palsy [4]. Care for women with eclampsia needs to be multidisciplinary, and must include an Obstetrician; delivery of the baby is often required. But the first step is to include it in the differential diagnosis of a first seizure.

References
1. H Angus-Leppan First seizure in adults BMJ 2014 348 g2470
2. Knight M Eclampsia in the United Kingdom 2005 BJOG 2007 114 1072-8
3. Which anticonvulsant for women with eclampsia? Evidence from the Collaborative Eclampsia Trial Lancet 1995; 345: 1455-63
4. Crowther CA et al Effect of magnesium sulfate given for neuroprotection prior to preterm birth: a randomized controlled trial JAMA 2003 290 2669-76

Competing interests: No competing interests

20 April 2014
Joanna C Girling
Consultant Obstetrician and Gynaecologist
West Middlesex Unjversity Hospital
Twickenham Road Isleworth TW7 6AF