VOL. 56, No.
1 71
Post-Partum Eclampsia*
LEROY JACKSON, M.D. AND ERNEST LOWE, M.D.
Department of Obstetrics and Gynecology,
Howard University and D.C. General Hospital, Washington, D.C.
( NE of the rare and still controversial com-
plications in obstetrics is post-partum
eclampsia.
The diagnosis of post-partum eclampsia in pa-
tients with convulsions beginning more than 48
hours following delivery is looked upon with
skepticism by Eastman.' The purpose of this paper
is to present a ten-year study of post-partum
edampsia at the District of Columbia General
Hospital in Washington, D. C., and to present
three case reports of patients with late post-partum
eclampsia. Their initial convulsions occurred more
than 48 hours following delivery.
MATERIAL
During the ten-year period, from 1951 to 1961,
there were 61,326 deliveries at D. C. General Hos-
pital of which 81 patients had eclampsia. Of these
patients 23 or 28 per cent had their convulsions
following delivery. Eighty-seven per cent of the
convulsions occurred within the first 24 hours
post-partum, however, three patients, whose cases
are discussed below, are of particular interest since
their convulsive episodes occurred later than the
second post-partum day, and incidence of 12 per
cent.
CASE REPORTS
Case 1-I. B. A 19-year-old Gravida I, Para 0, whose
last normal menstrual was February 9, 1952. Expected
date of confinement November 16, 1952. She received
prenatal care for three visits and was admitted at 36
weeks with a history of painless genital bleeding com-
mencing the morning of admission and headache for
three weeks prior to admission. No history of hyperten-
sion, renal disease, convulsive disorders, or diabetes.
Physical Examination. Blood pressure 160/100, Tem-
perature, pulse and respiration normal. Fundoscopic ex-
amination revealed arteriolar spasms. Abdominal exam-
ination-single fetus with uterine size comparable to age
of gestation with fetal heart tones 140. Extremities-no
edema.
Laboratory Data. 3+ Albumin; WBC-5-10; Hemo-
globin 10.0.
* Read at the 68th Annual Convention of the National Medi-
cal Association, Los Angeles, California, August 12-15, 1963.
The patient was given I.V. Nembutal and magnesium
sulfate and a sterile pelvic examination ruled out pla-
centa previa. Her membranes were ruptured and a living
male infant weighing 5 lbs., 3 oz. was delivered after 10
hours of labor with low forceps over a midline episio-
tomy and general anesthesia. The placenta showed 30 per
cent separation.
The immediate post-partum blood pressure was 120/
80, but increased to 160/100 on the second post-partum
day. She received penicillin and sulfadiazine for post-
partum endometritis and Methergine tablets and was
asymptomatic for five days.
On the sixth post-partum day she had two generalized
convulsions with blood pressure 150/100 and tempera-
ture 99°.
Fundoscopic-marked spasms; Urine 3+ albumin. She
was given magnesium sulfate and Nembutal without re-
currence of seizures and was discharged on the ninth
post-partum day with a borderline blood pressure of
140/100, no albuminuria and asymptomatic.
Case 2-M. M.: A 25-year-old Gravida II, Para II,
who was admitted five days post-partum complaining of
severe headache. She was admitted seven days prior to
this admission at 35-36 weeks in early labor with mod-
erate genital bleeding. Blood pressure 130/90; single
fetus with no fetal heart tone; Urinalysis showed 2+
Albumin; 1-3 WBC; Clotting time-7 minutes, and 1+
ankle edema. Sterile pelvic examination ruled out pla-
centa previa. The membranes were ruptured and spon-
taneous vaginal delivery of a stillborn infant girl fol-
lowed within one hour. The placenta showed 10 per cent
separation. She received Pitocin and morphine sulfate
immediately post-partum and was discharged in two days
with a bloo,d pressure of 130/90. Her past history was
negative and her prenatal course uneventful.
Physical Examination on readmission: Blood pressure
200/100, temperature, pulse and respiration normal. A
Grade II systolic murmur was heard over the aortic and
pulmonary areas. There was no edema and the reflexes
were physiologic. Urinalysis revealed a 3+ Albuminuria
with 50-60 RBC's and 1-3 WBC/HPF. The BUN was
15; Total Protein 5.3, with Albumin 1.4. She received
Nembutal and Unitensin with no effect on her pressure
and had a generalized convulsion 12 hours after admis-
sion. Lumbar puncture was done with normal pressure
and clear fluid, the skull film and EEG were negative.
In spite of Unitensin and Serpasil the blood pressure
remained elevated and four days after admission, her
ninth post-partum day, she had a second convulsion.
Complete neurological examination was negative except
for positive Hoffman's sign. During the next seven days
she experienced a decrease in blood pressure to 120/80
and albuminuria ceased along with the headaches. The
72 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
hematuria disappeared on her third hospital day and she
was discharged asymptomatic thirteen days after admis-
sion with a blood pressure of 120/80 and a completely
negative urine.
Case 3-F. M.: A 44-year-old gravida 5, para 5, who
was admitted 14 days post-partum after having a gen-
eralized convulsion at home on the day of admission, a
second seizure in the ambulance on the way to the hos-
pital, and a third seizure in the Emergency Room of
D. C. General Hospital. She had an uncomplicated pre-
natal course and delivery with antepartum and post-
partum blood pressures of 100-110/70. She experienced
severe headaches for 'four days prior to the convulsion.
Her past history was negative for hypertension, epi-
lepsy, renal disease and toxemia of pregnancy.
Physical examination on admission: Blood pressure
160/80, temperature, pulse and respiration normal. Fun-
doscopic examination-retinal edema. Pelvis-uterus were
the normal post-partum size. Extremities- 1+ edema.
Neurological examination showed no pathologic reflexes
or lateralizing signs.
Laboratory Data: Hct. 44; Urinalysis negative, BUN-
11. Spinal Tap-Pressure normal, clear fluid, no cells,
and normal chemistries. Skull films and EEG were nega-
tive.
She received Dilantin and Unitensin with good re-
sponse. The blood pressure remained at 100-110/60-70,
and there was no recurrence of seizures after the day of
admission. She was discharged on her sixth hospital day
asymptomatic.
DISCUSSION
The need for good prenatal care is re-empha-
sized in this review in that only one-third of these
patients received care. Three-fourths were primi-
gravida and their ages ranged from 13 to 44, the
average age being 19.
The three patients whose convulsions occurred
more than 48 hours post-partum, however, all
received prenatal care and only one was admitted
with pre-eclampsia. This patient was also the only
one to receive ergotrate during the early puerpe-
rium. The role of ergotrate in the etiology of
post-partum eclampsia was discussed by Samuels,2
and Hofmeister and Brown.3 Their ages ranged
from 19 to 44 and the parity from one to five.
All patients presented with the diagnostic com-
plex of hypertension, edema and/or albuminuria
associated with convulsions and coma. Complete
neurological examinations were negative and CNS
tests, including lumbar puncture, skull x-rays and
electroencephalograms, were also negative. All pa-
tients responded to therapy for eclampsia with the
blood pressure returning to normal, the disappear-
ance of albuminuria and edema, and the cessation
of convulsions.
JANUARY, 1964
The differential diagnosis of post-partum eclamp-
sia includes idiopathic epilepsy, hypertensive en-
cephalopathy, hypoglycemia, uremia, nephritis,
convulsions secondary to I.V. ergotrate, encephali-
tis, tetany, pheochromocytoma, subarachnoid hem-
orrhage, intracranial neoplasms,4 and cerebral ven-
ous thrombosis.5 These entities may be ruled out
by taking a careful obstetrical and general medical
history, complete physical examination, laboratory
tests including chemistries, hemogram, and urinal-
ysis, and a thorough central nervous system exam-
ination including lumbar puncture, skull x-rays and
electroencephalogram.
Samuels, in his review of the world literature,
found 19 cases of late post-partum eclampsia to
which he added four. Harer and McIndoe6 re-
ported one case treated by curettage. These three
cases met the diagnostic criteria for eclampsia with
the onset of toxemia occurring on the 5th, 6th,
and 14th post-partum day.
Many theories concerning the etiology of the
pre-eclampsia complex have been presented and
none have been all inclusive to explain this com-
plex medical phenomenon. The etiology remains
unknown and the treatment remains symptomatic
and empirical.
CONCLUSIONS AND SUMMARY
1. Twenty-three cases of post-partum eclampsia
at D. C. General Hospital, for the ten-year period
from 1951 to 1961, were reviewed.
2. Three cases of late post-partum eclampsia,
occurring on the 5th, 6th and 14th post-partum
days, were presented.
3. The incidence of post-partum eclampsia was
28 per cent in agreement with the usual statistics.
4. Eighty-seven per cent had convulsions during
the first 24 hours post-partum.
5. A brief discussion of the differential diag-
nosis of late post-partum eclampsia was given.
LITERARURE CITED
1. EASTMAN, N. and L. HELLMAN. Obstet., New York,
1961, Appleton-Century-Croft, Inc., P. 735.
2. SAMUELS, B. Obstet. Gynec., 15:748, 1960.
3. HOFMEISTER, P. J. and BROWN. Am. J. Obstet. &
Gynec., 41:498, 1953.
4. BARNES, J. and L. H. ABBOTT. Am. J. Obstet. &
Gynec., 82:192, 1961.
5. LORINZ, A. and R. MOORE. Am. J. Obstet. &
Gynec., 83:311, 1962.
6. HARER, W. B. and MCINDOE. Am. J. Obstet. &
Gynec., 84: 1349, 1962.