Can a pregnant woman with seizures but without hypertension or proteinuria have eclampsia?

Can Eclampsia Occur Without Hypertension or Proteinuria?

No, eclampsia cannot be diagnosed without hypertension according to current international guidelines, though the clinical picture is more nuanced than this strict definition suggests.

Diagnostic Requirements for Eclampsia

The International Society for the Study of Hypertension in Pregnancy (ISSHP) maintains that new-onset hypertension remains a required component for diagnosing preeclampsia, and by extension, eclampsia (seizures occurring in the setting of preeclampsia). 1 However, the guidelines explicitly acknowledge that "although it is probable that preeclampsia can be present in some cases without overt hypertension, ISSHP recommends maintaining new-onset hypertension in the diagnosis for now." 1

Critical Clinical Reality: Eclampsia Can Present With Minimal Hypertension

The most important clinical caveat is that eclampsia frequently occurs with only mild or borderline hypertension. Research demonstrates that 34% of eclamptic women have a maximum diastolic blood pressure ≤100 mmHg at the time of seizure. 2 This means that waiting for severe hypertension before considering eclampsia will miss one-third of cases, which is a critical pitfall in emergency management.

Proteinuria Is NOT Required

Proteinuria is definitively not required for either preeclampsia or eclampsia diagnosis. 1, 3 The ISSHP guidelines clearly state that proteinuria is present in only approximately 75% of preeclampsia cases. 3, 2 Preeclampsia—and therefore eclampsia—can be diagnosed when new-onset hypertension after 20 weeks is accompanied by any maternal organ dysfunction, including:

• Thrombocytopenia (platelets <100,000/μL) 3, 2
• Elevated liver enzymes (transaminases >2× normal) 3, 2
• Renal insufficiency (creatinine ≥1.1 mg/dL or doubling of baseline) 2
• Neurological complications (severe headache, visual disturbances, or seizures) 3, 2
• Pulmonary edema 3, 2
• Uteroplacental dysfunction (fetal growth restriction) 3, 2

Up to 38% of eclamptic seizures occur without premonitory signs of preeclampsia (hypertension, proteinuria, or edema). 4

Practical Clinical Algorithm for Seizures in Pregnancy

When evaluating a pregnant woman with seizures after 20 weeks' gestation:

1. Measure blood pressure immediately - Even mild elevation (≥140/90 mmHg) in the context of seizures should raise suspicion for eclampsia. 1, 2

2. Do not wait for severe hypertension - Remember that one-third of eclamptic patients have only mild hypertension. 2

3. Check for proteinuria but do not require it - Obtain dipstick urinalysis (≥1+ warrants quantification), but absence of proteinuria does not exclude eclampsia. 3, 2

4. Obtain laboratory investigations immediately: complete blood count, liver enzymes, serum creatinine, and electrolytes to identify organ dysfunction. 3, 2

5. Assess fetal well-being with ultrasound for growth restriction. 3

6. Exclude other causes of seizures - Eclampsia is a diagnosis of exclusion when seizures occur in the setting of preeclampsia features. 5, 4

Modified Diagnostic Criteria for Eclampsia

Eclampsia is defined as seizures occurring in pregnancy or within 10 days of delivery (though rare cases occur beyond one week postpartum), accompanied by at least two of the following features documented within 24 hours of the seizure: 4

• Hypertension
• Proteinuria
• Thrombocytopenia
• Raised liver transaminases 4

This broader definition acknowledges that eclampsia can occur without all classic features being present simultaneously.

Timing Considerations

• 38% of eclamptic seizures occur antepartum 4
• 18% occur during labor 4
• 44% occur postpartum 4
• Up to one-third of eclamptic seizures occur out of hospital 4

Postpartum eclampsia can still occur even after blood pressure has normalized, requiring continued vigilance. 6

Management Implications

Treat any pregnant woman with seizures after 20 weeks as having eclampsia until proven otherwise, regardless of blood pressure or proteinuria status. 3 This approach prioritizes maternal and fetal safety. Immediate management includes:

• Parenteral magnesium sulfate 5
• Antihypertensive therapy if BP ≥160/110 mmHg 2
• Early involvement of senior obstetric staff 4
• Multidisciplinary team including Obstetrics, Maternal-Fetal Medicine, and Critical Care 5

The mortality rate for eclampsia remains approximately 2% (1 in 50 women), with 23% requiring ventilation and 35% experiencing major complications including pulmonary edema, renal failure, DIC, HELLP syndrome, stroke, or cardiac arrest. 4 Stillbirth or neonatal death occurs in approximately 7% (1 in 14) of eclampsia cases. 4