Obstetric

Eclamptic seizure in unbooked pregnant patient

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Adult · 35yr · female

Patient Information

Dispatch	You are called to the medical tent at the Fremantle Arts & Craft Festival for a 35-year-old female (Sarah Nolan) who is fitting. Bystanders report she was complaining of a severe headache before collapsing.
Patient	Sarah Nolan — 35yr (65kg)
Incident History	Pt was browsing market stalls when she suddenly collapsed and began seizing. Bystanders state she had been complaining of a severe headache and said her vision 'had flashing lights in it' for approximately 20 minutes prior. Pt appears visibly pregnant. No antenatal care documented — gestational age unknown.
Emergency Contact	Daniel Nolan (Husband) — 0412 748 093

Initial Rapid Assessment

Response	Pain
Airway	Partially compromised — jaw clenched during tonic phase. Secretions present in oropharynx. No stridor audible.
Breathing	Irregular and laboured during active seizure. Rate difficult to assess accurately. SpO2 not yet obtainable.
Circulation	Radial pulse rapid and bounding. Skin flushed and diaphoretic. No visible external haemorrhage.
Disability	GCS 7 (E1V2M4) — actively seizing. Not orientated. Eyes deviated laterally. Tonic-clonic movements of all four limbs.
Exposure	Visibly pregnant abdomen — fundal height appears significant, estimated ≥28 weeks by visual inspection. No rash. No visible trauma from fall.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	82% (RA) — difficult to obtain accurate reading during active seizure	Severe	8	112	178/114	2s	7	4 4 SL — difficult to assess during seizure	37.4	5.4 mmol/L	–
10 mins	94% (O2 NRB 15L/min)	Moderate	16	104	172/108	<2s	10	4 4 ++ — post-ictal, eyes now open to voice	37.4	5.4 mmol/L	6

History Taking

Treatment Response

Diagnosis

This patient is suffering from eclampsia — a rare obstetric emergency characterised by new-onset grand mal seizures in a patient with pre-eclampsia (hypertension ≥140/90 mmHg with signs of organ involvement at ≥20 weeks gestation), occurring in the context of an unbooked pregnancy of unknown gestational age.

Facilitator Triggers — if trainees miss a critical step

! (If trainees do not immediately protect the patient from injury during the active seizure — move objects away, pad beneath head — have a bystander state 'she keeps hitting her arm on the chair leg.')
! (If trainees attempt to insert an OPA or force an airway device into the patient's mouth during the tonic-clonic phase — facilitator states: 'The patient's jaw is clenched. The device will not pass and you feel resistance.' Prompt trainees to consider NPA only once jaw relaxes or seizure resolves.)
! (If trainees do not place the patient in the left lateral position during or immediately after the seizure — facilitator states at 5 minutes: 'The patient's SpO2 has dropped further to 78% and you notice she looks more dusky.' The left lateral position is required for all pregnant patients to relieve aortocaval compression and facilitate airway drainage.)
! (If oxygen is not applied within 3 minutes of seizure cessation — facilitator states: 'The patient remains cyanosed and her lips appear blue.' SpO2 remains at 82%.)
! (If trainees do not perform a BGL — facilitator prompts: 'The patient's husband asks if she might be diabetic — should you check her sugar?')
! (If trainees do not identify or acknowledge the pregnancy — facilitator states: 'The patient's husband says — she is pregnant, does that matter?')
! (If trainees do not anticipate further seizure activity post-ictally — facilitator states at 8 minutes: 'The patient begins to stiffen again.' Trainees must re-implement seizure management steps.)
! (If trainees do not call for CSP support immediately — facilitator states at 6 minutes: 'The patient's husband is asking why no ambulance has been called yet.')
! (If trainees do not contact CSPSCC for advice — remind them at 7 minutes: 'Do you have any other resources or advice available to you?')

Treatment Objectives

1. Ensure scene safety — call for bystander assistance and clear area of hazardous objects around seizing patient
2. Protect patient from injury during active seizure — do NOT restrain limbs, pad beneath head, remove hazards from immediate area
3. Do NOT attempt to insert OPA during active tonic-clonic seizure — await jaw relaxation post-ictally
4. Prepare NPA with lubricant for airway management once seizure resolves or if airway at risk
5. Place patient in LEFT lateral position as soon as safely possible — relieves aortocaval compression in pregnancy and facilitates drainage of secretions
6. Apply suction to oropharynx if secretions present once seizure resolves and jaw allows access
7. Apply oxygen via Non-Rebreather Mask at 15 L/min targeting SpO2 94–98% as soon as practicable
8. Perform BGL — result 5.4 mmol/L, no hypoglycaemic treatment required
9. Obtain vital signs — note severe hypertension (178/114 mmHg), tachycardia (112 bpm), low SpO2 (82% RA)
10. Identify the pregnancy and acknowledge unknown gestational age — visually estimate fundal height
11. Gather SAMPLE history from bystanders and husband during/after seizure: Nil known allergies, nil medications, no antenatal care, gravida 2 para 1
12. Anticipate further seizure activity — eclamptic patients commonly re-seize; maintain readiness with airway adjuncts and suction
13. Call for CSP support immediately — eclampsia requires Advanced Care management (IV Magnesium Sulphate) which is beyond EHS scope; EHS role is airway management, positioning, oxygen, and urgent escalation.
14. Contact CSPSCC for clinical advice — document all advice received.
15. Continue monitoring vital signs every 5 minutes — note any further seizure activity, deterioration in GCS, or changes in respiratory status
16. Maintain left lateral position throughout — DO NOT allow patient to lie supine
17. Prepare for IMISTAMBO handover: convey eclampsia, estimated pregnancy, seizure timing, BGL, vitals trend, interventions performed
18. Scenario ends on arrival of ambulance and IMISTAMBO handover
19. Attention to hand hygiene will be given throughout the scenario.

Clinical references: Pre-Eclampsia & Eclampsia · Seizures · Oxygen Delivery · Suction · Nasopharyngeal Airway · Lateral Position · Blood Glucose Monitor · Blood Pressure · Primary Survey · Secondary & CNS Survey

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Signs/Symptoms	Severe frontal headache with visual disturbances (flashing lights) for approximately 20 minutes prior to collapse. Generalised tonic-clonic seizure witnessed by bystanders. Post-ictal confusion after seizure terminates.
Allergies	Nil known — obtained from husband.
Medications	Nil regular medications — no prenatal vitamins or supplements reported. No antenatal care attended.
Pertinent History	Gravida 2, Para 1. No antenatal care with this pregnancy — gestational age unknown. First pregnancy unremarkable. Husband states she has been complaining of swollen ankles and headaches for approximately 1 week but refused medical review. No known hypertension, renal disease, or diabetes.
Last Oral Intake	Ate approximately 2 hours ago at the festival food stalls.
Events Leading	Patient was walking through market stalls with her husband. She stopped and told him she had a severe headache and her vision was going 'blurry with flashing lights.' Approximately 20 minutes later she collapsed and began fitting.
Treatment Prior	No treatment administered prior to EHS arrival. Bystanders placed patient on their side when she collapsed.

Onset	Seizure onset approximately 5 minutes before EHS arrival. Headache and visual disturbance for 20 minutes prior.
Pain	Severe frontal headache — patient rates 9/10 once post-ictal and able to respond. Also reports upper abdominal discomfort.
Quality	Headache described as 'the worst I have ever had.' Upper abdominal pain described as dull and constant.
Radiates	Headache — no radiation reported. Abdominal pain — upper abdominal only.
Severity	9/10 headache reported post-ictally.