Eclampsia complicating hydatidiform molar pregnancy with a coexisting, viable fetus. A case report

BACKGROUND

Eclampsia is a rare and serious complication of pregnancy. The occurrence of preeclampsia prior to the 20th week of gestation has been associated with concurrent hydatidiform molar pregnancy. We present a case of eclampsia complicating a partial molar pregnancy associated with a viable fetus.

CASE

A 22-year-old white woman, gravida 1, para 0, at 14 weeks' gestation, presented with an excruciating headache associated with hypertension, proteinuria and a viable intrauterine fetus with gastroschisis. Subsequently the patient had a generalized tonic-clonic seizure which resolved with magnesium sulfate therapy. Markedly elevated quantitative human chorionic gonadotropin and a moderately thickened placenta were the sole clinical features suggestive of a molar gestation. Dilation and evacuation was performed revealing unremarkable products of conception. Pathologic and cytogenetic analyses revealed a triploid fetus (69,XXX) consistent with partial molar pregnancy.

CONCLUSION

Development of preeclampsia/eclampsia prior to 20 weeks of gestation should prompt a clinical evaluation to exclude the possibility of an underlying hydatidiform molar pregnancy.

Perceived causes of eclampsia in four ethnic groups in Borno State, Nigeria

This study was conducted among the four major ethnic groups(Kanuri, Babur, Shuwa and Marghi) of Borno State, North-east Nigeria. The aim of the study was to identify the perceived causes of eclampsia, a leading cause of maternal death in the State. The data were obtained through focus group discussions (FGDs), questionnaires and in-depth interviews. A total of 16 FGDs and 1,167 questionnaire interviews were conducted among the rural populace. In-depth interviews were conducted on relatives of thirty eclamptic patients admitted to the University of Maiduguri Teaching Hospital. The findings revealed that evil spirits/witches and wizards, poor nutrition, heredity early marriage, destiny from God and machinations of co-wives are the perceived causes of eclampsia in the area. These perceptions result in the use of the following as means of treatment: drinks of various concoctions, inhalation of smoked herbs in rooms, potash drinks, and the wearing of talisman around the neck. These perceptions and traditional medications have implications for design of educational and informational messages aimed at reducing maternal mortality from eclampsia in Borno State.

Perioperative management of intra-partum seizure

A young nulliparous woman previously diagnosed with pregnancy-induced hypertension suffered a seizure during active first stage labour. Pre-seizure blood pressure was borderline high but she did not fulfill other criteria for preeclampsia. She underwent emergency caesarean section for presumed eclampsia. Postoperatively, she deteriorated neurologically. CT scan showed an intracranial haemorrhage requiring neurosurgical intervention. The similarities of presentation of a primary cerebrovascular event and eclampsia following an intra-partum seizure made the differential diagnosis difficult.

Antenatal complications in adolescent mothers aged below 14 years

Antenatal complications in 340 booked and 710 unbooked adolescent mothers aged 12-14 years were evaluated over a 2-year period at the Specialist Hospital, Yola, Adamawa State, Nigeria. Emesis gravidarum was observed in 290 (85.3%) and 612 (86.2%) booked and unbooked mothers, respectively. While 112 (32.9%) booked mothers had malaria, this ailment was observed in 508 (71.5%) of unbooked mothers. Forty-six (13.5%) booked mothers suffered from anaemia as against 483 (68.0%) unbooked patients. It was observed that preeclampsia manifested in 62 (18.2%) booked and 158 (22.2%) unbooked mothers, while eclampsia occurred in 18 (5.3%) and 66 (9.3%) booked and unbooked mothers, respectively. The rates of premature deliveries were 16.20% in booked mothers and 22.82% in the unbooked group. Other notable complications observed in both groups include premature rupture of fetal membranes (PROM), preterm contractions, antepartum haemorrhage, and urinary tract infections. There were slightly higher frequencies of the above complications in 12-year-olds, and these decreased slightly towards the age of 14 years. Nine of the 10 above observed complications occurred more in the lower socioeconomic classes [3-4] than in the upper social economic classes [1-2] in significant proportions.

[Observations on pe-eclampsia-eclampsia and the advances in the evolution of some laboratory tests]

The preeclampsia-eclampsia syndrome is a vasospastic disorder and probably has a placental origin. Once the hypertensive syndrome is established the uteroplacental blood flow is reduced as well as the intervillous blood flow. Since 18-24 weeks of gestation and before the symptoms of preeclampsia become overt, changes in placental flow velocity can be detected with Doppler technics. The placental theories for the etiology of preeclampsia are focused on the hypoxic effect in the trophoblastic tissue of second trimester. The placental ischemic changes are evident and seen in the uteroplacental bed. They are interrelated with the stages of trophoblastic invasion of the spiral arteries during the 14 and 20 weeks. When the trophoblastic invasion is over, the spiral arteries become a high resistance system. The defect observed in preeclampsia is the lack of invasion of the trophoblast to the maternal arteries. The diminished placental perfusion probably creates endothelial damage. This damage has several effects: decreased prostaglandin production, activated coagulation cascade, stimulated fibrin aggregation, and increased vascular permeability. The ideal laboratory test for preeclampsia shall predict the onset of this entity. Recent findings seem promising. The fibronectin concentration increases 2-3 wks. prior to the clinical manifestation of preeclampsia. Severe hypertension shows an abnormal decrease in fibronectin levels. Hypocalciuria has been described as an early predictor in the development of preeclampsia. Other agents undergoing extensive evaluation as predictors are: uric acid, b-thromboglobin, prolactin and atrial natriuretic peptide. Recently high levels of b-HCG (human corionic gonadotrophin) have been linked to a lack of trophoblastic invasion during the second trimester, therefore this is a potential marker for those patients that will eventually develop preeclampsia.

Coital rate and pregnancy-induced hypertension

Previous workers have emphasized the possibility that pregnancy-induced hypertension (PIH) is associated with a change of sexual partner. It is noted here that any such association is far weaker than that between PIH and fecundability (the probability of conceiving in a month at risk). This latter association is so strong as to suggest its closeness to a true cause. Of the determinants of fecundability, coital rate seems the most promising to pursue as a possible cause of PIH.

Hypertension in pregnancy: current concepts of preeclampsia

Hypertensive disorders (gestational hypertension, preeclampsia, chronic hypertension, superimposed preeclampsia) are the most common medical complications of pregnancy and constitute a major cause of maternal and perinatal morbidity and mortality. Prediction of those women destined to develop preeclampsia remains elusive. The benefits of calcium supplementation for prevention of preeclampsia are encouraging; however, the definitive study is not yet complete. Aspirin therapy for high-risk has not been helpful; results of therapy for high-risk women are pending. More experience is being gained with antihypertensive therapy and expectant management in severe preeclampsia. Conservative management of severe preeclampsia, when performed in a tertiary care center, may benefit a select group of women and their fetuses.

Hypertension in pregnancy

Normal pregnancy is characterized by a marked reduction in peripheral vascular resistance. Blood pressure is diminished, while cardiac output, blood volume, renal blood flow and the glomerular filtration rate are increased. These hemodynamic changes are reversed in preeclampsia-eclampsia (PE-E), a condition considered to be related to a dysfunction of the endothelium. Decreases in the production of nitric oxide (NO) and prostacyclin (in association with an increased synthesis of thromboxane A2) may play a role in the pathogenesis of PE-E. Recent reports have supported the concept that an imbalance between vasodilators and vasoconstrictors may explain the clinical, laboratory and hemodynamic disturbances observed in PE-E. Particular attention has been given to the fact that a state of L-arginine NO deficiency may be present. The control of hypertension, rest, and close clinical and laboratory surveillance remain the gold standard to minimize the severity of the complications of PE-E. However, on the basis of its physiology and pathophysiology, low-dose aspirin has been recommended in pregnancies at risk to prevent or, at least, to delay the occurrence of PE-E. Although initial reports showed promising results, recent conclusions from large trials have moderated this optimism. The use of supplemental L-arginine may be considered another possibility of treatment, and experimental data have given convincing results, but there are no reports on PE-E. Therefore, the practical management of PE-E requires prudence, careful follow-up and prompt decisions on the precise moment for delivery (which remains the most effective therapeutic procedure).

Lower body nerve stretch: a role in essential hypertension or pre-eclampsia?

Despite the relatively high incidence of essential hypertension and pregnancy-induced hypertension, the etiologies of these disorders remain enigmatic. A link between stretching of neural structures in the lower body and the induction of hypertension in these disorders is hypothesized. Hypertension has been documented in patients undergoing femoral and tibial lengthening procedures; in experimental models the stretching of lower extremity nerves appeared to be responsible for the increase in blood pressure with bone lengthening. The upright posture of humans puts an added strain on nerves and an increased pressure on lumbar disks may put increasing tension on the nerve roots. The resultant nerve stretch in pregnant women may be exacerbated by the hormone relaxin. A possible link between the stretching of neural structures and the genesis of essential hypertension or pre-eclampsia/eclampsia is hypothesized.

Endothelin-1 stimulates the proliferation and invasion of first trimester trophoblastic cells in vitro--a possible role in the etiology of pre-eclampsia?

BACKGROUND

Endothelin-1 is a potent mitogen and stimulates cell chemokinesis, but these properties have not been investigated in the placenta. Trophoblastic cells from pre-eclamptic pregnancies have a reduced invasive potency and secrete less endothelin-1 than those from normal pregnancies. The present study tested the hypothesis that endothelin-1 affects trophoblast proliferation and invasion.

METHODS

Trophoblastic cells were isolated from 37 placentae of normal human pregnancies at week 12 by dispastrypsin digestion and subsequently immunopurified to remove nontrophoblastic components. The effects of 5, 10, and 20 nmol/mL endothelin-1 on proliferation and invasion were determined after 24 and 72 hours, respectively, by fluorescence-activated pulse cytometry (FACS) analysis, by measuring DNA synthesis using two different methods and by a Matrigel invasion assay.

RESULTS

All cell preparations uniformly responded to 10 nmol/mL by increased proliferation, owing to a greater proportion of cells in the S-phase of their cell cycle, and invasion. The effects were more pronounced after 24 hours than after 72 hours, by which time cell viability, as measured by the secretion of human chorionic gonadotropin (hCG-beta), had deteriorated. The nonselective receptor antagonist PD 142893 inhibited both endothelin-1 effects.

CONCLUSION

Endothelin-1 is a mitogenic stimulus for first trimester trophoblastic cells in vitro. The stimulation of cellular invasion represents a novel effect of endothelin-1. We suggest the implication of endothelin-1 in proliferation and invasion of trophoblast and tumour cells and hypothesize a possible role in the etiology of pre-eclampsia.

Obesity and the risk of toxaemia of pregnancy

The purpose of the present study was to examine the relationship between severe pre-eclampsia/eclampsia (toxaemia) and obesity. We collected sociodemographic, anthropometric, medical and pregnancy outcome data from the hospital records of 248 Israeli women diagnosed with either pregnancy-induced or chronic hypertension, and compared these data to a control group of 236 women. Univariate analysis showed that while there exists a statistically significant positive association between obesity and hypertension (both pregnancy-induced and chronic) obesity presents no added risk to the development of toxaemia. Furthermore, we found a significant decrease in the rate of obesity among primigravid versus multigravid mothers with toxaemia superimposed on pregnancy-induced hypertension. On the other hand, primigravid mothers with PIH were at an increased risk of developing toxaemia as compared to multigravid women. These results suggest that obesity is not a significant factor in the development of toxaemia.

[Systemic lupus erythematosus and pregnancy (analysis of 84 cases)]

We present 84 pregnancies (3 twin pregnancies) of 80 women with Systemic Lupus Erythematosus. Although there was a multidisciplinary prenatal control, in 83% of the cases there were one or more complications during pregnancy, most of them being preterm labor, premature rupture of membranes and preeclampsia-eclampsia. There were flares up in 15 of 84 cases, (17.85%). Worsening of renal function was the most common finding. There were 9 abortions, 3 stillbirths, 1 neonatal death and two newborns with congenital heart block. No maternal deaths were present.

[The role of nutritional factors in pre-eclampsia and eclampsia]

Preeclampsia and eclampsia are very important health problems because they are the main contributors to maternal and perinatal morbidity and mortality. These disorders are unique in pregnancy and are characterized by oedema, proteinuria and hypertension. they occur in 0.5% to 30% of all pregnancies, primarily in primigravidas, after the 20-th week of gestation. Preeclampsia and eclampsia are diseases of undetermined cause. Many different factors might play an important role in the development of these diseases. One of them is nutrition. Recent studies have emphasized the possible role of general nutritional deficiency or imbalance of several specific nutrients in the aetiology of the disease. Deficiency of a variety of nutrients has been reported in patients with preeclampsia. The obtained results are contradictory and further study is necessary. Nevertheless, some evidence is highly suggestive of a relationship between nutritional status and the onset or progress of the disease. The article reviews the study that correlates the role of several nutritional elements with the pathophysiology of preeclampsia and eclampsia: proteins, lipids, calcium, vitamin D, sodium, magnesium and zinc. The evidence that supports or rejects the role of each of these nutrients is presented. In this way a guideline for general nutritional counseling in the prenatal period that will promote a healthier pregnancy, is offered.

[Management of HELLP syndrome before 32 weeks of amenorrhea. 22 cases]

OBJECTIVES

Assess expression and management of HELLP syndrome (hemolysis, elevated liver enzymes, low platelet count) occurring before 32 weeks gestation.

METHODS

Among 50 patients presenting HELLP syndrome from 1990 to 1994, 22 (44%) who developed the syndrome before 32 weeks gestation were evaluated retrospectively.

RESULTS

Most of the patients were primiparous and HELLP syndrome recurred in 2 during a second gestation before 32 weeks gestation. Only three cases began during the post partum period. All patients had severe pre-eclampsia before discovery of the HELLP syndrome. Episodes of eclampsia also occurred in 6. The most frequent clinical manifestation was epigastric pain. Ten patients had acute severe renal failure. The 3 post partum patients had severe complications (eclampsia, renal failure, subcapsular hepatic hematoma). Obstetrical intervention was required in all cases. Cesarean section was performed within 48 hours of diagnosis. Pregnancy had to be terminated in 3 cases between 24 and 29 weeks gestation. There was one fetal death in utero and one during the neonatal period. Seventeen live infants were delivered. In the group of 11 infants born after 30 weeks gestation, only 1 had hyalin membrane disease which developed in all those born before 30 weeks, including 2 with broncho-pulmonary dysplasia.

CONCLUSION

Based on the physiological mechanisms involved in HELLP syndrome, criteria for obstetrical extraction and the possibilities for conservative management in very premature pregnancies, we propose a management protocol for HELLP syndrome developing before 32 weeks gestation. Corticosteroid therapy may be given for 48 hours in cases without maternal or fetal complications in order to accelerate fetal maturation before extraction.

-Obstetric prognosis after pre-eclampsia, eclampsia or HELLP syndrome-

Preeclampsia, eclampsia and the HELLP syndrome are serious pregnancy complications associated with increased maternal and perinatal mortality and morbidity. The question of subsequent pregnancy outcome in these patients is of great importance for the patient and the obstetrician. The risk of recurrence of hypertensive complications during subsequent pregnancy is related to the time of the onset and the clinical signs of hypertension during the first pregnancy. Patients having hypertensive pregnancies should be examined for chronic hypertension, kidney disease and other internal diseases. The recurrence risk is for preeclampsia between 19.5% and 25.9% and for eclampsia between 21.9% and 46.8%. Patients developing the disease early in pregnancy and with chronic hypertension are at higher risk. For the HELLP syndrome the risk of recurrence is between 3% and 5%. These patients should be considered to be at increased risk for obstetric complications in subsequent pregnancies and close perinatal care is indicated in subsequent pregnancies.

Complexity and complicity in eclampsia: barriers or bridges?

The aetiology of pre-eclampsia-eclampsia remains largely unclarified, despite over 100 years of systematic study. The assumption that the triggering event is linear and amenable to reductionist techniques has characterized these efforts. The main purpose of this paper is to show that complexity and complicity characterize most pathophysiological processes in pre-eclampsia-eclampsia, a situation suggesting that similar mechanisms must exist at the origin of the disease. The unique configuration of the intervillous space and the intensity of energy transference through the fetomaternal interface offer many dysfunctional possibilities, even in clinically normal pregnancies. The most characteristic seem to be: the shedding and deportation of trophoblast, the fragmentation of villi, the escape of fetal blood, and events associated with trophoblast damage, degeneration and death. The pathogenic potential of these natural processes seems to depend on the association with amplifiers and permissive factors, which vary from person to person and from time to time. Thus, considering the convergence of multiple factors and the presence of nonlinearity in some of their interactions as a plausible working hypothesis, further exploration on this subject should adhere to the rules of this different reality. To find the best possible method of inquiry and to recognize its limitations will be the surest way to avoid failure.

[An attempt at optimization of diagnosis for patients in puerperium treated due to eclampsia and systemic complications in the Department of Anesthesiology and Intensive Therapy in the Silesian Medical Academy in Katowice]

Conditions under which episodes of eclampsia occurred in puerperal, who were than admitted to the Intensive Care Units for treatment are presentation the paper. Multidirectional diagnostic procedures introduced in those 30 patients are discussed. In the analysed group of patients various types of organ complications were diagnosed. The paper underlines value and benefits of the interdisciplinary consultation in diagnostic procedure in cases of dramatic and rapidly occurring complications overlapping existing puerperal status.

Hypertensive disorders of pregnancy and stillbirth in North Carolina, 1988 to 1991

BACKGROUND

The objectives of this study were (i) to assess the effect of hypertensive disorders of pregnancy on the risk of stillbirth, and (ii) to characterize the relationship between hypertension and stillbirth separately by gravidity, race, 'explained' versus 'unexplained' causes of stillbirth, and antepartum versus intrapartum stillbirths.

METHODS

The study was based on a retrospective cohort of approximately 400,000 pregnancies identified through the birth and fetal death certificates in North Carolina, USA, between 1988 and 1991. Multivariable polytomous logistic regression was used to generate odds ratios comparing stillbirth risk in hypertensive compared to non-hypertensive mothers, adjusted for potential confounders.

RESULTS

The risk of chronic hypertension was 7.6 per 1000 pregnancies, while pregnancy-induced hypertension (PIH) and eclampsia were reported in 36.6 and 6.0 per 1000 pregnancies, respectively. Pregnancies among chronic hypertensives were more likely to result in losses after 28 weeks gestation (RR = 3.29, 95% CI: 2.43-4.43), while the risk ratio was 2.16 (95% CI: 1.45-3.22) for losses prior to 28 weeks' gestation. Pregnancies to patients with PIH were at 1.42 (95% CI: 1.15-1.79) times greater risk of terminating in late stillbirth, while the risk ratio for eclampsia was 2.23 (95% CI: 1.51-3.30). The risk ratio for 'explained' antepartum stillbirth was higher than intrapartum stillbirth for all of the hypertensive diseases.

CONCLUSIONS

Hypertensive disorders were found to have a strong adverse impact on stillbirth suggesting that early diagnosis of hypertension during pregnancy and adequate medical intervention may help reduce the risk of stillbirth.

Epidemiology of eclampsia

The purpose of this study was to examine the risk of eclampsia in relation to several maternal characteristics and exposures, including demographic characteristics, reproductive history, and tobacco use during pregnancy. A case control study was conducted using data for all singleton births from the Washington State birth certificates for 1984-1990. In the check box feature employed by these certificates, eclampsia is listed under maternal conditions. Risk estimates, adjusted for various confounders, were calculated comparing eclampsia among exposed versus unexposed women. The risk of eclampsia was elevated in women without prenatal care, those with weight gain of more than thirty pounds during pregnancy, nulliparous women, and those with chronic hypertension. The association with tobacco smoking were inverse and dose related. Women's race, urban or rural place of residence, history of pre-term births, and anemia were not associated with eclampsia. Our data reaffirm the importance of prenatal care, and provide further evidence of an inverse relationship with prenatal smoking. As eclampsia and pre-eclampsia are important pregnancy complications, further research is needed to explore their possible causes.