Eclampsia

This article defines and then delineates pre-eclampsia and eclampsia, reviewing the clinical features, neurologic manifestations, and underlying causes. There is a review of the pathophysiology including hypertension, coagulopathy, and cerebral pathology including newer findings involving immune system abnormalities. The diagnosis including laboratory studies, imaging, and electroencephalography.

Severe preeclampsia and postpartum eclampsia associated with placenta previa and cesarean and hysterectomy: a case report

Several prior studies have demonstrated that the presence of placenta previa protects against the development of preeclampsia. Also, there are no reported cases of eclampsia following cesarean section and hysterectomy. However, we encountered a patient with total placenta previa and accreta who developed severe antepartum preeclampsia followed by the onset of eclamptic seizures after a cesarean section and a subtotal hysterectomy. This case confirms that severe preeclampsia may occur in patients with placenta previa and demonstrate that severe preeclampsia may occur after placental removal and even after subtotal hysterectomy, which removed most of the trophoblastic tissue.

Eclampsia: 134 consecutive cases

OBJECTIVE

A retrospective analysis of all cases of eclampsia (134) at Korle Bu Teaching Hospital, Accra, Ghana, in 1991, was undertaken to determine future directions in prevention and management.

METHODS

One hundred and thirty-four consecutive cases of eclampsia were reviewed to assess possible risk factors, associated medical impact, and the usefulness of prenatal care.

RESULTS

Risk factors for the development of eclampsia include: young age, delivery in the rainy season, nulliparity, multiple pregnancy, prolonged labor, and lack of prenatal care. Eclampsia is associated with high maternal and perinatal mortality.

CONCLUSIONS

Future emphasis on prenatal clinics, and earlier detection and management of pre-eclampsia should lessen the incidence of this severe obstetric emergency.

[Incidence of hypertension in pregnancy in relation to the definition of hypertension]

According to a proposal of the International Society for the Study of Hypertension in Pregnancy (ISSHP) the definition of hypertension is based on a diastolic blood pressure of 90 mmHg or more. Systolic and mean arterial blood pressure (e.g. MAP II) are not be taken into account. Out of a clear defined district the totality of n = 2259 pregnant women has been strictly supervised till to delivery and afterwards. The frequency of hypertension according to the old ACOG-definition was calculated to be 15.9% (n = 360). According to the newer ISSHP-definition it was 12.7% (n = 287). To detect severe and hazardous cases the newer ISSHP-definition seems to be better than the older definition of ACOG. Therefore, the acceptance of the ISSHP-proposal is recommended.

Eclampsia in association with partial molar pregnancy and congenital abnormalities

A case of eclampsia in association with partial molar pregnancy is described. Cytogenetic analysis confirmed a 69,XXX karyotype, and pathologic examination of the fetus showed a meningomyelocele, exomphalos, incomplete intestinal rotation, and cerebral ventricular dilatation.

Maternal and perinatal mortality due to eclampsia

Forty-four mothers with eclampsia and their newborns managed during the year 1988 at the University Hospital of Banaras Hindu University, Varanasi were analyzed. The incidence of eclampsia was 2.2% of all hospital deliveries. Eclampsia was more common in women (below 20 years) and at gestation of 36 weeks and below, and amongst the mothers deprived of antenatal care. The maternal mortality amongst cases of eclampsia was 31.8% and perinatal loss was 38.6%. A relatively high incidence of eclampsia and maternal and perinatal loss was considered to be related to lack of antenatal care and late referral to the hospital. Our findings suggest that more frequent use of properly timed cesarean section can improve the maternal outcome.

Recurrent eclampsia. Clinical data, morbidity and pathogenic considerations

The analysis of 24 patients with recurrent eclampsia showed that (i) the first attack complicated the second or later pregnancies in nine cases, (ii) there was one or more apparently normal gestations before the second eclampsia in one-third of the patients, (iii) total maternal and neonatal mortality were twice those of general eclampsia, (iv) four autopsies revealed chronic pyelonephritis and cardiac hypertrophy in addition to the characteristic glomerular and hepatic lesions, (v) all six deaths were due to brain damage, and (vi) chronic hypertension was diagnosed in half of the survivors. The results of this study demonstrate that (i) one or several normal pregnancies after eclampsia do not cancel the possibility of another attack, (ii) recurrent eclampsia is an extremely severe event even though most clinical data are no different from general eclampsia, (iii) underlying diseases seem to play a decisive role, and (iv) some aspects of recurrent eclampsia challenge single cause pathogenic mechanisms.

Cigarette smoking and preeclampsia

OBJECTIVE

To examine the relationship between cigarette smoking during pregnancy and the development of preeclampsia.

METHODS

A case-control study compared the smoking histories of 110 nulliparous preeclamptic women and 115 healthy nulliparas aged 15-35 years who delivered at North Carolina Memorial Hospital.

RESULTS

Unconditioned logistic regression relating smoking during pregnancy to preeclampsia yielded an odds ratio of 0.71 (95% confidence interval 0.33-1.50) when adjusting for working during pregnancy, alcohol use, medication use, contraceptive choices with the father of the index pregnancy, and family history of preeclampsia. There was no evidence of a dose-response effect of reduced risk for heavier smokers.

CONCLUSIONS

Despite major methodologic improvements from previous studies, including rigorous diagnostic criteria for preeclampsia, a negative, non-statistically significant association persisted between cigarette smoking during pregnancy and preeclampsia, similar in magnitude to that of previous reports.

[Liver diseases in pregnancy]

An analysis is made of the hepatopathies characteristic of pregnancy according to the latest research and from experience of the Pathology Department of the Hospital Central of San Luis Potosí. Such entities are the fatty liver, the hyperemesis gravidarum, the preeclampsia and eclampsia and the cholestasis of pregnancy. It is estimated that the eclamptic state is capable of showing clinical, structural and laboratory manifestations which vary absolutely and which bring us to consider as dependent upon the fatty liver, the HELLP syndrome and some cases of cholestasis. Also, cholestasis of pregnancy, determined genetically, must be distinguished from that which is associated with eclampsia or determined by drugs or other causes. Similarly, hyperemesis gravidarum may be primary, although rarely so, or be due to neurological causes; it is also capable of causing slight liver dysfunction. Finally, the above-mentioned ailments are correlated within the classic physiopathological grid of jaundice.

Hypertensive disease in pregnancy

The possible involvement of genetic and immune mechanisms in the etiology of preeclampsia has attracted increasing attention. Preeclampsia is characterized by a generalized disturbance in endothelial physiology, and not merely by an isolated defect in vascular prostacyclin synthesis. The increased production of oxygen-free radicals, elastase, or both by activated lymphoid cells in the pregnant decidua, a mainly lymphoid tissue, may be the link between the hypothetical immunologic mechanisms and the endothelial injury occurring in preeclampsia. New treatment protocols emphasize timely referral to a perinatal center to obtain optimal maternal and perinatal care. Intensive fetal and maternal monitoring are of vital importance. Optimal management usually involves balancing risks of expectant management for mother and fetus against the risk of extreme prematurity from immediate delivery.

Maternal hydrops syndrome: a review

The maternal hydrops syndrome (Ballantyne syndrome, mirror syndrome, pseudotoxemia, triple edema) is a preeclampsia-like disease observed in some pregnancies with severe fetal and/or placental hydrops. We describe three pregnancies with severe immunological fetal-placental hydrops resulting in fetal death, in spite of intrauterine transfusions. The mothers suffered severe hydrops syndrome, one of which was complicated by an eclamptic convulsion. All three women had anemia, low hematocrit, and elevated plasma uric acid levels. It is suggested that low hematocrit is an important pathophysiological feature in maternal hydrops syndrome.

Pre-eclampsia/eclampsia at Yekatit 12 Hospital, Addis Ababa, Ethiopia (1987-1989)

In Ethiopia, pre-eclampsia/eclampsia was reported to be uncommon. A clinical analysis of 327 (4.8%) pre-eclamptic and 21 (0.3%) eclamptic patients in 6766 deliveries at Yekatit 12 Hospital, Addis Ababa was made. Out of 327 pre-eclamptics, there were 52 (15.9%) cases of mild, 142 (43.4%) cases of moderate and 133 (40.7%) cases of severe pre-eclampsia. Among patients with pre-eclampsia/eclampsia, 78.2% had no antenatal care and only 39.3% of women from the total number of deliveries were unbooked. There were significantly high frequency of low birth-weight babies of patients with severe pre-eclampsia (mean +/- SD) 2154 +/- 506gms compared to the mean birth-weight of babies from the total number of deliveries 3112 +/- 461gms). In both pre-eclamptic and eclamptic patients, the perinatal mortality rate was 165 per 100 deliveries. This was a significantly higher rate than the total rate (28 per 1000 deliveries). These data suggest that this condition is more common in Ethiopian patients than presently appreciated and antenatal care among other factors remains to be one of the cornerstones in the prevention and control of pre-eclampsia/eclampsia.

[Eclampsia at the Hospital Center of Libreville. 53 cases among 41,285 deliveries from 1985 to 1989]

Eclampsia is a serious complication at the end of pregnancy. This retrospective study over a 5-year period at the Libreville CHU hospital shows that the incidence of 0.12 p. cent is comparable to the incidence fond in other countries at a similar level of development. Promoting causes include youth of the patients, twin births, the "cold" season, the lack of follow-up after prenatal consultations. The consequences are increased maternal and perinatal death. Cesarean section remains the best way of dealing with an attack of eclampsia and improves both maternal and fetal prognosis. It is possible to eliminate, or at least reduce, the number of cases by developing conscientious and regular prenatal consultations.

[A case of pregnant woman with lupus anticoagulant positive systemic lupus erythematosus complicated with intrauterine fetal death, eclampsia, and brainstem vascular damage]

A 28-year-old female patient with SLE was found to have complications from intrauterine fetal death, eclampsia, and brainstem vascular damage during pregnancy. These symptoms were associated with lupus anticoagulant (LAC). An LAC positive SLE case with accompanying cerebrovascular disease and fetal loss at the same time has rarely been reported. The first brain CT scan revealed the presence of multiple middle pons infarction. Ten days after onset, a brain MRI showed the change into hemorrhagic infarction in the same region, suggesting disseminated intravascular coagulation (DIC) caused by severe obstetric complications. Although the severity of the brain damage implied poor prognosis, her symptoms were alleviated by intensive care with a large amount of steroid therapy and active rehabilitation. LAC-positive SLE patients are apt to encounter obstetric complications in pregnancy. Therefore they must be treated by medical specialists in cooperation with gynecologists. When they also have accompanying with cerebrovascular diseases, active therapy for SLE is necessary for a good prognosis.

[Pregnancy, labor and postpartum development after kidney transplantation and triple therapy with cyclosporin A--follow-up in relation to literature review]

This report pertains to a 26-year old primigravida three years after kidney transplantation and still on immunotherapy. Her pregnancy progressed without severe complications until the 33rd week of gestation. Then a sudden and rapidly worsening pre-eclampsia led to admission and delivery. The postoperative period was complicated by an episode of severe septic shock. Reported is a review of the literature. Problems following pregnancy after kidney transplantation and triple therapy including Cyclosporin A are pointed out.

Eclampsia in twin pregnancy

A clinical analysis of 37 cases of twin pregnancy complicated by eclampsia showed that: (1) the incidence of twins in the total 1,030 cases of eclampsia was three times the figure in the general population, (2) the maternal mortality was slightly higher and perinatal mortality slightly lower than in unselected eclamptic patients, (3) patients with postpartum eclampsia showed significant differences in comparison with antepartum and intrapartum cases, (4) perinatal and maternal mortality were lower in cases delivered by cesarean section, (5) perinatal mortality was significantly higher in male fetuses, and (6) five of the six maternal deaths occurred in cases of male twins. In addition, the data suggest the presence of a reciprocal negative influence between maternal eclampsia and male twins and that this type of eclampsia may be the best example of essential preeclampsia.

The relationship of one abnormal glucose tolerance test value and pregnancy complications

While an abnormal oral glucose tolerance test (GTT) is known to be associated with an increased risk of pregnancy complications, the impact of one abnormal value is not clear. In 1986 we screened 4618 pregnant women for gestational diabetes at 24-28 weeks' gestation. Eighty-seven percent had normal results; of the 13% with abnormal screening tests, 139 had one abnormal value on the subsequent 3-hour oral GTT. These women were then compared with 725 randomly selected patients with a normal screening test. The frequency of chronic hypertension, cesarean section, 5-minute Apgar score below 7, preterm delivery, shoulder dystocia, congenital malformations, and perinatal mortality did not differ significantly between the groups. The incidence of macrosomia (birth weight above 4000 g) was significantly greater in the study group (18.0%) than in the control group (6.6%) (odds ratio 2.18; 95% confidence interval 1.77-5.37), a relationship that persisted after controlling for confounding risk factors by logistic regression modeling (odds ratio 2.55; 95% confidence interval 1.44-4.52). The incidence of preeclampsia/eclampsia was significantly greater in the study group (7.9%) than in the control group (3.3%) (odds ratio 2.51; 95% confidence interval 1.14-5.52), which also persisted after controlling for confounding risk factors using logistic regression modeling (odds ratio 2.81; 95% confidence interval 1.26-6.28). Our results suggest that patients with one abnormal value on an oral GTT during pregnancy are at risk for delivering macrosomic infants and developing preeclampsia/eclampsia.