Preeclampsia into eclampsia: toward a new paradigm

Magnesium sulphate versus lytic cocktail for eclampsia

BACKGROUND

Eclampsia, the occurrence of a seizure in association with pre-eclampsia, is a rare but serious complication of pregnancy. A number of different anticonvulsants have been used to control eclamptic fits and to prevent further seizures.

OBJECTIVES

The objective of this review was to assess the effects of magnesium sulphate compared with lytic cocktail (usually chlorpromazine, promethazine and pethidine) when used for the care of women with eclampsia. Magnesium sulphate is compared with diazepam and with phenytoin in other Cochrane reviews.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (July 2010) and the Cochrane Central Register of Trials (The Cochrane Library 2010, Issue 2).

SELECTION CRITERIA

Randomised trials comparing magnesium sulphate (intravenous or intramuscular administration) with lytic cocktail for women with a clinical diagnosis of eclampsia.

DATA COLLECTION AND ANALYSIS

Two review authors (L Duley and D Chou) assessed trial quality and extracted data.

MAIN RESULTS

We included three small trials (total 397 women) of average quality in the review. Magnesium sulphate was associated with fewer maternal deaths (risk ratio (RR) 0.14, 95% confidence interval (CI) 0.03 to 0.59; 3 trials, 397 women) and was better at preventing further seizures (RR 0.06, 95% CI 0.03 to 0.12; 3 trials, 397 women) than lytic cocktail. Magnesium sulphate was also associated with less respiratory depression (RR 0.12, 95% CI 0.02 to 0.91; 2 trials, 198 women), less coma (RR 0.04, 95% CI 0.00 to 0.74; 1 trial, 108 women), and less pneumonia (RR 0.20, 95% CI 0.06 to 0.67; 2 trials, 307 women). There was no clear difference in the RR for any death of the baby (RR 0.35, 95% CI 0.05 to 2.38, random effects; 2 trials, 177 babies).

AUTHORS' CONCLUSIONS

Magnesium sulphate, rather than lytic cocktail, for women with eclampsia reduces the RR of maternal death, of further seizures and of serious maternal morbidity (respiratory depression, coma, pneumonia). Magnesium sulphate is the anticonvulsant of choice for women with eclampsia; the use of lytic cocktail should be abandoned.

[Prehospital management of severe preeclampsia]

Prior to transport, agreement must be reached among all the senior medical staff members involved in the transfer. Tight clinical surveillance is necessary during the transport. The aim of the pharmacological control of a severe hypertension is to allow a moderate reduction of the mean arterial blood pressure as well as dampening the large pressure variations. Boluses of calcium channel inhibitors, eventually combined with labetalol, are to be used as first line treatment. Systematic fluid expansion prior to admission is not recommended. However, it is indicated if obvious signs of hypovolaemia are present, such as a sudden drop in blood pressure, secondary to the initiating of an antihypertensive therapy. It is possible to use i.v. benzodiazepines for the treatment of eclampsia in the prehospital setting. If magnesium sulfate therapy has been initiated in a preeclamptic woman with neurological signs, it may be continued during her transport.

Ophthalmic Artery-Resistive Index and Evidence of Overperfusion-Related Encephalopathy in Severe Preeclampsia

Neurological findings in preeclampsia fulfill diagnostic criteria of posterior reversible encephalopathy syndrome (PRES), which is related to cerebral autoregulation impairment associated with high blood pressure. In preeclampsia, PRES may occur without a significant increase in blood pressure. Our aim was to investigate the association between ophthalmic artery resistive index (OARI) and clinical evidence of PRES, defined as the presence of headache and blurred vision, in patients with severe preeclampsia. OARI and main clinical and laboratory parameters were obtained in 112 patients with severe preeclampsia. Differences in these parameters were analyzed in the function of clinical evidence of PRES with a 2-sample t test. The area under receiver operating characteristic curve for each of these parameters in the function of clinical evidence of PRES was obtained. Logistic regression models were established with parameters categorized by cutoff points obtained in receiver operating characteristic curves. Among 112 patients with severe preeclampsia, 46 (41%) presented clinical evidence of PRES. These patients presented lower OARI ( P <0.0001), higher mean blood pressure at admission ( P <0.0001), higher mean blood pressure elevation after the first trimester ( P <0.0001), and higher lactate dehydrogenase ( P <0.0001) than those without clinical evidence of PRES. OARI presented an area under receiver operating characteristic curve of 0.810±0.039 (95% CI: 0.742 to 0.895; P <0.0001). OARI <0.56 was associated with clinical evidence of PRES, with an odds ratio of 12.67 (95% CI: 4.08 to 39.39; P <0.0001). Data suggest that OARI is a relevant biomarker of PRES in severe preeclampsia.

Pregnancy and Severe Chronic Hypertension: Maternal Outcome

OBJECTIVE

To determine the maternal outcome associated with severe chronic hypertension during the second half of pregnancy.

METHODS

An analysis of data obtained of women with severe chronic hypertension (> or = 160/110 mm Hg) and > or = 20 weeks' gestation who were hospitalized and delivered during a 5-year period. The pregnancy outcome data were collected retrospectively from medical records. Each patient was observed closely throughout hospitalization with intensive monitoring of the clinical status of both mother and fetus. Antihypertensive drugs were used for systolic or diastolic blood pressure > or = 160 and > or = 110 mm Hg, respectively. Women with superimposed preeclampsia received magnesium sulfate. The main outcome measures were peak of blood pressure, superimposed preeclampsia, and major maternal complications.

RESULTS

Of 154 women studied, 111 (72%) had pregestational chronic hypertension, and 120 (78%) developed superimposed preeclampsia. The mean weeks' gestation was 34.5 +/- 4.6. Overall, 110 (71.4%) pregnancies were delivered by cesarean section. Maternal age and parity were significantly higher among women who had pregestational chronic hypertension than those who had chronic hypertension diagnosed during the first half of pregnancy. Abruptio placentae (8.4%), HELLP syndrome (8.4%), acute renal insufficiency (3.9%), pulmonary edema (1.3%), and postpartum hypertensive encephalopathy (1.3%) were the most frequent maternal complications. There were no maternal deaths, disseminated intravascular coagulation, or eclampsia.

CONCLUSION

Three-quarters of women with severe chronic hypertension in the second half of pregnancy developed superimposed preeclampsia. Intensive monitoring of the clinical status of the mother was associated with low maternal morbidity and the absence of maternal deaths. Pregestational chronic hypertension does not change the maternal prognosis.

The Use of Standard Dose of Magnesium Sulphate in Prophylaxis of Eclamptic Seizures: Do Body Mass Index Alterations Have Any Effect on Success?

OBJECTIVE

We anticipated that the universal use of a standard magnesium sulfate infusion to prevent eclamptic convulsions in preeclamptic patients would result in alterations in circulating magnesium levels that were negatively correlated with the patient's body mass index. We postulated that the highest failure rate with seizure prophylaxis would occur in patients with the highest body mass index.

MATERIALS AND METHODS

After discarding 6 patients, this study was performed in 194 of 200 preeclamptic patients admitted to our high risk pregnancy unit between February 2000 and August 2000, who were divided into four groups determined by body mass indices. A standard magnesium sulfate infusion protocol (loading dose 4.5 g/15 minutes followed by 1.8 g/hour) was administered to 194 preeclamptic patients. One hundred and thirty-eight severe preeclamptic patients received magnesium sulfate during both antepartum and postpartum periods. The remaining 56 patients only received the therapy during the postpartum period. Serial serum magnesium levels of each groups were recorded and compared.

RESULTS

The 1.8 g infusion rate produced acceptable magnesium levels in the majority of patients but most were in the lower 50% of the therapeutic range. Levels were lowest in patients with high body mass indices (this group recorded most of the subtherapeutic levels, particularly when patient were infused antepartum). Apart from 13 referred patients who had convulsed prior to admission no eclampsia occurred during the antepartum period while seizures occurred in nine women during the postpartum period. Two hours after the initiation of the therapy, magnesium levels were inversely related to the body mass index (BMI) both during the ante- and postpartum periods (Prepartum; group I: 5.97 mg/dl, group II: 4.90 mg/dl, group III: 4.35 mg/dl, group IV: 3.88 mg/dl; Postpartum; group I: 5.89 mg/dl, group II: 5.71 mg/dl, group III: 4.82 mg/dl and group IV: 4.61 mg/dl, Table 4). Although the lowest levels were detected in patients with high body mass indices, in contrast to our hypothesis, eclamptic seizures occurred in four patients with low body mass indices. Furthermore therapeutic serum magnesium levels were detected in three of these patients. There was no association between treatment failures and body mass or with magnesium levels.

CONCLUSION

The infusion regimen described herein resulted in therapeutic levels in the majority of patients that correlated inversely with body mass index. However most levels fell within the lower range of what many studies consider "therapeutic" suggesting that maintenance infusion rates of at least 2-2.5 g/hour would be more appropriate. This would be particularly true in patients with body mass indices exceeding 30, where subtherapeutic levels occurred most frequently. The study's limited power prevents conclusions on outcomes but what is of interest is that eclamptic convulsions did not correlate with either body mass index or circulating plasma magnesium levels.

Diagnosis and management of atypical preeclampsia-eclampsia

Preeclampsia, eclampsia, and hemolysis, elevated liver enzymes, and low platelets syndrome are major obstetric disorders that are associated with substantial maternal and perinatal morbidities. As a result, it is important that clinicians make timely and accurate diagnoses to prevent adverse maternal and perinatal outcomes associated with these syndromes. In general, most women will have a classic presentation of preeclampsia (hypertension and proteinuria) at > 20 weeks of gestation and/or < 48 hours after delivery. However, recent studies have suggested that some women will experience preeclampsia without > or = 1 of these classic findings and/or outside of these time periods. Atypical cases are those that develop at < 20 weeks of gestation and > 48 hours after delivery and that have some of the signs and symptoms of preeclampsia without the usual hypertension or proteinuria. The purpose of this review was to increase awareness of the nonclassic and atypical features of preeclampsia-eclampsia. In addition, a stepwise approach toward diagnosis and treatment of patients with these atypical features is described.

[Eclampsia: retrospective study about 16 cases]

OBJECTIVE

To determine the etiologic factors, circumstances of diagnosis, obstetrical management and complications of eclampsia and to value the maternal and perinatal outcomes.

PATIENTS AND METHODS

We conducted a retrospective descriptive study, from January 1996 to December 2006 in a maternity type IIB.

RESULTS

Sixteen cases of eclampsia were studied. The prevalence of eclampsia over the study period was 8.1 per 10,000 births, without annual change in the incidence. The mean age of the patients was 27.8+/-6.7 years. The major risk factor was the primipaternity (87.5%). The eclampsia occurred in ante-, peri- and post-partum in 56, 6 and 38% of the cases, respectively. In cases of eclampsia, 75% of the patients had elevated blood pressure, 93% presented headache, but 62% presented with an atypical form with less than three functional symptoms (headache, visual trouble, hyperreflexia). Various treatments had been started: antihypertensive treatment (75%), antiepileptic treatment (69%) and magnesium sulphate (94%). Eleven patients had developed complications, mainly HELLP syndrome (10 patients). No maternal death was noted. The mean birth weight was 2366+/-818 g, 43.8% of children had birth weight less than the 10th percentile, and 87.5% of children were girls. One fetal and one perinatal death at day 19 had been noted.

DISCUSSION AND CONCLUSION

Nowadays, the physiopathology of eclampsia remains misunderstood. It is difficult to establish risk factors, the primipaternity being certainly one of these. Eclampsia may occur in an atypical and unforeseeable form in well followed patients, without risk factor. The diagnosis should be done quickly for an adapted treatment and obstetrical management.

Maternal deaths due to eclampsia and HELLP syndrome

OBJECTIVE

To evaluate maternal deaths associated with eclampsia, HELLP syndrome, and the concurrence of these conditions.

METHOD

A review of Medline studies reporting maternal deaths associated with eclampsia or HELLP syndrome published in English, Spanish, and Portuguese between 1995 and June 2008.

RESULTS

A total of 304 deaths were identified: 100 due to eclampsia, 117 due to eclampsia/HELLP, and 87 associated with HELLP syndrome. Of the total deaths, 71.3% of women had seizures and 67.1% developed HELLP syndrome. In high-income countries 3.9% of deaths were due to eclampsia without HELLP syndrome, while in low-income countries this figure was 42.5% (P<0.0001). The presence of HELLP syndrome in the women who died of eclampsia was 90.6% (29/32) in high-income countries compared with 47.6% (88/185) in low-income countries (P<0.001).

CONCLUSION

Concurrent eclampsia and HELLP syndrome was diagnosed in 5-6 out of 10 deaths associated with eclampsia or HELLP syndrome in this review.

Atypical postpartum eclampsia: status epilepticus without preeclamptic prodromi

BACKGROUND

Eclampsia remains as a major obstetric problems that plagues a large percentage of women resulting in a large percentage of maternal and perinatal morbidities. In general, most women will have a classical presentation of preeclampsia. However, studies have suggested that some women will develop eclampsia without the classical findings.

CASE REPORT

We report a case of postpartum eclampsia with the first manifestation of convulsions resistant to diazepam and magnesium sulfate. In this patient high blood pressure was first detected after the seizures. Electroencephalography and CT scan of brain were normal. Patient's blood pressure returned to normal 1 month after parturition.

CONCLUSION

Postpartum eclampsia can manifest without a preceding preeclampsia phase. Therefore, eclampsia is not always preventable. Pregnancies complicated by eclampsia require a well-formulated management plan.

Postpartum preeclampsia: emergency department presentation and management

STUDY OBJECTIVE

Postpartum preeclampsia/eclampsia is the presence of hypertension and proteinuria, with or without seizures, occurring up to 4 weeks after delivery. We describe the Emergency Department (ED) presentation, signs and symptoms, results of diagnostic studies, management, and outcome in a cohort of patients diagnosed with postpartum preeclampsia/eclampsia at our institutions, and use this to review the diagnosis and management of postpartum preeclampsia/eclampsia.

METHODS

A retrospective chart review was conducted at two urban teaching hospitals. Twenty-two cases were identified via ICD-9 (International Classification of Diseases, 9(th) revision) codes of discharge diagnoses over an 8-year period. Only those patients who initially presented to an ED in the postpartum period after hospital discharge were included. A standardized data tool was used to extract demographic data, signs and symptoms of preeclampsia/eclampsia, ancillary studies previously associated with eclamptic pathology, and outcome during admission.

RESULTS

Of the 22 women, over half (55%) had not been diagnosed with preeclampsia in the ante- or peripartum period. Common prodromal symptoms and signs in the postpartum presentation included headache, visual changes, hypertension, edema, proteinuria, elevated uric acid, and elevated liver function tests. All 4 patients who seized had prodromal symptoms. Women presented from 3 to 10 days postpartum (median: 5 days). Only 10 women were primiparas. Nineteen women presented with diastolic blood pressures > 90 mm, and only 3 of these had diastolic blood pressures of 110 mm Hg or greater.

CONCLUSIONS

Postpartum preeclampsia/eclampsia often presents to the ED without a history of preeclampsia during the pregnancy. Further, not all women with this diagnosis who present to the ED in the postpartum period will have each of the "classic" features of this disease, including elevated blood pressure, edema, proteinuria, and hyperreflexia. This report is intended to inform emergency physicians of the presentation of preeclampsia/eclampsia in the postpartum period, including symptoms of headache, vision changes, elevated blood pressure, or seizure up to 4 weeks after delivery.

Eclampsia, study of 342 cases

OBJECTIVES

To conduct a prospective review of all cases of eclampsia over a 4-year period and to establish prognostic factors that may assist in reducing morbidity and mortality in these patients.

METHODS

The population studied was split into two groups: Group1 (survivors) and Group 2 (deceased). We compared their demographic, clinical, biological and radiological data. Patients were regularly followed for 2 months after discharge. Quantitative and qualitative statistic tests were used.

RESULTS

342 cases of eclampsia were studied. Based on 37,467 pregnancies in the 4-year period, in our catchment area, we estimated an overall incidence of 0.91%. 62.5% of patients were nulliparous and 82% of all patients had no ongoing antenatal care. 71% were delivered by Cesarean section. 23 (6.7%) maternal deaths were recorded. Our findings suggested that poor prognosis factors were: diastolic blood pressure 115 mm Hg, Glasgow Coma Scale 8, thrombocytopenia, liver cytolysis, acute renal failure, cerebral edema and hemorrhage, and pulmonary edema.

CONCLUSIONS

This disease remains a veritable health problem in our country. We need to improve antenatal follow-up by increasing mothers' awareness and by facilitating access to medical care.

Substandard care in maternal mortality due to hypertensive disease in pregnancy in the Netherlands

OBJECTIVES

To review the standard of care in cases of maternal mortality due to hypertensive diseases in pregnancy and to make recommendations for its improvement.

DESIGN

Care given to women with hypertensive disease in pregnancy was audited and substandard care factors identified.

SETTING

Confidential enquiry by the Dutch Maternal Mortality Committee (MMC) from the Netherlands Society of Obstetrics and Gynaecology.

POPULATION

All maternal deaths reported to the MMC due to hypertensive disease in pregnancy in the Netherlands during the years 2000-04.

METHODS

Assessment for substandard care factors using a checklist based on the Dutch guideline of 'Hypertensive Disorders in Pregnancy'.

MAIN OUTCOME MEASURES

Substandard care in cases of maternal mortality due to hypertensive diseases in pregnancy.

RESULTS

A total of 27 cases of maternal death due to hypertensive disease in pregnancy were reported to the committee in the study period. In 26 cases (96%), substandard care factors were present, of which in 17 cases (63%), these were for more than five different items. In community midwifery care, the most frequent substandard care factor was no testing for proteinuria when clearly indicated (41%). In hospital care, the most frequent substandard care was related to insufficient diagnostic testing when indicated (41%), insufficient management of hypertension by obstetricians (85%), no use or inadequate use of magnesium sulphate (67%), inadequate stabilisation before transport to tertiary care centres and/or delivery (52%) and failure to consider timely delivery (44%).

CONCLUSIONS

Education of pregnant women concerning danger signs of hypertensive disease should be improved. Training of midwives and obstetricians should be improved in the following areas: performing basic diagnostic tests, adequate management of hypertension and eclampsia, with more attention to treatment of systolic blood pressure. This training should be guided by clear local protocols. Delivery should not be delayed in serious cases of hypertensive disease in pregnancy, not only after 32-34 weeks but also in early-onset pre-eclampsia as maternal risks often outweigh possible fetal benefits of temporising management.

Critical care management of eclamptics: challenges in an African setting

We conducted a retrospective study of the management and outcome for eclampsia patients in the intensive care unit (ICU) of National hospital, Abuja between November 2001 and April 2005 (42 months). The patients' case files and ICU records were used to extract the necessary data. During the study period, there were a total of 4857 deliveries, with 5051 total births (including multiple births) and 4854 live births. Forty eclamptics were admitted to the ICU, giving an ICU admission rate of 8.2/1000 live births. The records of two patients were incomplete. The average age of the patients was 28.4 years (range 17-4 years). Six patients (15.8%) were booked and 32 (84.2%) were not. The average duration of stay in ICU was 5 days. Twenty patients (52.6%) had antepartum eclampsia, 12 (31.6%) had postpartum eclampsia and six (15.8%) presented with intrapartum eclampsia. Twenty-nine (76.3%) gave birth via caesarean section and nine (23.7%) delivered per vagina augmented by oxytocin infusion. Seventeen (45%) received mechanical ventilation; 20 (53%) received oxygen via nasal prongs, nasal catheters or variable performance facemask. One patient (2%) did not receive oxygen therapy. All the patients were admitted postpartum. There were 11 maternal deaths, giving a case fatality rate of 29%. There were five (45.4%) deaths due to haemolysis, elevated liver enzymes and low platelet count syndrome and two (18.2%) due to disseminated intravascular coagulation. The remaining deaths were due to cerebrovascular accident (9.1%), lobar pneumonia (9.1%), acute renal failure (9.1%) and multiple organ failure (9.1%). All patients were admitted postpartum. This fatality rate is higher than that detailed in the reports reviewed in this study. Early referral of eclamptics or at risk patients to a tertiary care institution may help reduce morbidity and mortality. In addition, early referral to a facility providing basic essential obstetric care or comprehensive essential obstetric care is also important. Another important factor is the correct diagnosis of pre-eclampsia during antenatal and postpartum care by screening, noting blood pressure levels, performing urinalysis for protein and asking about warning signs such as headache, blurred vision, epigastric pain, etc.

Maternal Serum Interleukin-10, Interleukin-2 and Interleukin-6 in Pre-Eclampsia and Eclampsia

PROBLEM

The aim of the study was to investigate and compare the concentrations of interleukin (IL)-2, IL-6, and IL-10 in serum of women with mild pre-eclampsia, severe pre-eclampsia, eclampsia, and normotensive pregnancy.

METHOD OF STUDY

A total of 69 consecutive cases, 38 mild pre-eclampsia, 20 severe pre-eclampsia, 11 eclampsia, and 20 normotensive controls were included in this study. Serum IL-2, IL-6, and IL-10 levels were determined using enzyme-linked immunosorbent assay method.

RESULTS

Gestational age (P = 0.210) and body mass index (P = 0.214) between the groups were similar. The mean concentration of serum IL-2 and IL-6 were not different between the groups (P = 0.261, P = 0.141 respectively). The median concentrations of serum IL-10 in patients with mild and severe pre-eclampsia were similar (P < 0.282) and was significantly lower than those of controls (P < 0.001) and patients with eclampsia (P < 0.001). In patients with eclampsia, the median concentration of IL-10 was significantly higher than that of all other groups (P < 0.001 for each comparison).

CONCLUSION

Pre-eclampsia is associated with a deficiency serum IL-10. High serum IL-10 is correlated with the presence of eclampsia.

Hypertension in pregnancy

Hypertensive disorders of pregnancy are the most common medical disorders of pregnancy and are associated with increased maternal and perinatal risks. The pathophysiology, diagnosis, and treatment are herein reviewed for chronic hypertension, preeclampsia, gestational hypertension, and severe hypertension. The benefits and risks of treating mild, moderate, and severe hypertension are discussed. A variety of oral and parenteral therapies are approved for the treatment of hypertension in pregnancy; methyldopa, labetalol, and nifedipine have been used safely in pregnancy, as has hydrochlorothiazide in those already taking this medication before conception. Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers are contraindicated in pregnancy because of adverse fetal effects, and atenolol should be avoided due to concerns with fetal growth. Severe hypertension >160/110 mmHg may require parenteral therapy, and treatment with intravenous labetalol now supplants the use of hydralazine. Women may remain hypertensive for a period postpartum and require treatment for a short interval. Early or severe preeclampsia warrants workup postpartum for secondary causes. Pregnancy induced hypertension or preeclampsia are emerging as risk factors for future cardiovascular risk.

Leukocytosis might precede in-hospital eclampsia in preeclamptic women who do not receive magnesium sulfate

In an effort to better define preeclamptic women at risk of eclampsia, we examined the predictive value of maternal demographic characteristics and admission maternal laboratory values for the risk of subsequent development of eclampsia in preeclamptic women, who were not receiving magnesium sulfate during hospitalization. The decision to use magnesium sulfate prophylaxis was at the discretion of the treating physician. Preeclamptic women admitted throughout a 3-year period and treated with a protocol exempting magnesium sulfate therapy were retrospectively included (n=497). Maternal data at admission were recorded and analyzed. Eight women developed an eclamptic seizure during subsequent hospital follow-up. Logistic regression models were used to assess the independent predictive role of each variable on the development of eclampsia. Lower serum fibrinogen values, increased leukocyte counts, and increased diastolic blood pressure at admission were independent predictors of a subsequent in-hospital eclamptic seizure. An initial diastolic blood pressure >or=120 mm Hg, blood leukocyte count >16,000/microL, and serum fibrinogen value <450 mg/dL were associated with a 25.4-, 7.1-, and 26.6-fold increased risk of eclampsia, respectively. We conclude that marked leukocytosis and diastolic blood pressure increment might precede the development of eclampsia. Serum fibrinogen concentrations >450 mg/dL seem to be protective for eclampsia. The association between inflammation and eclampsia merits further investigation.

A review of the management of eclampsia: practical issues

We reviewed 90 cases of eclampsia, an obstetric emergency associated with high blood pressure and convulsions, treated in two hospitals in Durban, South Africa. We present a protocol for the management of eclampsia based on this review and extensive clinical experience on this subject, which includes hemodynamic stabilization of the mother, prevention of recurrent convulsions, prompt delivery, and intensive monitoring in the immediate post-partum period.

Maternal and perinatal outcome in pregnancies complicated with hypertensive disorder of pregnancy: a seven year experience of a tertiary care center

OBJECTIVE

The aim of the study was to determine the risk factors, prevalance, epidemiological parameters and maternal-perinatal outcome in pregnant women with hypertensive disorder.

MATERIALS AND METHODS

A retrospective analysis was undertaken on 255 consecutive cases of hypertensive disorder in pregnancy who were managed at Kocaeli University, School of Medicine, Department of Obstetrics and Gynecology from June 1997 to November 2004. Demographic data involving age, parity, gestational week, clinical and laboratory findings were recorded from the medical files. Additionally delivery route, indications of cesarean section, fetal and maternal complications were determined. Statistical analysis was performed by SPSS programme using Kruskal Wallis nonparametric test, ANOVA (Analysis of variance) and chi-square tests.

RESULTS

Of 5,155 deliveries in our clinic during the defined period, 438 cases (8.49%) were managed as hypertensive disorder of pregnancy. Medical records of 255 cases could be avaliable. Of 255 cases, 138 patients (54.11%) were found to have severe preeclampsia while 88 cases (34.50%) were diagnosed as mild preeclampsia. Twenty-nine patients (11.37%) were suffering from chronic hypertension. Of 138 severely preeclamptic cases, 28 cases (11%) had eclamptic convulsion and another 28 patients (11%) were demonstrated to have HELLP syndrome. Intrauterine growth restriction, oligohydramnios, placental ablation were the obstetric complications in 75 (29.4%), 49 (19.2%), 19 (7.5%) cases, respectively. Additionally multiple pregnancy and gestational diabetes mellitus were noted in 5.9% (n:15) and 3.9% (n:10) of the patients. Delivery route was vaginal in 105 patients (41.2%) while 150 patients (58.8%) underwent cesarean section with the most frequent indication to be fetal distress in 69 cases (46%). Cesarean section rate seemed to be the lowest (48.3%) in chronic hypertensive women while the highest (63.8%) in severe preeclamptic patients. Maternal mortality occured in 3 cases (1.2%) and all of those cases were complicated with HELLP syndrome. Intracranial bleeding was the cause of maternal death in one case while the other two cases were lost due to acute renal failure and disseminated intravascular coagulation, respectively. Intrauterine fetal demise was recorded in 24 cases on admission. Ten fetuses died during the intrapartum period. Mean gestational age and birth weight were 28 +/- 3.5 and 1000 +/- 416 g, respectively in this group. In these ten women, five cases were diagnosed as HELLP syndrome, two were severely preeclamptic and three were eclamptic. Perinatal mortality rate was found to be 144/1,000 births

CONCLUSION

Hypertensive disorder of pregnancy is associated with increased risk of maternal-perinatal adverse outcome. The complications of severe preeclampsia and eclampsia could be prevented by more widespread use of prenatal care, education of primary medical care personnel, prompt diagnosis of high-risk patients and timely referral to tertiary medical centers.

Diagnosis, prevention, and management of eclampsia

The pathogenesis of eclamptic convulsions remains unknown. Cerebral imaging suggests that cerebral abnormalities in eclampsia (mostly vasogenic edema) are similar to those found in hypertensive encephalopathy. However, cerebral imaging is not necessary for the diagnosis or management of most women with eclampsia. The onset of eclamptic convulsions can be antepartum (38-53%), intrapartum (18-36%), or postpartum (11-44%). Recent data reveal an increase in the proportion of women who develop eclampsia beyond 48 hours after delivery. Other than early detection of preeclampsia, there are no reliable tests or symptoms for predicting the development of eclampsia. In developed countries, the majority of cases reported in recent series are considered unpreventable. Magnesium sulfate is the drug of choice for reducing the rate of eclampsia developing intrapartum and immediately postpartum. There are 4 large randomized trials comparing magnesium sulfate with no treatment or placebo in patients with severe preeclampsia. The rate of eclampsia was significantly lower in those assigned to magnesium sulfate (0.6% versus 2.0%, relative risk 0.39, 95% confidence interval 0.28-0.55). Thus, the number of women needed to treat to prevent one case of eclampsia is 71. Magnesium sulfate is the drug of choice to prevent recurrent convulsions in eclampsia. The development of eclampsia is associated with increased risk of adverse outcome for both mother and fetus, particularly in the developing nations. Pregnancies complicated by eclampsia require a well-formulated management plan. Women with a history of eclampsia are at increased risk of eclampsia (1-2%) and preeclampsia (22-35%) in subsequent pregnancies. Recommendations for diagnosis, prevention, management, and counseling of these women are provided based on results of recent studies and my own clinical experience.

Magnesium sulfate prophylaxis in preeclampsia: Lessons learned from recent trials

In the US, the routine use of magnesium sulfate for seizure prophylaxis in women with preeclampsia is an ingrained obstetric practice. During the past decade, several observational studies and randomized trials have described the use of various regimens of magnesium sulfate to prevent or reduce the rate of seizures and complications in women with preeclampsia. There are only 2 double-blind, placebo-controlled trials evaluating the use of magnesium sulfate in mild preeclampsia. There were no instances of eclampsia among 181 women assigned to placebo, and there were no differences in the percentage of women who progressed to severe preeclampsia (12.5% in magnesium group vs 13.8% in the placebo group, relative risk [RR] 0.90; 95% CI 0.52-1.54). However, the number of women enrolled in these trials is too limited to draw any valid conclusions. There are 4 randomized controlled trials that compare the use of no magnesium sulfate, or a placebo vs magnesium sulfate, to prevent convulsions in patients with severe preeclampsia. The rate of eclampsia was 0.6% among 6343 patients assigned to magnesium sulfate vs 2.0 % among 6330 patients assigned to a placebo or control (RR 0.39; 95% CI 0.28-0.55). However, the reduction in the rate of eclampsia was not associated with a significant benefit in either maternal or perinatal outcome. In addition, there was a higher rate of maternal respiratory depression among those assigned magnesium sulfate (RR 2.06; 95% CI 1.33-3.18). The evidence to date confirms the efficacy of magnesium sulfate in reduction of seizures in women with eclampsia and severe preeclampsia; however, this benefit does not affect overall maternal and perinatal mortality and morbidities. The evidence regarding the benefit-to-risk ratio of magnesium sulfate prophylaxis in mild preeclampsia remains uncertain, and does not justify its routine use for that purpose.

Is Eclampsia Preventable? A Case Control Review of Consecutive Cases from an Urban Underserved Region

OBJECTIVES

The purpose of this study was to determine whether eclampsia is potentially preventable.

METHODS

This was a retrospective case control study comparing 25 cases of eclampsia, 33 cases of preeclampsia and 50 pregnant controls. Eclampsia cases were classified as follows: group A was potentially preventable by patient education if there were preeclamptic symptoms before presenting to the hospital; group B was potentially preventable by health care provider if patient presented to health care with evidence of preeclampsia and was not appropriately treated; group C was not preventable if eclampsia developed without symptoms or preeclampsia. Statistical analysis was done as applicable.

RESULTS

The mean gestational age at seizure was 34 weeks; 50% of seizures occurred outside a hospital and 44% had multiple seizures. Twenty were antepartum, three intrapartum, and two postpartum. Fourteen (56%) cases were classified as group A, 4 (16%) as group B and 7 (28%) as group C. Compared to controls, African-Americans, nulliparity, premature delivery, and increased neonatal morbidity were significantly associated with eclampsia. Compared with preeclamptics, eclamptic subjects had more symptomatology and more adverse maternal complications.

CONCLUSIONS

In this underserved population, a significant percentage of eclampsia cases are potentially preventable by patient education or health care response. In a smaller percentage, eclampsia may develop without any symptomatology or preeclampsia.

Facteurs de risque d’éclampsie : étude cas-témoins

OBJECTIVE

Our purpose was to characterize the risk factors of eclampsia in women with preeclampsia.

PATIENTS AND METHODS

A case-control study was conducted at Monastir hospital to investigate risk factors for eclampsia between 1st January 1995 and 30th June 2000. Cases were matched to preeclamptic controls on a 2:1 ratio. Univariate analysis was used to determine which of the independent variables were significantly different between the groups. Those with significant differences were then entered into multiple logistic regression analysis to determine the characteristics that were independently related to eclampsia.

RESULT

A total of 41 cases of eclampsia were ascertained from deliveries. The ratio of eclampsia cases to number of deliveries over the study period was 1.87 per 1000. The first seizures occurred at home in 59% of the cases. Univariate analysis revealed statistical significance for the following variables associated with eclampsia: systolic hypertension > or =160 mmHg and diastolic > or =110 mmHg, headache, visual symptoms, vivid deep tendon reflexes, proteinuria >3+ or >3 g d(-1), uric acid concentration > or =350 micromol l(-1), serum creatinine concentration >100 micromol l(-1) and aminotransferase aspartate >30 IU l(-1). A history of abortion appears to be the protective factor against eclampsia. However, with subsequent multivariate analysis, only vivid deep tendon reflexes and elevated uric acid concentration remained significant.

CONCLUSION

These data indicate a need for improved prenatal care and medical attention focused on prodroms of eclampsia as well as the detection of preeclampsia to reduce the incidence of eclampsia.

Late postpartum eclampsia: a common presentation of an uncommon diagnosis

We present two cases of late postpartum eclampsia. Both patients presented with a chief complaint of headache, and were diagnosed with eclampsia after the onset of seizures. Neither patient had proteinuria or edema. Further evaluation did not yield another diagnosis for the seizures, and treatment with i.v. magnesium sulfate was successful in stopping the seizures. No further seizure activity occurred in either patient.

Platelets: thrombotic thrombocytopenic purpura

Abnormalities of plasma von Willebrand factor (VWF) have been recognized to be associated with thrombotic thrombocytopenic purpura (TTP) for over 20 years. Patients with chronic, relapsing TTP have VWF multimers that are larger than normal, similar in size to those secreted by cultured endothelial cells. Recent observations have documented that a deficiency of a VWF-cleaving protease (termed ADAMTS13) may be responsible for the presence of these unusually large VWF multimers. Multiple mutations of the ADAMTS13 gene can result in ADAMTS13 deficiency and cause congenital TTP; autoantibodies neutralizing ADAMTS13 protease activity have been associated with acquired TTP. In Section I, Dr. Evan Sadler reviews the structure, biosynthesis, and function of the ADAMTS13 protease. He describes the mutations that have been identified in congenital TTP and describes the relationship of ADAMTS13 deficiency to the development of both congenital and acquired TTP. Dr. Sadler postulates that the development of TTP may be favored by conditions that combine increased VWF secretion, such as during the later stages of pregnancy, and decreased ADAMTS13 activity. In Section II, Dr. Bernhard Lämmle describes the assay methods for determining ADAMTS13 activity. Understanding the complexity of these methods is essential for understanding the difficulty of assay performance and the interpretation of assay data. Dr. Lämmle describes his extensive experience measuring ADAMTS13 activity in patients with TTP as well as patients with acute thrombocytopenia and severe illnesses not diagnosed as TTP. His data suggest that a severe deficiency of ADAMTS13 activity (< 5%) is a specific feature of TTP. However, he emphasizes that, although severe ADAMTS13 deficiency may be specific for TTP, it may not be sensitive enough to identify all patients who may be appropriately diagnosed as TTP and who may respond to plasma exchange treatment. In Section III, Dr. James George describes the evaluation and management of patients with clinically suspected TTP, as well as adults who may be described as having hemolytic-uremic syndrome (HUS). Dr. George presents a classification of TTP and HUS in children and adults. Appropriate evaluation and management are related to the clinical setting in which the diagnosis is considered. A clinical approach is described for patients in whom the diagnosis of TTP or HUS is considered (1) following bone marrow transplantation, (2) during pregnancy or the postpartum period, (3) in association with drugs which may cause TTP either by an acute immune-mediated toxicity or a dose-related toxicity, (4) following a prodrome of bloody diarrhea, (5) in patients with autoimmune disorders, and (6) in patients with no apparent associated condition who may be considered to have idiopathic TTP. Patients with idiopathic TTP appear to have the greatest frequency of ADAMTS13 deficiency and appear to be at greatest risk for a prolonged clinical course and subsequent relapse. Management with plasma exchange has a high risk of complications. Indications for additional immunosuppressive therapy are described.

Emergency management of eclampsia and severe pre-eclampsia

Eclampsia and severe pre-eclampsia are rare, but potentially life-threatening conditions that emergency physicians must be able to diagnose and treat promptly, because initial presentations to the ED are real possibilities. The treatment of the major complications of this disorder, hypertension and seizures, have been the focus of much research. Magnesium sulphate is now the first line agent for acute treatment and prophylaxis of seizures in eclampsia and pre-eclampsia. Severe pre-eclampsia should be treated with magnesium to prevent progression to eclampsia. Severe hypertension requires treatment with an intravenous antihypertensive agent familiar to the clinician. No single antihypertensive has been proven to be better than another, although in Australia, hydralazine is probably the initial intravenous agent of choice. Routine use of invasive haemodynamic monitoring and volume expansion is not recommended and consultation with obstetric colleagues is essential.

A current concept of eclampsia

Eclampsia is defined by the occurrence of seizures resulting from hypertensive encephalopathy on the background of preeclampsia. The development of hypertension during pregnancy, a serious and potentially fatal condition, is a leading cause of maternal and fetal morbidity and death in the United States.(1-3) It is a disease with preventable complications. The pathophysiology of hypertension during pregnancy is unclear, but there is consensus that aggressive treatment is warranted to prevent complications to both fetus and mother. A current concept of pathophysiological character, diagnosis, prevention, and management of eclampsia is discussed.

Recurrent post-partum seizures after epidural blood patch

There are many causes for headaches after childbirth. Even though postdural puncture headache (PDPH) has to be considered in a woman with a history of difficult epidural anaesthesia, pre-eclampsia should always be excluded as an important differential diagnosis. We report a case with signs of late-onset pre-eclampsia where administration of an epidural blood patch (EBP) was associated with eclampsia. A hypothetical causal relationship between the EBP and seizures was discarded on the basis of evidence presented in this report.

Preeclampsia. Part 1: clinical and pathophysiologic considerations

Preeclampsia-eclampsia is still one of the leading causes of maternal and fetal morbidity and mortality. Despite active research for many years, the etiology of this disorder exclusive to human pregnancy is an enigma. Recent evidence suggests there may be several underlying causes or predispositions leading to the signs of hypertension, proteinuria, and edema, findings that allow us to make the diagnosis of the "syndrome" of preeclampsia. Despite improved prenatal care, severe preeclampsia and eclampsia still occur. Although understanding of the pathophysiology of these disorders has improved, treatment has not changed significantly in over 50 years. Although postponement of delivery in selected women with severe preeclampsia improves fetal outcome to a degree, this is not done without risk to the mother. In the United States, magnesium sulfate and hydralazine are the most commonly used medications for seizure prophylaxis and hypertension in the intrapartum period. The search for the underlying cause of this disorder and for a clinical marker to predict those women who will develop preeclampsia-eclampsia is ongoing, with its prevention the ultimate goal. This review begins with the clinical and pathophysiologic aspects of preeclampsia-eclampsia (Part 1). In Part 2, the experimental observations, the search for predictive factors, and the genetics of this disorder will be reviewed.

[Criteria of pregnancy termination in women with preeclampsia]

Preeclampsia remains an important cause of maternal and neonatal mortality and morbidity. Delivery is always the appropriate therapy for the mother but may be responsible for neonatal adverse outcomes, particularly when it occurs at less than < 34 weeks' gestation. In women with severe preeclampsia at < 34 weeks expectant management to improve neonatal mortality and morbidity may be performed under close monitoring of both the mother and the fetus. Any severe condition of the mother (HELLP syndrome, abruptio placentae, eclampsia) or the fetus (abnormal fetal heart rate) should lead to prompt delivery. In women with mild preeclampsia, expectant management should be performed until 38 weeks gestation.

Late postpartum eclampsia: a preventable disease?

OBJECTIVE

The purpose of this study was to determine whether there is a shift in the timing of eclampsia in relation to delivery and whether traditional symptoms precede impending postpartum eclampsia.

STUDY DESIGN

A multicenter analysis of data from patients with eclampsia from March 1996 through February 2001 at the University of Cincinnati, the University of Tennessee, Memphis, and Central Baptist Hospital, Lexington. Data were collected regarding the relationship of the patient's first seizure to delivery, prodromal symptoms, neuroimaging studies, use of magnesium sulfate, antihypertensive therapy, and follow-up medical care. The analysis focused on women who had late postpartum eclampsia.

RESULTS

During the study period, 89 patients were diagnosed with eclampsia. Twenty-nine women (33%) had postpartum eclampsia, of whom 23 women (79%) had late onset (>48 hours). Interestingly, only 5 of these 23 women (22%) had been previously diagnosed with preeclampsia. Twenty-one patients (91%) with late postpartum eclampsia had at least 1 prodromal symptom, and 12 patients (52%) had >1 symptom that heralded the seizure: 20 women (87%) had headache; 10 women (44%) had visual changes; 5 women (22%) had nausea or vomiting; and 2 women (9%) experienced epigastric pain. Only 7 of these 21 women (33%) sought care for their symptoms, of whom 6 women (86%) had clinical evidence of preeclampsia that was not considered by the treating physician. Among all patients with eclampsia, there were 7 cases of aspiration pneumonia, 3 cases of pulmonary edema, 3 cases of pleural effusion, 2 cases of disseminated intravascular coagulation, and no cases of maternal death.

CONCLUSION

Current obstetric treatment in the United States has resulted in a shift of eclampsia toward the postpartum period, with most cases being seen as late post partum. To reduce the rate of late postpartum eclampsia, efforts should be directed to the education of the health care providers and patients regarding the importance of prompt reporting and evaluation of symptoms of preeclampsia during the postpartum period.

Evaluation of women with clinically suspected thrombotic thrombocytopenic purpura-hemolytic uremic syndrome during pregnancy

Thrombotic thrombocytopenic purpura-hemolytic uremic syndrome (TTP-HUS) is more common in women, and commonly occurs during pregnancy and the immediate postpartum period. An important clinical issue is the distinction of TTP-HUS from the more common obstetric complications, preeclampsia and HELLP syndrome (hemolysis, elevated liver function tests, low platelets). Clinical suspicion of TTP-HUS requires urgent intervention with plasma exchange treatment, a procedure with substantial risk, while preeclampsia and HELLP syndrome typically resolve spontaneously following delivery. Since clinical features of these syndromes can be similar, especially if preeclampsia becomes severe or if seizures (defining eclampsia) occur, the differential diagnosis may be arbitrary. This review addresses the evaluation and management of these syndromes and describes a clinical approach for determining when plasma exchange is appropriate.

Headache during pregnancy

Headache in pregnancy is a common problem but diagnosis and management can be challenging. Most headaches in pregnant women are either migraine or tension types and can be easily treated. Rarely, the headache in a pregnant patient signals a life-threatening condition. Obstetricians should be able to effectively manage the common causes of headache as well as recognize the warning signs of potentially serious conditions. Diagnosis and management should be systematic yet individualized.

New insights in hypertensive disorders of pregnancy

Research reported during the past year has enhanced our understanding of conditions that lead to the complex changes that are observed in hypertensive disorders of pregnancy. An association between placental pathology and a multisystem disorder that is characterized by endothelial dysfunction which involves genetic and immunological investigations has been identified. On the basis of these findings, promising screening tools for early detection of pre-eclampsia were identified. No marked changes in anaesthetic approach to hypertensive disorders of pregnancy occurred during the period of review, apart from a reappraisal of spinal anaesthesia as a safe technique in caesarean section, even in patients with severe pre-eclampsia. A multidisciplinary approach to management and therapy is needed and the right balance must be sought between the needs of the mother and baby, both of which are jeopardized by the hypertensive disorders of pregnancy.