Mechanisms of convulsions in eclampsia

Posterior reversible encephalopathy syndrome in 46 of 47 patients with eclampsia

OBJECTIVE

We sought to investigate the concurrence of posterior reversible encephalopathy syndrome (PRES) with eclampsia and to describe the obstetric, radiological, and critical care correlates.

STUDY DESIGN

This was a single-center, 2001-2010 retrospective cohort study of all patients with eclampsia who underwent neuroimaging via magnetic resonance imaging (MRI) or computerized tomography (CT) with or without contrast.

RESULTS

Forty-six of 47 of eclamptic patients (97.9%) revealed PRES on neuroimaging using 1 or more modalities: MRI without contrast, 41 (87.2%); MRI with contrast, 27 (57.4%); CT without contrast, 16 (34%); CT with contrast, 7 (14.8%); and/or magnetic resonance angiography/magnetic resonance venography, 2 (4.3%). PRES was identified within the parietal, occipital, frontal, temporal, and basal ganglia/brainstem/cerebellum areas of the brain. Eclampsia occurred antepartum in 23 patients and postpartum in 24 patients. Headache was the most common presenting symptom (87.2%) followed by altered mental status (51.1%), visual disturbances (34%), and nausea/vomiting (19.1%). Severe systolic hypertension was present in 22 patients (47%).

CONCLUSION

The common finding of PRES in patients with eclampsia suggests that PRES is a core component of the pathogenesis of eclampsia. Therapy targeted at prevention or reversal of PRES pathogenesis may prevent or facilitate recovery from eclampsia.

Refractory status epilepticus spontaneously resolved by parturition

Status epilepticus (SE) in pregnancy is very rare, and there are only a few case reports of refractory SE (RSE) during pregnancy. The patient was a 27-year-old primigravida woman with a 21-year history of seizures from cortical dysplasia. At 23 weeks of pregnancy, the patient's seizure frequency progressively increased, and the patient came to the ER in a confused mental state and with intermittent convulsive movements of her left arm. Electroencephalography (EEG) revealed repeated seizures. She was admitted to the ICU, and continuous EEG monitoring was done. Treatment was immediately started with various anti-SE medications, but her SE was not controlled. A cesarean section was done, and SE spontaneously stopped two weeks after the parturition. Parturition may be beneficial and the best treatment option in pregnant patients with RSE.

[Sixty-nine consecutive cases of eclampsia: prodromes and circumstances]

OBJECTIVE

To specify clinical and biological characteristics of patients developing eclampsia, and identify atypical eclampsia without prior signs and symptoms of severe preeclampsia.

PATIENTS AND METHODS

This was a retrospective observational study conducted from January 1996 to December 2008 in a maternity type IIB in French Guiana. Data of patients who experienced eclampsia were collected from obstetric records.

RESULTS

Sixty-nine patients were selected among 21,525 patients who delivered during this period, corresponding to a prevalence of 3.2 ‰. The average patient age was 21 years (range from 12 to 45 years). Sixty-six percent of patients were nulliparous. The gestational age was greater than 37 weeks of gestation for 62% of patients, between 26 and 37 weeks of gestation for 36% and less than 26 weeks of gestation for 2% of patients. Two thirds of the patients had been examined less than a month before the eclamptic seizure, blood pressure was normal in 62% of cases. Seventy-four percent of patients had at least one Doppler study of the uterine and umbilical arteries velocimetry, the Dopplers studies were normal in 78% of cases. The eclampsia occurred in ante-, peri- and post-partum in 59, 6 and 35% of the cases, respectively 10% of patients were hospitalized for preeclampsia at the time of eclamptic seizure. Less than 10% of patients developed HELLP syndrome. One patient had died of aspiration pneumonia. Newborns had a mean birth weight over 2500 g in 88% of cases. During the follow-up period, 41% of the patients had subsequent pregnancies with 62% without hypertension, 24% complicated by recurrent gestational hypertension, 24% by preeclampsia and 4% by eclampsia.

DISCUSSION AND CONCLUSION

In a majority of the patients in our study, eclampsia was the main manifestation, and only 10% were preceded by severe preeclampsia. These results are comparable to recent studies, which found in their series that 40 to 60% of eclampsia manifested without preeclamptic prodromi. Eclampsia can occur after an unremarkable pregnancy, in women without risk factors, and then it is hardly predictable. Prenatal follow-up must be very cautious paying attention to any markers such as intermittent hypertension, functional symptoms or appearance of proteinuria.

Neurokinin B and pre-eclampsia: a decade of discovery

At the start of the last decade, we provided evidence that levels of the peptide neurokinin B were highly elevated in pre-eclampsia. We hypothesized that elevated levels of neurokinin B may be an indicator of pre-eclampsia and that treatment with certain neurokinin receptor antagonists may be useful in alleviating the symptoms. At the time of the original hypothesis many questions remained outstanding. These included - Does neurokinin B have any diagnostic value in the detection and diagnosis of pre-eclampsia? - What is the cause of the elevated levels of neurokinin B during pre-eclampsia? - What is the physiological significance of neurokinin B in the placenta? This review discusses the answers to these questions taking into account the subsequent developments of the past ten years and analyzing the plethora of discoveries that have arisen from those initial observations.