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Dixit P, Mishra TK, Nargawe D, Singh S. Maternal and Perinatal Outcome in Patients With Eclampsia: A Study Done at a Tertiary Care Centre. Cureus 2023; 15:e45971. [PMID: 37900531 PMCID: PMC10600615 DOI: 10.7759/cureus.45971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Accepted: 09/26/2023] [Indexed: 10/31/2023] Open
Abstract
Background One of the leading causes contributing to morbidity and mortality globally is attributed to eclampsia. Hence, it is vital to comprehensively review each female having eclampsia and to evaluate the factors that govern the outcomes in females with eclampsia. Aim To decode the fetal and maternal outcomes in subjects having eclampsia and to evaluate various factors that govern the outcomes. Methods This retrospective cohort and epidemiological study commenced at the Department of Obstetrics and Gynaecology, Netaji Subhash Chandra Bose Medical College, Jabalpur, Madhya Pradesh, in January 2016 till April 2017, and included females that either developed eclampsia in hospital stay duration or presented with pre-existing eclampsia. In included females, various fetal and maternal parameters were assessed along with the outcome of pregnancy. The institutional data records and the database were also used to determine the prevalence and incidence of eclampsia. Baseline maternal parameters were recorded from the already-existing institute data. These included the gestational age (in years), socioeconomic status, educational attainment, parity, gravidity, and the number of weeks of gestation present at the time of delivery. Antenatal care data assessed were blood pressure recordings, any proteinuria documented in the data, and the number of antenatal visits by the subjects. Statistical analysis was performed to assess both parameters. Results In the current investigation, there were 0.34% eclampsia cases among females visiting the institution for deliveries. Incidences of stillbirth were seen in 19.04% and 8% of study participants, respectively. We found 9.52% (n=4) of female infants to have perished from eclampsia. Preterm births, a delayed start to the treatment, and insufficient care were all linked to poor foetal and mother outcomes. The longer the period between the beginning of a fit and delivery, the greater the likelihood of unfavourable results. Seizure onset before or after birth, parity, or subject age had no impact on mother or foetal health. The p-value for statistical significance was kept at 0.05. Conclusion Most of the research participant women, had intrapartum eclampsia, postpartum eclampsia, and antepartum eclampsia, based on the time of the convulsions in relation to the labor. It was highlighted that there was no conclusive evidence linking the date of the fit's beginning to unfavourable results or an elevated risk of complications. Neonatal mortality and stillbirth were observed with vaginal delivery in eclampsia cases. Outcomes in eclampsia can be improved by early treatment initiation, timely and appropriate referral, early disease recognition, and appropriate antenatal care.
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Affiliation(s)
- Pratibha Dixit
- Department of Obstetrics and Gynaecology, Government Medical College and Hospital, Ratlam, IND
| | - Tarunendra K Mishra
- Department of General Medicine, Government Medical College and Hospital, Ratlam, IND
| | - Devendra Nargawe
- Department of Pediatrics, Government Medical College and Hospital, Ratlam, IND
| | - Sandeep Singh
- Department of General Medicine, Netaji Subhash Chandra Bose Medical College, Jabalpur, IND
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Beyuo TK, Lawrence ER, Kobernik EK, Oppong SA. Clinical presentation and predictors of eclampsia among women with hypertensive disorders of pregnancy in Ghana. Pregnancy Hypertens 2022; 30:171-176. [DOI: 10.1016/j.preghy.2022.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 10/10/2022] [Accepted: 10/10/2022] [Indexed: 11/27/2022]
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Fishel Bartal M, Sibai BM. Eclampsia in the 21st century. Am J Obstet Gynecol 2022; 226:S1237-S1253. [PMID: 32980358 DOI: 10.1016/j.ajog.2020.09.037] [Citation(s) in RCA: 66] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 09/14/2020] [Accepted: 09/22/2020] [Indexed: 12/12/2022]
Abstract
The reported incidence of eclampsia is 1.6 to 10 per 10,000 deliveries in developed countries, whereas it is 50 to 151 per 10,000 deliveries in developing countries. In addition, low-resource countries have substantially higher rates of maternal and perinatal mortalities and morbidities. This disparity in incidence and pregnancy outcomes may be related to universal access to prenatal care, early detection of preeclampsia, timely delivery, and availability of healthcare resources in developed countries compared to developing countries. Because of its infrequency in developed countries, many obstetrical providers and maternity units have minimal to no experience in the acute management of eclampsia and its complications. Therefore, clear protocols for prevention of eclampsia in those with severe preeclampsia and acute treatment of eclamptic seizures at all levels of healthcare are required for better maternal and neonatal outcomes. Eclamptic seizure will occur in 2% of women with preeclampsia with severe features who are not receiving magnesium sulfate and in <0.6% in those receiving magnesium sulfate. The pathogenesis of an eclamptic seizure is not well understood; however, the blood-brain barrier disruption with the passage of fluid, ions, and plasma protein into the brain parenchyma remains the leading theory. New data suggest that blood-brain barrier permeability may increase by circulating factors found in preeclamptic women plasma, such as vascular endothelial growth factor and placental growth factor. The management of an eclamptic seizure will include supportive care to prevent serious maternal injury, magnesium sulfate for prevention of recurrent seizures, and promoting delivery. Although routine imagining following an eclamptic seizure is not recommended, the classic finding is referred to as the posterior reversible encephalopathy syndrome. Most patients with posterior reversible encephalopathy syndrome will show complete resolution of the imaging finding within 1 to 2 weeks, but routine imaging follow-up is unnecessary unless there are findings of intracranial hemorrhage, infraction, or ongoing neurologic deficit. Eclampsia is associated with increased risk of maternal mortality and morbidity, such as placental abruption, disseminated intravascular coagulation, pulmonary edema, aspiration pneumonia, cardiopulmonary arrest, and acute renal failure. Furthermore, a history of eclamptic seizures may be related to long-term cardiovascular risk and cognitive difficulties related to memory and concentration years after the index pregnancy. Finally, limited data suggest that placental growth factor levels in women with preeclampsia are superior to clinical markers in prediction of adverse pregnancy outcomes. This data may be extrapolated to the prediction of eclampsia in future studies. This summary of available evidence provides data and expert opinion on possible pathogenesis of eclampsia, imaging findings, differential diagnosis, and stepwise approach regarding the management of eclampsia before delivery and after delivery as well as current recommendations for the prevention of eclamptic seizures in women with preeclampsia.
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Affiliation(s)
- Michal Fishel Bartal
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX.
| | - Baha M Sibai
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX
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Vidaeff AC, Saade GR, Sibai BM. Preeclampsia: The Need for a Biological Definition and Diagnosis. Am J Perinatol 2021; 38:976-982. [PMID: 31986536 DOI: 10.1055/s-0039-1701023] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
The centuries-old approach to the prevention of eclampsia and its associated maternal morbidity and mortality is based on the recognition of the presence of premonitory signs and symptoms such as hypertension and proteinuria. The spectrum of preceding signs and symptoms came to be known as preeclampsia, which is debatably considered to be an early stage on a clinical continuum possibly leading to eclampsia. The premonitory signs and symptoms were then construed as diagnostic criteria for the poorly understood syndrome of preeclampsia, and this led to a perpetual debate that remains subject to wide disagreement and periodic updates. In this commentary, we will draw attention to the fact that the criteria for preeclampsia should be viewed from the prism of a screening test rather than as diagnostic of a condition in itself. Focusing research on developing better diagnostic and screening methods for what is clinically important, namely maternal and perinatal morbidity and mortality from hypertensive disorders of pregnancy, a long overdue upgrade from what was possible centuries ago, will ultimately lead to better management approaches to what really matters.
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Affiliation(s)
- Alex C Vidaeff
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
| | - George R Saade
- Department of Obstetrics and Gynecology, University of Texas Medical Branch at Galveston, Galveston, Texas
| | - Baha M Sibai
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School, UT Health, Houston, Texas
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Blood Pressure Changes in Adolescents with Preeclampsia: A Multicentre, Case-Control Study in Latin American Hospitals. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2020; 43:50-57. [PMID: 33041217 DOI: 10.1016/j.jogc.2020.06.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Revised: 06/24/2020] [Accepted: 06/24/2020] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To determine the minimum blood pressure increases that would confirm or exclude, with the greatest predictive values, hypertensive disorders of pregnancy (HDP) in pregnant adolescents after 24 weeks gestation. METHODS We conducted a case-control study of pregnant women aged ≤19 years with and without HDP. Using systolic and diastolic blood pressure increases, a predictive analysis was performed, and the area under the curve was calculated. RESULTS The cases and controls had systolic blood pressure increases of 45.3 ± 17.5 mm Hg and 6.4 ± 7.9 mm Hg, respectively (P = 0.001) and diastolic blood pressure increases of 30.8 ± 11.7 mm Hg and 3.5 ± 5.7 mm Hg, respectively (P = 0.001). Systolic and diastolic increases of ≥20 mm Hg showed the greatest sensitivity and specificity. A combined analysis showed that an increase of ≥20 mm Hg had a greater positive likelihood ratio of 35.4 (95% CI 22.4-55.9) and negative likelihood ratio of 0.10 (95% CI 0.07-0.13), with an area under the curve of 0.98 (95% CI 0.96-0.99). CONCLUSIONS Systolic and diastolic blood pressure increases of ≥20 mm Hg must be considered in the diagnostic criteria for preeclampsia and gestational hypertension among pregnant adolescents past 24 weeks gestation.
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Pandey PK, Bhatt AP, Sinha VK, Agarwal N, Agrawal G. Role of plasma exchange in management of patients clinically diagnosed of postpartum thrombotic microangiopathies: A retrospective observation from a tertiary health-care center. Asian J Transfus Sci 2020; 14:142-148. [PMID: 33767541 PMCID: PMC7983147 DOI: 10.4103/ajts.ajts_43_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Accepted: 09/09/2018] [Indexed: 11/18/2022] Open
Abstract
Introduction: Diagnosis of postpartum thrombotic microangiopathies in pregnancy is a challenge, but plasma exchange (PE) is life-saving in such cases. This study was conducted with the aim to find the result of the early start of PE in such patients. MATERIALS AND METHODS: There were a total of seven clinically diagnosed cases of post partum thrombotic microangiopathies (PP-TMA) where PE was done. The diagnosis of PP-HUS and decision to start PE in such cases were based on the classical triad of microangiopathic hemolytic anemia, thrombocytopenia, and acute renal failure. All the PE procedures were done using fully automatic COM.TEC (Fresenius Kabi, Germany). RESULTS: Immediately before the start of PE, the mean platelet count and serum lactate dehydrogenase (LDH) and hemoglobin (Hb) were 53.1 × 109/L, 10,943 IU/L, and 6.4 gm%, respectively. After seven sessions of PE, platelet count improved to 158 × 109/L and LDH dropped to 609 IU/L, and Hb improved to 10.3 gm% (P < 0.05). We got a positive renal response in four patients in whom serum creatinine value reached within normal range while in the remaining three patients, no positive renal response was obtained and serum creatinine remained above normal range. Thus, the response of PE was shown to be inadequate in three patients. Compliance to PE was good. Patients were discharged after 20 days (mean) of hospital admission. CONCLUSION: PE is life-saving in PP-HUS. High degree of clinical suspicion to it and early start of PE were crucial for successful outcome in our patient population.
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Affiliation(s)
| | - Anil Prasad Bhatt
- Department of Nephrology, Jaypee Hospital, Noida, Uttar Pradesh, India
| | - Vijay Kumar Sinha
- Department of Nephrology, Jaypee Hospital, Noida, Uttar Pradesh, India
| | - Nitin Agarwal
- Department of Transfusion Medicine, Jaypee Hospital, Noida, Uttar Pradesh, India
| | - Gyanendra Agrawal
- Department of Nephrology, Jaypee Hospital, Noida, Uttar Pradesh, India
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Janzarik WG, Jacob J, Katagis E, Markfeld-Erol F, Sommerlade L, Wuttke M, Reinhard M. Preeclampsia postpartum: Impairment of cerebral autoregulation and reversible cerebral hyperperfusion. Pregnancy Hypertens 2019; 17:121-126. [DOI: 10.1016/j.preghy.2019.05.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 05/26/2019] [Accepted: 05/29/2019] [Indexed: 11/28/2022]
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Asali A, Ravid D, Miller N, Daher R, Cohen O, Berkovitz A. Can we predict the need for antihypertensive treatment during the early postpartum period for women with preeclampsia or gestational hypertension? Pregnancy Hypertens 2019; 17:133-137. [DOI: 10.1016/j.preghy.2019.05.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 05/29/2019] [Accepted: 05/29/2019] [Indexed: 10/26/2022]
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Uludag SZ, Gokmen Karasu AF, Kutuk MS, Takmaz T. Incidence and outcomes of eclampsia: a single-center 30-year study. Hypertens Pregnancy 2019; 38:119-123. [PMID: 30880504 DOI: 10.1080/10641955.2019.1590719] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 03/01/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVE We aimed to determine the incidence of eclampsia at Erciyes University Hospital which is a tertiary referral center situated at central Anatolia. Additionally, we investigated eclampsia-associated maternal and perinatal outcomes for the 30-year study period. METHODS A retrospective review was performed for all women who were diagnosed with eclampsia and admitted to the Erciyes University Medical School, Department of Obstetrics and Gynecology from January 1985 to December 2015. Improvement in management gained over time was determined by comparing the results of the years 2005-2015 with data which were already published from years 1985-1999 and 2000-2004. RESULTS Eclampsia prevalence was 289/46,928 (% 0.61). Maternal age at the time of diagnosis did not differ statistically; however, gestational age at diagnosis and birth weight decreased significantly throughout the years (p < 0.005). The perinatal mortality rate showed a slight decrease throughout the years (p = 0.238). Maternal mortality rate also decreased throughout the years; it was 1.7% in 2005-2009 and 0 % in 2010-2015 (p = 0.246). CONCLUSION The prevalence of eclampsia cases has decreased over the years. Maternal mortality attributed to eclampsia has also declined. The early diagnosis and treatment of eclampsia have resulted in the increase of premature deliveries. The perinatal mortality rate showed a slight decrease throughout the years (p = 0.238); however, it is not at a desirable rate compared to developed countries.
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Affiliation(s)
- Semih Zeki Uludag
- a Department of Obstetrics and Gynecology , Erciyes University Medical Faculty , Kayseri , Turkey
| | - Ayse Filiz Gokmen Karasu
- b Department of Obstetrics and Gynecology , Bezmialem Vakif University Medical Faculty , Istanbul , Turkey
| | - Mehmet Serdar Kutuk
- b Department of Obstetrics and Gynecology , Bezmialem Vakif University Medical Faculty , Istanbul , Turkey
| | - Taha Takmaz
- b Department of Obstetrics and Gynecology , Bezmialem Vakif University Medical Faculty , Istanbul , Turkey
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Increased proteinuria and uric acid levels are associated with eclamptic crisis. Pregnancy Hypertens 2019; 15:93-97. [DOI: 10.1016/j.preghy.2018.12.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 11/18/2018] [Accepted: 12/10/2018] [Indexed: 12/22/2022]
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Engjom HM, Morken NH, Høydahl E, Norheim OF, Klungsøyr K. Risk of eclampsia or HELLP-syndrome by institution availability and place of delivery – A population-based cohort study. Pregnancy Hypertens 2018; 14:1-8. [DOI: 10.1016/j.preghy.2018.05.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Revised: 05/06/2018] [Accepted: 05/13/2018] [Indexed: 10/28/2022]
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The acquired form of ADAMTS-13 deficiency as the cause of thrombotic microangiopathy in a pregnant woman with recurrent cerebral circulation disorders, venous thromboembolism, preeclampsia and fetal loss syndrome. CASE REPORTS IN PERINATAL MEDICINE 2017. [DOI: 10.1515/crpm-2017-0023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Abstract
Background
Thrombotic microangiopathy (TMA) is one of the most difficult thrombotic complications, characterized by damage of microvessels of various organs and accompanied by thrombocytopenia and hemolytic anemia. Today, TMA includes thrombotic thrombocytopenic purpura, hemolytic-uremic syndrome, heparin-induced thrombocytopenia and hemolysis, elevated liver enzymes and low platelet count (HELLP) syndrome. A key characteristic in the development of TMA is endothelial dysfunction. Recent discoveries suggest that this pathology is more widespread than it was previously. One of the most important triggers for TMA is pregnancy.
Methods
The clinical observation of a patient with an inhibitory form of a disintegrin and metalloproteinase with a thrombospondrin type 1 motif, member 13 (ADAMTS-13) deficiency, recurrent thrombotic and “typical obstetric” severe complications is presented.
Results
We diagnosed a reduction in the activity of ADAMTS-13, an increase in the level of antibodies to ADAMTS-13 and disturbances in functioning of the protein C system along with symptoms of disorders of blood flow in the mother-placenta-fetus system as a poor prognosis in regard to both thrombotic and placenta-mediated combinations.
Conclusions
An analysis of cases such as this patient immediately pushes the clinician to the idea of antiphospholipid syndrome (APS). It is questionable whether this patient could be regarded as an APS patient if her symptoms do not correspond with the classic diagnostic criteria for the syndrome. At the same time, the discovery of molecular mechanisms of TMA warrants a fresh look into the pathogenesis of thrombotic complications associated with pregnancy, as well as the pathogenesis of placental obstetric complications, including severe forms of preeclampsia, premature detachment of normally situated placenta and septic shock.
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Blood pressure in adolescent patients with pre-eclampsia and eclampsia. Int J Gynaecol Obstet 2017; 138:335-339. [DOI: 10.1002/ijgo.12237] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Revised: 04/24/2017] [Accepted: 06/07/2017] [Indexed: 11/07/2022]
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Berhan Y, Endeshaw G. Clinical and Biomarkers Difference in Prepartum and Postpartum Eclampsia. Ethiop J Health Sci 2016; 25:257-66. [PMID: 26633929 PMCID: PMC4650881 DOI: 10.4314/ejhs.v25i3.9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background There is a large body of literature which assessed the incidence and risk factors of eclampsia, but little was done in assessing the association of clinical features and biological markers with prepartum and postpartum eclampsia. Methods A total of 361 eclamptic women admitted to three teaching hospitals between 2008 and 2013 were included in this analysis. A comparative analysis was done for several clinical and biological variables to assess their association with prepartum and postpartum eclampsia. Results The overall incidence of eclampsia was 1.2% (prepartum 71% and postpartum 29%). The majority of women with prepartum eclampsia were young, primigravida, more hypertensive, symptomatic and proteinuric. Conversely, the majoritys of the women with post-partum eclampsia were adult, multiparous, carrying pregnancy to term, anemic, thrombocytopenic, and with hepatic dysfunction. The commonest severity symptom (headache) was less common in postpartum eclamptic women. Conclusion The incidence of eclampsia was among the highest in the world. And, the analysis has shown that the clinical and biochemical spectrum of prepartum and postpartum eclampsia were apparently different. The majority of the women who developed postpartum eclampsia were multiparous and adult. Derangement of biomarkers was also more common in women with postpartum eclampsia.
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Affiliation(s)
- Yifru Berhan
- College of Medicine and Health Sciences, Hawassa University, Ethiopia
| | - Gezahegn Endeshaw
- College of Medicine and Health Sciences, Hawassa University, Ethiopia
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Edlow AG, Edlow BL, Edlow JA. Diagnosis of Acute Neurologic Emergencies in Pregnant and Postpartum Women. Emerg Med Clin North Am 2016; 34:943-965. [PMID: 27741996 DOI: 10.1016/j.emc.2016.06.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Acute neurologic symptoms in pregnant and postpartum women may be caused by exacerbation of a preexisting neurologic condition, the initial presentation of a non-pregnancy-related problem, or a new neurologic problem. Pregnant and postpartum patients with headache and neurologic symptoms are often diagnosed with preeclampsia or eclampsia; however, other etiologies must also be considered. A team approach with close communication between emergency physicians, neurologists, maternal-fetal medicine specialists, and radiologists is the key to obtaining best outcomes. This article reviews the clinical features and differential diagnosis of acute serious neurologic conditions in pregnancy and the puerperium, focusing on diagnosis.
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Affiliation(s)
- Andrea G Edlow
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Mother Infant Research Institute, Tufts Medical Center, 800 Washington Street, Box 394, Boston, MA 02111, USA
| | - Brian L Edlow
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, 175 Cambridge Street, Suite 300, Boston, MA 02114, USA
| | - Jonathan A Edlow
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, One Deaconess Place, West Clinical Center, 2nd Floor, Boston, MA 02215, USA.
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Liu L, Han X, Huang Q, Zhu X, Yang J, Liu H. Increased neuronal seizure activity correlates with excessive systemic inflammation in a rat model of severe preeclampsia. Hypertens Res 2016; 39:701-708. [DOI: 10.1038/hr.2016.53] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2015] [Revised: 03/22/2016] [Accepted: 03/29/2016] [Indexed: 12/15/2022]
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Berhan Y. No Hypertensive Disorder of Pregnancy; No Preeclampsia-eclampsia; No Gestational Hypertension; No Hellp Syndrome. Vascular Disorder of Pregnancy Speaks for All. Ethiop J Health Sci 2016; 26:177-86. [PMID: 27222631 PMCID: PMC4864347 DOI: 10.4314/ejhs.v26i2.12] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Hypertensive disorders complicate 5%-10% of pregnancies with increasing incidence mainly due to upward trends in obesity globally. In the last century, several terminologies have been introduced to describe the spectrum of this disease. The current and widely used classification of hypertensive pregnancy disorders was introduced in 1972 and in 1982, but has not been free of controversy and confusion. Unlike other diseases, the existing terminology combines signs and symptoms, but does not describe the underlying pathology of the disease itself. In this commentary, a detailed account is given to vascular disorder of pregnancy (VDP) as an inclusive terminology taking into account the underlying pathology of the disease on affected organs and systems. A simple and uniform classification scheme for VDP is proposed.
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Affiliation(s)
- Yifru Berhan
- Addis Ababa University, College of medicine and health sciences, Ethiopia
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Abstract
Preeclampsia is a hypertensive, multisystem disorder of pregnancy that affects several organ systems, including the maternal brain. Cerebrovascular dysfunction during preeclampsia can lead to cerebral edema, seizures, stroke, and potentially maternal mortality. This review will discuss the effects of preeclampsia on the cerebrovasculature that may adversely affect the maternal brain, including cerebral blood flow (CBF) autoregulation and blood-brain barrier disruption and the resultant clinical outcomes including posterior reversible encephalopathy syndrome (PRES) and maternal stroke. Potential long-term cognitive outcomes of preeclampsia and the role of the cerebrovasculature are also reviewed.
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Affiliation(s)
- Erica Shields Hammer
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Vermont, Burlington, VT, USA,
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The Role of Headache in the Classification and Management of Hypertensive Disorders in Pregnancy. Obstet Gynecol 2015; 126:297-302. [DOI: 10.1097/aog.0000000000000966] [Citation(s) in RCA: 83] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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20
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Abstract
Eclampsia, clinically defined as unexplained seizure in a woman with preeclampsia, is a life threatening complication unique to the pregnant state. However, a subpopulation of women with seemingly uncomplicated pregnancies experience de novo seizure without preeclamptic signs or symptoms, suggesting pregnancy alone may predispose the brain to seizure. Here, we hypothesized that normal pregnancy lowers seizure threshold and investigated mechanisms by which pregnancy may affect seizure susceptibility, including neuroinflammation and plasticity of gamma-aminobutyric acid type A receptor (GABAAR) subunit expression. Seizure threshold was determined by quantifying the amount of pentylenetetrazole (PTZ) required to elicit electrical seizure in Sprague Dawley rats that were either nonpregnant (Nonpreg, n = 7) or pregnant (Preg; d20, n = 6). Seizure-induced vasogenic edema was also measured. Further, activation of microglia, a measure of neuroinflammation (n = 6-8/group), and GABAAR δ- and γ2-subunit protein expression in the cerebral cortex and hippocampus (n = 6/group) was determined. Seizure threshold was lower in Preg compared to Nonpreg rats (36.7±9.6 vs. 65.0±14.5 mg/kg PTZ; p<0.01) that was associated with greater vasogenic edema formation (78.55±0.11 vs. 78.04±0.19% water; p<0.05). The % of active microglia was similar between groups; however, pregnancy was associated with downregulation of cortical GABAAR-δ and hippocampal GABAAR-γ2 expression. Overall, pregnancy appears to be a state of increased seizure susceptibility that is not due to neuroinflammation, but rather is associated with reduced expression of GABAAR subunits and greater edema. Understanding neurophysiological changes occurring in normal pregnancy could allow for better prevention and management of de novo seizure, including pathologic states such as eclampsia.
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Affiliation(s)
- Abbie Chapman Johnson
- Department of Neurological Sciences, University of Vermont College of Medicine, Burlington, Vermont, 05405, United States of America
| | - Keith J. Nagle
- Department of Neurological Sciences, University of Vermont College of Medicine, Burlington, Vermont, 05405, United States of America
| | - Sarah M. Tremble
- Department of Neurological Sciences, University of Vermont College of Medicine, Burlington, Vermont, 05405, United States of America
| | - Marilyn J. Cipolla
- Department of Neurological Sciences, University of Vermont College of Medicine, Burlington, Vermont, 05405, United States of America
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Vermont College of Medicine, Burlington, Vermont, 05405, United States of America
- Department of Pharmacology, University of Vermont College of Medicine, Burlington, Vermont, 05405, United States of America
- * E-mail:
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Asıcıoglu O, Güngördük K, Yildirim G, Aslan H, Günay T. Maternal and perinatal outcomes of eclampsia with and without HELLP syndrome in a teaching hospital in western Turkey. J OBSTET GYNAECOL 2015; 34:326-31. [PMID: 24798114 DOI: 10.3109/01443615.2014.881791] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
In this study, we compared the perinatal and maternal outcomes of women with eclampsia with and without HELLP syndrome. A total of 219 pregnancies complicated by eclampsia with and without HELLP syndrome managed between January 2002 and December 2011, were reviewed. The incidence of eclampsia was 1.7/1,000 deliveries. Among 219 patients with eclampsia, 141 (64.4%) did not develop HELLP syndrome and 78 (35.6%) did develop HELLP syndrome. Maternal age and the rates of nulliparity were similar in both groups. Interval time from eclamptic seizure to delivery was significantly longer in the without-HELLP syndrome group (0.92 ± 0.29 weeks vs 0.16 ± 0.12 weeks, p = 0.028). Furthermore, overall perinatal mortality (particularly after gestational week 32) was significantly higher in the with-HELLP syndrome group (20.5% vs 9.9%, p = 0.029). In conclusion, patients with HELLP syndrome had significantly higher perinatal mortality than those with eclampsia without HELLP syndrome and no regular prenatal care.
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Affiliation(s)
- O Asıcıoglu
- Department of Obstetrics and Gynecology, Şişli Etfal Training and Research Hospital , İstanbul
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Berhan Y, Berhan A. Should magnesium sulfate be administered to women with mild pre-eclampsia? A systematic review of published reports on eclampsia. J Obstet Gynaecol Res 2015; 41:831-42. [DOI: 10.1111/jog.12697] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Revised: 01/08/2015] [Accepted: 01/13/2015] [Indexed: 11/27/2022]
Affiliation(s)
- Yifru Berhan
- Hawassa University College of Medicine and Health Sciences; Hawassa Ethiopia
| | - Asres Berhan
- Hawassa University College of Medicine and Health Sciences; Hawassa Ethiopia
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Perinatal Outcome in Women with Hypertensive Disorders of Pregnancy: A Retrospective Cohort Study. INTERNATIONAL SCHOLARLY RESEARCH NOTICES 2015; 2015:208043. [PMID: 27347505 PMCID: PMC4897150 DOI: 10.1155/2015/208043] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Accepted: 12/23/2014] [Indexed: 11/18/2022]
Abstract
Background. Hypertensive disorders of pregnancy (HDP) are multisystem diseases known to increase the risk of perinatal mortality worldwide, with a significant proportion of these deaths occurring in low income countries. However, little is known about the obstetric and treatment predictors of perinatal mortality in women with HDP. Methods. A retrospective cohort study design was used to include 1015 hypertensive pregnant women who gave birth to 1110 babies between 2008 and 2013 in three university teaching hospitals. Bivariate and multivariate regression models were used to estimate the associations between selected predictor variables and perinatal mortality taking the onset of HDP illness to death or discharge from the hospital as the time period. Results. There were 322 perinatal deaths resulting in a perinatal mortality rate (PMR) of 290/1000 total births. The proportion of stillbirths was more than 4-fold higher than early neonatal deaths (81% versus 19%). The multivariate analysis demonstrated that multiparity (OR, 1.6; 95% CI, 1.12–228), grand multiparity (OR, 2.8; 95% CI, 1.55–4.92), preterm (OR, 1.5; 95% CI, 1.02–2.35) and very preterm gestational age (OR, 7.7; 95% CI, 5.26–11.20), lack of antenatal care (OR, 2.0; 95% CI, 1.43–2.67), having eclampsia (OR, 4.1; 95% CI, 2.85–6.04), antepartum or before (OR, 6.6; 95% CI, 3.40–12.75) and intrapartum onset of HDP (OR, 4.0; 95% CI, 1.99–8.04), raised SGOT level (OR, 2.3; 95% CI, 1.30–3.91), vaginal delivery (OR, 5.3; 95% CI, 2.93–9.54), low fetal birth weight (OR, 4.3; 95% CI, 2.56–7.23), and maternal death (OR, 12.8; 95% CI, 2.99–54.49) were independent predictors of perinatal mortality. Conclusion. This study showed that the PMR of HDP was among the highest in the world. Parity, gestational age, type and onset of HDP, mode of delivery, birthweight, and maternal outcome were strong predictors of perinatal mortality.
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Berhan Y, Endeshaw G. Maternal mortality predictors in women with hypertensive disorders of pregnancy: a retrospective cohort study. Ethiop J Health Sci 2015; 25:89-98. [PMID: 25733789 PMCID: PMC4337086 DOI: 10.4314/ejhs.v25i1.12] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Hypertensive disorders of pregnancy (HDP) are multisystem disorders unique to human pregnancy. They are becoming the leading causes of maternal mortality worldwide, with the majority of deaths occurring in low income countries. However, little is known about the predictors of maternal mortality in women with HDP. METHODS A retrospective cohort study was conducted between 2008 and 2013 in three university teaching hospitals among 1015 women admitted with a diagnosis of HDP. Statistically significant associations were assessed by the hazard ratio (HR) with 95% confidence using the Cox proportional hazards model and by the Log Rank test using the Kaplan-Meier survival analyses. RESULTS There were 51(5%) maternal deaths and the majority died after they developed eclampsia. The median delay in arrival among the deaths was longer than the survivors. The multivariate survival analyses showed an increased risk of maternal mortality among women with eclampsia (HR=8.4), no antenatal care (HR=2.3), being grand multiparous (HR=2.8), having low diastolic blood pressure (HR=4.5), high creatinine level (HR=9.9), use of diazepam as anticonvulsant (HR=2.7) and untreated with antihypertensive drug (HR=4.2). CONCLUSIONS The case fatality rate of HDP was among the highest in the world and a delay in initiation of treatment because of delay in health care-seeking contributed to the majority of maternal deaths.
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Affiliation(s)
- Yifru Berhan
- Hawassa University College of Medicine and Health Sciences, Ethiopia
| | - Gezahegn Endeshaw
- Hawassa University College of Medicine and Health Sciences, Ethiopia
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Vasquez DN, Das Neves AV, Zakalik G, Aphalo VB, Sanchez AM, Estenssoro E, Intile AD, Canales HS, Loudet CI, Scapellato JL, Desmery PM. Hypertensive disease of pregnancy in the ICU: a multicenter study. J Matern Fetal Neonatal Med 2014; 28:1989-95. [PMID: 25316558 DOI: 10.3109/14767058.2014.974540] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVE To describe characteristics, outcomes and clinical presentations for hypertensive disease of pregnancy (HDP) in patients admitted to three ICUs in Argentina. METHODS Case-series multicenter study. RESULTS There were 184 patients with HDP. Mean age 26 ± 8; 90% did not present comorbidity; APACHEII 9[6-14]; SOFA24 2[1-4]; ICU-LOS 3[2-6] days and hospital-LOS 8[5-12] days. Gestational age 34 ± 5 weeks; 46% (85) nulliparous and 71% received routine prenatal care. Maternal mortality 3.3% (6) - 50% attributed to intracranial hemorrhage (ICH). Neonatal mortality 13.6%. Diagnostic categories: eclampsia (64; 35%), severe preeclampsia (60; 32.6%), HELLP (33; 17.9%), eclampsia-HELLP (18; 9.8%) and other (chronic/gestational-hypertension) (9: 4.7%). Severe hypertension in 46%, multiple organ dysfunction in 23%, acute respiratory distress in 8.7% and acute renal failure in 8%. Variables independently associated with eclampsia: maternal age (OR 1.07 [1.02-1.13], gestational age (OR 1.14 [1.04-1.24]) and nulliparity (OR 2.40 [1.19-4.85]). CONCLUSIONS Although patients were young and the majority received appropriate prenatal care, they spent considerable time in hospital and presented severe morbidity. Maternal mortality was 3.3% and in half of these cases it was attributed to ICH. Eclampsia and severe preeclampsia represented two thirds of the diagnostic categories. Variables independently associated with eclampsia were maternal and gestational ages and nulliparity.
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Affiliation(s)
- Daniela N Vasquez
- a Intensive Care Unit , Sanatorio Anchorena, Capital Federal , Ciudad de Buenos Aires , Argentina .,b Intensive Care Unit , HIGA Gral. San Martín , La Plata, provincia de Buenos Aires , Argentina , and
| | - Andrea V Das Neves
- b Intensive Care Unit , HIGA Gral. San Martín , La Plata, provincia de Buenos Aires , Argentina , and
| | - Graciela Zakalik
- c Intensive Care Unit , Hospital L. Lagomaggiore , Mendoza , Argentina
| | - Vanina B Aphalo
- a Intensive Care Unit , Sanatorio Anchorena, Capital Federal , Ciudad de Buenos Aires , Argentina
| | - Angela M Sanchez
- c Intensive Care Unit , Hospital L. Lagomaggiore , Mendoza , Argentina
| | - Elisa Estenssoro
- b Intensive Care Unit , HIGA Gral. San Martín , La Plata, provincia de Buenos Aires , Argentina , and
| | - Alfredo D Intile
- a Intensive Care Unit , Sanatorio Anchorena, Capital Federal , Ciudad de Buenos Aires , Argentina
| | - Héctor S Canales
- b Intensive Care Unit , HIGA Gral. San Martín , La Plata, provincia de Buenos Aires , Argentina , and
| | - Cecilia I Loudet
- b Intensive Care Unit , HIGA Gral. San Martín , La Plata, provincia de Buenos Aires , Argentina , and
| | - José L Scapellato
- a Intensive Care Unit , Sanatorio Anchorena, Capital Federal , Ciudad de Buenos Aires , Argentina
| | - Pablo M Desmery
- a Intensive Care Unit , Sanatorio Anchorena, Capital Federal , Ciudad de Buenos Aires , Argentina
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Adverse maternal and fetal outcomes and deaths related to preeclampsia and eclampsia in Haiti. Pregnancy Hypertens 2014; 4:279-86. [PMID: 26104817 DOI: 10.1016/j.preghy.2014.09.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2014] [Accepted: 09/24/2014] [Indexed: 01/07/2023]
Abstract
OBJECTIVE The purpose of this study was to define the prevalence and clinical characteristics of preeclampsia and eclampsia at a hospital in rural Haiti. METHODS This is a retrospective review of women presenting to Hôpital Albert Schweitzer (HAS) in Deschapelles, Haiti with singleton pregnancy and diagnosis of preeclampsia or eclampsia from January 1, 2011 through December 31, 2012. Hospital charts were reviewed to obtain medical and prenatal history, hospital course, delivery information, and fetal/neonatal outcomes. The outcomes included placental abruption, antepartum eclampsia, postpartum eclampsia, maternal death, birthweight <2500g and stillbirth. Data are presented as median (quartile 1, quartile 3) or n (%) and risk ratios. RESULTS During the study period, 1743 women were admitted to the maternity service at HAS and 290 (16.6%) were diagnosed with preeclampsia or eclampsia. Only singleton pregnancies were analyzed (N=270). Nearly all (95.0%) patients admitted with preeclampsia had severe preeclampsia. There were 83 patients with eclampsia (30.7%) of which 61 (73.4%) had antepartum eclampsia. There were 48 stillbirths (17.8%) and 5 maternal deaths (1.9%). Patients with antepartum eclampsia were younger, more likely to be nulliparous and had less prenatal care compared to women with antepartum preeclampsia. Antepartum eclampsia was associated with placental abruption and maternal death. CONCLUSIONS The rates of preeclampsia and its associated complications, such as eclampsia, placental abruption, maternal death and stillbirth, are high at this facility in Haiti. Such data are essential to developing region-specific systems to prevent preeclampsia-related complications.
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Roy J, Mitra JK, Pal A. Magnesium sulphate versus phenytoin in eclampsia - Maternal and foetal outcome - A comparative study. Australas Med J 2013; 6:483-95. [PMID: 24133541 DOI: 10.4066/amj.2013.1753] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Eclampsia manifests as seizures and is unique to the pregnant state. It remains an important cause of maternal mortality especially in resource-challenged countries that lack access to prenatal care. AIMS The aim of our study was to compare maternal and foetal outcomes in mothers with eclampsia with the administration of either magnesium sulphate or phenytoin in a resource- challenged situation. METHOD The work was conducted from January 2012 to December 2012. A total of 80 patients were assigned alternately to two groups - one group was treated with magnesium sulphate (Group-M; n=40), and the other treated with phenytoin (Group-P; n=40) (Figure 1). The magnesium sulphate was administered according to Pritchard's regimen; phenytoin administered according to Ryan's regimen. With either regimen, anticonvulsant therapy was continued for 24 hours postpartum or 24 hours after the last convulsion, whichever was later. RESULTS Fifty-four per cent of patients regained consciousness within eight hours of treatment onset in Group-P compared to 5.3 per cent in Group-M (p=0.0001, χ(2)=19.24). Seven patients in Group-P had recurrence of convulsions as compared to none of the 40 women assigned to Group-M (p=0.032, χ(2)=4.62). The incidence of Caesarean section was greater (62.5 per cent) in Group-M compared to Group-P (25 per cent; p=0.001, χ(2)= 9.96). No statistically significant differences were found in the foetal outcomes between the two groups. CONCLUSION Phenytoin use may be reconsidered in selective cases in low and middle income countries (LMIC) as it has been found simpler to use, has several benefits and also curtails treatment cost. Magnesium sulphate is substantially more effective than phenytoin with regard to recurrence of convulsions. Proper training in the management of eclampsia should be given to all health care workers to ensure appropriate management of eclamptic mothers. Thus, the treatment of this disease calls for more research especially in resource-challenged settings.
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Affiliation(s)
- Jayeeta Roy
- Department of Obstetrics & Gynaecology, College of Medicine and JNM Hospital, WBUHS, Kalyani, West Bengal, India
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Guerrier G, Oluyide B, Keramarou M, Grais RF. Factors associated with severe preeclampsia and eclampsia in Jahun, Nigeria. Int J Womens Health 2013; 5:509-13. [PMID: 23983493 PMCID: PMC3751380 DOI: 10.2147/ijwh.s47056] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objective To explore traditional herbal medicines as potential risk factors of severe preeclampsia and eclampsia in Nigeria. Methods We conducted a retrospective case-control study from October 2010 to May 2011. The cases were all pregnant women admitted to the Jahun Hospital during the study period with severe preeclampsia or eclampsia and women presenting with normal pregnancy after 22 weeks. Results During the study period, a total of 1,257 women (44%) were recorded as having normal pregnancy, and 419 (16%) women had severe preeclampsia/eclampsia (175 with severe preeclampsia and 244 with eclampsia). The risk factors found to be associated with a greater risk of severe preeclampsia/eclampsia included personal history of preeclampsia (odds ratio [OR] = 21.5; P < 0.001), personal history of preexisting hypertension (OR = 10.5; P < 0.001), primiparity (OR = 2.5; P = 0.001), occupation as housewife (OR = 1.9; P = 0.008), and fewer than four antenatal care visits (OR = 1.6; P = 0.02). Use of traditional treatments during pregnancy was associated with a higher risk of developing severe preeclampsia/eclampsia (OR = 1.6 95%; confidence interval [CI]: 1.2–2.1) by univariate analysis only. Conclusion Use of traditional treatment, which increases delays before consulting the official health sector, might be a marker for harmful behavior. Community-based studies could provide additional information on the practice of herbal therapy in this population.
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Abstract
Hypertension affects 10% of pregnancies, many with underlying chronic hypertension, and approximately 1-2% will undergo a hypertensive crisis at some point during their lives. Hypertensive crisis includes hypertensive urgency and emergency; the American College of Obstetricians and Gynecologists describes a hypertensive emergency in pregnancy as persistent (lasting 15 min or more), acute-onset, severe hypertension, defined as systolic BP greater than 160 mmHg or diastolic BP >110 mmHg in the setting of pre-eclampsia or eclampsia. Pregnancy may be complicated by hypertensive crisis, with lower blood pressure threshold for end-organ damage than non-pregnant patients. Maternal assessment should include a thorough history. Fetal assessment should include heart rate tracing, ultrasound for growth and amniotic assessment, and Doppler evaluation if growth restriction is suspected. Initial management of hypertensive emergency (systolic BP >160 mmHg or diastolic BP >110 mmHg in the setting of pre-eclampsia or eclampsia) generally includes the rapid reduction of blood pressure through the use of intravenous antihypertensive medications, with goal systolic blood pressure between 140 mmHg and 150 mmHg and diastolic pressure between 90 mmHg and 100 mmHg. First-line intravenous drugs include labetalol and hydralazine, but other agents may be used, including esmolol, nicardipine, nifedipine, and, as a last resort, sodium nitroprusside. Among patients with hypertensive urgency, slower blood pressure reduction can be provided with oral agents. The objective of this article is to review the current understanding, diagnosis, and management of hypertensive crisis during pregnancy and the postpartum period.
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Affiliation(s)
- Gloria T Too
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Eastern Virginia Medical School, 825 Fairfax Ave, Suite 310, Norfolk, VA 23507, USA
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Abstract
Seizures during pregnancy complicate <1% of all gestations; however, they are associated with increased adverse maternal and perinatal outcomes (acute and long term). The differential diagnosis of seizures in pregnancy is extensive. Determining the underlying etiology is crucial in the management of these patients. Medical providers caring for pregnant women should be educated about possible etiologies of seizures during pregnancy and the importance of prompt management of these women in a timely fashion. Evaluation and management should be performed in a stepwise fashion and may require a multidisciplinary approach with other specialties such as neurology. The objective of this review is to increase awareness and to provide a stepwise approach toward the diagnosis and management of pregnancies complicated by seizures.
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Affiliation(s)
- Laura A Hart
- Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Texas Health Science Center at Houston, Houston, TX 77030, USA
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Brewer J, Owens MY, Wallace K, Reeves AA, Morris R, Khan M, LaMarca B, Martin JN. Posterior reversible encephalopathy syndrome in 46 of 47 patients with eclampsia. Am J Obstet Gynecol 2013; 208:468.e1-6. [PMID: 23395926 DOI: 10.1016/j.ajog.2013.02.015] [Citation(s) in RCA: 115] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2012] [Revised: 01/04/2013] [Accepted: 02/05/2013] [Indexed: 01/08/2023]
Abstract
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.
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Steiner N, Weintraub AY, Madi Y, Barski L, Sheiner E. The unfavorable slope from mild preeclampsia through severe preeclampsia, to eclampsia. Pregnancy Hypertens 2013; 3:146-50. [DOI: 10.1016/j.preghy.2013.01.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2012] [Revised: 12/25/2012] [Accepted: 01/04/2013] [Indexed: 11/26/2022]
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Cipolla MJ. The adaptation of the cerebral circulation to pregnancy: mechanisms and consequences. J Cereb Blood Flow Metab 2013; 33:465-78. [PMID: 23321787 PMCID: PMC3618397 DOI: 10.1038/jcbfm.2012.210] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2012] [Revised: 12/02/2012] [Accepted: 12/08/2012] [Indexed: 12/21/2022]
Abstract
The adaptation of the cerebral circulation to pregnancy is unique from other vascular beds. Most notably, the growth and vasodilatory response to high levels of circulating growth factors and cytokines that promote substantial hemodynamic changes in other vascular beds is limited in the cerebral circulation. This is accomplished through several mechanisms, including downregulation of key receptors and transcription factors, and production of circulating factors that counteract the vasodilatory effects of vascular endothelial growth factor (VEGF) and placental growth factor. Pregnancy both prevents and reverses hypertensive inward remodeling of cerebral arteries, possibly through downregulation of the angiotensin type 1 receptor. The blood-brain barrier (BBB) importantly adapts to pregnancy by preventing the passage of seizure provoking serum into the brain and limiting the permeability effects of VEGF that is more highly expressed in cerebral vasculature during pregnancy. While the adaptation of the cerebral circulation to pregnancy provides for relatively normal cerebral blood flow and BBB properties in the face of substantial cardiovascular changes and high levels of circulating factors, under pathologic conditions, these adaptations appear to promote greater brain injury, including edema formation during acute hypertension, and greater sensitivity to bacterial endotoxin.
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Affiliation(s)
- Marilyn J Cipolla
- Departments of Neurological Sciences, Obstetrics, Gynecology and Reproductive Sciences, Pharmacology, University of Vermont College of Medicine, Burlington, VT, USA.
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Bourret B, Compère V, Torre S, Azhougagh K, Provost D, Rachet B, Gillet R, Rieu M, Marpeau L, Dureuil B. [Magnesium sulfate in the prophylaxis of eclampsia: a retrospective study]. ACTA ACUST UNITED AC 2012; 31:933-6. [PMID: 23117038 DOI: 10.1016/j.annfar.2012.09.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2011] [Accepted: 09/05/2012] [Indexed: 11/17/2022]
Abstract
INTRODUCTION The use of magnesium sulfate (MgSO(4)) has been advocated since 2000 in France in the management of eclampsia. The aim of this study was to determine the frequency of use of this treatment for eclampsia in a French department. PATIENTS AND METHODS All patients obstetrical patients admitted to Critical Care Units of Seine-Maritime for eclampsia over a period of 7 years (2002-2008) were included. Obstetric data, the treatment used for eclampsia and pre-eclampsia and maternofetal complications were collected. The primary outcome parameter was the use of MgSO(4) in the secondary prevention of eclampsia. RESULTS Thirty-nine patients were included. Nineteen patients (48%) had eclampsia in prepartum, three (8%) in per-partum and 17 (44%) in post-partum periods. The use of MgSO(4) in the secondary prevention of eclampsia was observed in 92% of cases (36/39). Primary prevention was seen in 8% of cases. The duration of treatment was 2 days (1-7 days). The maternal and perinatal mortality was respectively 2.5 and 11%. CONCLUSION In this study, the use of MgSO(4) in the secondary prevention is frequent. This result emphasizes the importance of the recommendations of learned societies in the homogenization of the management of rare but serious conditions such as eclampsia.
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Affiliation(s)
- B Bourret
- Département d'anesthésie-réanimation chirurgicale et samu, centre hospitalier universitaire de Rouen, 1 rue de Germont, Rouen, France
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Abstract
Studies lack data regarding incidence, risk factors, optimal treatment and outcome of postpartum eclampsia (PPE), convulsions within 7 days (mostly convulsions occur within 24 - 48 h) after delivery of fetus placenta. However, convulsions can occur late, up to 4 weeks. After 48 h, it is late PPE. Late postpartum eclampsia without preceding pre-eclampsia is rare and poses a diagnostic challenge. An observational study was carried out to find the frequency of PPE, late PPE and clinical profile for prediction/prevention of mortality. PPE cases were analysed from retrospective records and prospective cases. Of 39,050 births, 386 were eclampsia (0.98%); PPE 101 (26.1% eclampsia, 0.26% births); 14.85% were late PPE. Of PPE, 52 (51.48%) were diagnosed hypertensive disorders pre-delivery and 49 (48.51%) were de novo. Prior to convulsions, 56 (55.5%) had headaches, six (5.9%) visual disturbances; nine (8.9) dizziness; four (4.0%) epigastric pain; 18 (17.8%) had no complaints. Research needs to continue and quality care is essential.
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Affiliation(s)
- S Chhabra
- Department of Obstetrics and Gynaecology, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Maharashtra, India. chhabra_s@rediff mail.com
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Cipolla MJ, Bishop N, Chan SL. Effect of pregnancy on autoregulation of cerebral blood flow in anterior versus posterior cerebrum. Hypertension 2012; 60:705-11. [PMID: 22824983 DOI: 10.1161/hypertensionaha.112.198952] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Severe preeclampsia and eclampsia are associated with brain edema that forms preferentially in the posterior cerebral cortex possibly because of decreased sympathetic innervation of posterior cerebral arteries and less effective autoregulation during acute hypertension. In the present study, we examined the effect of pregnancy on the effectiveness of cerebral blood flow autoregulation using laser Doppler flowmetry and edema formation by wet:dry weight in acute hypertension induced by phenylephrine infusion in the anterior and posterior cerebrum from nonpregnant (n=8) and late-pregnant (n=6) Sprague-Dawley rats. In addition, we compared the effect of pregnancy on sympathetic innervation by tyrosine hydroxylase staining of posterior and middle cerebral arteries (n=5-6 per group) and endothelial and neuronal NO synthase expression using quantitative PCR (n=3 per group). In nonpregnant animals, there was no difference in autoregulation between the anterior and posterior cerebrum. However, in late-pregnant animals, the threshold of cerebral blood flow autoregulation was shifted to lower pressures in the posterior cerebrum, which was associated with increased neuronal NO synthase expression in the posterior cerebral cortex versus anterior. Compared with the nonpregnant state, pregnancy increased the threshold of autoregulation in both brain regions that was related to decreased expression of endothelial NO synthase. Lastly, acute hypertension during pregnancy caused greater edema formation in both brain cortices that was not attributed to changes in sympathetic innervation. These findings suggest that, although pregnancy shifted the cerebral blood flow autoregulatory curve to higher pressures in both the anterior and posterior cortices, it did not protect from edema during acute hypertension.
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Affiliation(s)
- Marilyn J Cipolla
- Department of Neurology, University of Vermont, 149 Beaumont Ave, HSRF 416, Burlington, VT 05405, USA.
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Shin JE, Nam SY, Lee Y, Lee G, Shin JC, Kim YH, Kil KC. Comparison of outcomes after typical and atypical eclampsia: a retrospective study. J Matern Fetal Neonatal Med 2012; 25:2419-23. [PMID: 22671915 DOI: 10.3109/14767058.2012.699117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To evaluate the characteristics, clinical features and maternal-perinatal outcomes after atypical eclampsia. METHODS In a retrospective study, we compared demographics, clinical characteristics and outcomes between typical and atypical eclampsia. RESULTS Of 90 eclamptic patients, 56 had typical eclamptic features and 34 had atypical features. Compared to typical eclampsia, atypical eclampsia had higher gestational age (37.6 ± 3.3 vs. 34.6 ± 4.2 weeks, p = 0.001), a higher incidence of no antenatal risk factors [25 (73.5%) vs. 12 (21.4%), p < 0.001], less antepartum seizures [11 (32.4%) vs. 45 (80.4%), p < 0.001], a lower incidence of prodromal symptoms [20 (58.5%) vs. 49 (87.5%), p = 0.002], and a higher incidence of no lesion in brain imaging [16 (47.1%) vs. 12 (21.4%), p = 0.010). Although atypical eclampsia was associated with a lower odd ratio (OR) in composite perinatal complications (OR = 0.22, 95% CI = 0.08-0.60, p = 0.003), composite maternal complications did not differ between the two groups (OR = 0.52, 95% CI = 0.08-0.60, p =0.191). CONCLUSIONS Maternal outcomes did not differ between the two groups. Therefore, more attention should be focused on atypical eclampsia.
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Affiliation(s)
- Jae Eun Shin
- Department of Obstetrics and Gynecology, College of Medicine, Catholic University, Seoul, Korea
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Sibai BM. Etiology and management of postpartum hypertension-preeclampsia. Am J Obstet Gynecol 2012; 206:470-5. [PMID: 21963308 DOI: 10.1016/j.ajog.2011.09.002] [Citation(s) in RCA: 167] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2011] [Revised: 08/17/2011] [Accepted: 09/06/2011] [Indexed: 11/18/2022]
Abstract
Postpartum hypertension can be related to persistence of gestational hypertension, preeclampsia, or preexisting chronic hypertension, or it could develop de novo postpartum secondary to other causes. There are limited data describing the etiology, differential diagnosis, and management of postpartum hypertension-preeclampsia. The differential diagnosis is extensive, and varies from benign (mild gestational or essential hypertension) to life-threatening such as severe preeclampsia-eclampsia, pheochromocytoma, and cerebrovascular accidents. Therefore, medical providers caring for postpartum women should be educated about continued monitoring of signs and symptoms and prompt management of these women in a timely fashion. Evaluation and management should be performed in a stepwise fashion and may require a multidisciplinary approach that considers predelivery risk factors, time of onset, associated signs/symptoms, and results of selective laboratory and imaging findings. The objective of this review is to increase awareness and to provide a stepwise approach toward the diagnosis and management of women with persistent and/or new-onset hypertension-preeclampsia postpartum period.
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Affiliation(s)
- Baha M Sibai
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Cincinnati, Cincinnati, Ohio, USA
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Dixit A, Bhardwaj M, Sharma B. Headache in pregnancy: a nuisance or a new sense? Obstet Gynecol Int 2012; 2012:697697. [PMID: 22518165 PMCID: PMC3306951 DOI: 10.1155/2012/697697] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2011] [Accepted: 11/30/2011] [Indexed: 11/23/2022] Open
Abstract
Headache is a very commonly encountered symptom in pregnancy and is usually due to primary headache disorders which are benign in nature. It can however be quite debilitating for some women who may need therapeutic treatment of which there are several options safe to use in pregnancy. It is equally important though to recognise that headache may be a sign of serious underlying pathology. This paper aims to provide a clinically useful guidance for differentiation between primary and secondary headaches in pregnancy. The primary headache disorders and their management in pregnancy are explored in depth with brief overviews of the causes for secondary headaches and their further investigation and management.
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Affiliation(s)
- Archana Dixit
- West Middlesex University Hospital, Twickenham Road, Isleworth, Middlesex TW7 6AF, UK
| | - Manish Bhardwaj
- ST6 Anaesthesia, John Radcliffe Hospital, Oxford QX3 9DU, UK
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Cipolla MJ, Pusic AD, Grinberg YY, Chapman AC, Poynter ME, Kraig RP. Pregnant serum induces neuroinflammation and seizure activity via TNFα. Exp Neurol 2012; 234:398-404. [PMID: 22281105 DOI: 10.1016/j.expneurol.2012.01.005] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2011] [Revised: 12/14/2011] [Accepted: 01/05/2012] [Indexed: 12/23/2022]
Abstract
Preeclampsia is a hypertensive disorder of pregnancy that affects many organs including the brain. Neurological complications occur during preeclampsia, the most serious of which is seizure known as eclampsia. Although preeclampsia can precede the eclamptic seizure, it often occurs during normal pregnancy, suggesting that processes associated with normal pregnancy can promote neuronal excitability. Here we investigated whether circulating inflammatory mediators that are elevated late in gestation when seizure also occurs are hyperexcitable to neuronal tissue. Evoked field potentials were measured in hippocampal slices in which control horse serum that slices are normally grown in, was replaced with serum from nonpregnant or late-pregnant Wistar rats for 48 h. We found that serum from pregnant, but not nonpregnant rats, caused hyperexcitability to hippocampal neurons and seizure activity that was abrogated by inhibition of tumor necrosis factor alpha (TNFα) signaling. Additionally, application of TNFα mimicked this increased excitability. Pregnant serum also caused morphological changes in microglia characteristic of activation, and increased TNFα mRNA expression that was not seen with exposure to nonpregnant serum. However, TNFα protein was not found to be elevated in pregnant serum itself, suggesting that other circulating factors during pregnancy caused activation of hippocampal slice cells to produce a TNFα-mediated increase in neuronal excitability. Lastly, although pregnant serum caused neuroinflammation and hyperexcitability of hippocampal slices, it did not increase blood-brain barrier permeability, nor were pregnant rats from which the serum was taken undergoing seizure. Thus, the BBB has an important role in protecting the brain from circulating neuroinflammatory mediators that are hyperexcitable to the brain during pregnancy. These studies provide novel insight into the underlying cause of eclampsia without elevated blood pressure and the protective role of the BBB that prevents exposure of the brain to hyperexcitable factors.
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Affiliation(s)
- Marilyn J Cipolla
- Department of Neurology, University of Vermont, Burlington, VT 05405, USA.
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Abstract
Eclampsia is defined in the obstetrical literature as the occurrence of unexplained seizure during pregnancy in a woman with preeclampsia. In the Western world, the incidence of eclampsia is ~1 per 2000 to 1 per 3000 pregnancies, but the incidence is 10-fold higher in tertiary referral centers and undeveloped countries where there is poor prenatal care, and in multi-fetal gestations. Nearly 1 in 50 women with eclampsia die as do 1 in 14 of their offspring, and mortality rates are considerably higher in undeveloped countries. Eclampsia is also associated with significant life-threatening complications, including neurological events. Seizure acutely can cause stroke, haemorrhage, oedema and brain herniation and thus lead to epilepsy and cognitive impairment later in life.
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Turck M, Carles G, El Guindi W, Helou G, Alassas N, Dreyfus M. [Sixty-nine consecutive cases of eclampsia: prodromes and circumstances]. ACTA ACUST UNITED AC 2011; 40:340-7. [PMID: 21353400 DOI: 10.1016/j.jgyn.2011.01.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2010] [Revised: 01/10/2011] [Accepted: 01/13/2011] [Indexed: 12/01/2022]
Abstract
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.
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Affiliation(s)
- M Turck
- Service de gynécologie obstétrique, centre hospitalier de l'Ouest Guyanais, 16, boulevard du Général-Leclerc, BP 245, 94393 Saint-Laurent-du-Maroni, France.
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Vaisbuch E, Whitty JE, Hassan SS, Romero R, Kusanovic JP, Cotton DB, Sorokin Y, Karumanchi SA. Circulating angiogenic and antiangiogenic factors in women with eclampsia. Am J Obstet Gynecol 2011; 204:152.e1-9. [PMID: 21062661 PMCID: PMC3057127 DOI: 10.1016/j.ajog.2010.08.049] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2010] [Revised: 06/10/2010] [Accepted: 08/30/2010] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The objective of the study was to determine whether eclampsia has a different circulating profile of angiogenic (placental growth factor [PlGF]) and antiangiogenic factors (soluble vascular endothelial growth factor receptor-1 [sVEGFR-1] and soluble endoglin [sEng]) from severe preeclampsia. STUDY DESIGN This cross-sectional study included pregnant women in the following groups: (1) normal pregnancy (n = 40); (2) severe preeclampsia (n = 40); and (3) eclampsia (n = 20). Maternal serum PlGF, sVEGFR-1, and sEng concentrations were determined using an enzyme-linked immunosorbent assay. RESULTS The study results included the following: (1) the median concentration of sVEGFR-1 and sEng was higher and of PlGF was lower in severe preeclampsia or eclampsia than in normal pregnancy (P < .001 for all); and (2) the median concentrations of these 3 analytes did not differ significantly between patients with severe preeclampsia and those with eclampsia. CONCLUSION Eclampsia is associated with higher maternal circulating concentrations of sVEGFR-1 and sEng and lower concentrations of PlGF than normal pregnancy but with similar concentrations to severe preeclampsia. These findings suggest that eclampsia shares a common pathogenic pathway as severe preeclampsia.
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Affiliation(s)
- Edi Vaisbuch
- Perinatology Research Branch, Intramural Division, the Eunice Kennedy Shriver National Institute of Child Health and Human Development/National Institutes of Health/Department of Health and Human Services, Hutzel Women's Hospital, Bethesda, MD, USA
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Abstract
BACKGROUND Eclampsia, the occurrence of a seizure in association with pre-eclampsia, remains a rare but serious complication of pregnancy. A number of different anticonvulsants are used to control eclamptic fits and to prevent further fits. OBJECTIVES The objective of this review was to assess the effects of magnesium sulphate compared with diazepam when used for the care of women with eclampsia. Magnesium sulphate is compared with phenytoin and with lytic cocktail in other Cochrane reviews. SEARCH STRATEGY We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 September 2010) and CENTRAL (2010, Issue 3). SELECTION CRITERIA Randomised trials comparing magnesium sulphate (intravenous or intramuscular administration) with diazepam for women with a clinical diagnosis of eclampsia. DATA COLLECTION AND ANALYSIS Two authors assessed and extracted data independently. MAIN RESULTS We have included seven trials, involving 1396 women. Three trials (1030 women) were good quality. Magnesium sulphate was associated with a reduction in maternal death (seven trials;1396 women; risk ratio (RR) 0.59, 95% confidence interval (CI) 0.38 to 0.92) and recurrence of seizures (seven trials;1390 women; RR 0.43, 95% CI 0.33 to 0.55) compared to diazepam. There were no clear differences in other measures of maternal morbidity.There was no clear difference in perinatal mortality (four trials; 788 infants; RR 1.04, 95% CI 0.81 to 1.34) or neonatal mortality (four trials; 759 infants; RR 1.18, 95% CI 0.75 to 1.84). In the magnesium sulphate group, fewer liveborn babies had an Apgar score less than seven at one minute (two trials; 597 babies; RR 0.75, 95% CI 0.65 to 0.87) or at five minutes (RR 0.70, 95% CI 0.54 to 0.90), and fewer appeared to need intubation at the place of birth (two trials; 591 infants; RR 0.67, 95% CI 0.45 to 1.00). There was no difference in admission to a special care nursery (four trials; 834 infants; RR 0.91, 95% CI 0.79 to 1.05), but fewer babies in the magnesium sulphate group had a length of stay more than seven days (three trials 631 babies; RR 0.66, 95% CI 0.46 to 0.96). AUTHORS' CONCLUSIONS Magnesium sulphate for women with eclampsia reduces the risk ratio of maternal death and of recurrence of seizures, compared with diazepam.
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Affiliation(s)
- Lelia Duley
- University of LeedsCentre for Epidemiology and BiostatisticsBradford Institute for Health ResearchBradford Royal Infirmary, Duckworth LaneBradfordWest YorkshireUKBD9 6RJ
| | - David J Henderson‐Smart
- Queen Elizabeth II Research InstituteNSW Centre for Perinatal Health Services ResearchBuilding DO2University of SydneySydneyNSWAustralia2006
| | - Godfrey JA Walker
- The University of LiverpoolC/o Cochrane Pregnancy and Childbirth Group, School of Reproductive and Developmental Medicine, Division of Perinatal and Reproductive MedicineFirst Floor, Liverpool Women's NHS Foundation TrustCrown StreetLiverpoolUKL8 7SS
| | - Doris Chou
- World Health OrganizationUNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research20 Avenue AppiaGenevaSwitzerland1211
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Chia CC, Huang SC. Post-delivery complex partial seizure mimicking eclampsia. Taiwan J Obstet Gynecol 2010; 49:370-2. [PMID: 21056328 DOI: 10.1016/s1028-4559(10)60078-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/30/2009] [Indexed: 11/17/2022] Open
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Abstract
BACKGROUND Eclampsia, the occurrence of a seizure in association with pre-eclampsia, remains 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 phenytoin when used for the care of women with eclampsia. Magnesium sulphate is compared with diazepam and with lytic cocktail in other Cochrane reviews. SEARCH STRATEGY We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 April 2010). SELECTION CRITERIA Randomised trials comparing magnesium sulphate (intravenous or intramuscular administration) with phenytoin for women with a clinical diagnosis of eclampsia. DATA COLLECTION AND ANALYSIS Two review authors assessed trial quality and extracted data. MAIN RESULTS We have included data from seven trials, involving 972 women. One large trial (775 women) was of good quality. Magnesium sulphate was associated with a substantial reduction in the recurrence of seizures, when compared to phenytoin (six trials, 972 women; risk ratio (RR) 0.34, 95% confidence interval (CI) 0.24 to 0.49). The trend in maternal mortality favours magnesium sulphate, but the difference does not reach statistical significance (three trials, 847 women; RR 0.50, 95% CI 0.24 to 1.05). There were reductions in the risk of pneumonia (one trial, RR 0.44, 95% CI 0.24 to 0.79), ventilation (one trial, RR 0.68, 95% CI 0.50 to 0.91) and admission to an intensive care unit (one trial, RR 0.67, 95% CI 0.50 to 0.89) associated with the use of magnesium sulphate rather than phenytoin.For the baby, magnesium sulphate was associated with fewer admissions to a special care baby unit (SCBU) (one trial, 518 babies; RR 0.73, 95% CI 0.58 to 0.91) and fewer babies who died or were in SCBU for more than seven days (one trial, 643 babies; RR 0.77, 95% CI 0.63 to 0.95) than phenytoin. There was no clear difference in perinatal deaths (two trials, 665 babies; (RR 0.85, 95% CI 0.67 to 1.09). AUTHORS' CONCLUSIONS Magnesium sulphate, rather than phenytoin, for women with eclampsia reduces the risk ratio of recurrence of seizures, probably reduces the risk of maternal death, and improves outcome for the baby. Magnesium sulphate is the drug of choice for women with eclampsia. The use of phenytoin should be abandoned.
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Affiliation(s)
- Lelia Duley
- Centre for Epidemiology and Biostatistics, University of Leeds, Bradford Institute for Health Research, Bradford Royal Infirmary, Duckworth Lane, Bradford, West Yorkshire, UK, BD9 6RJ
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Abstract
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.
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Affiliation(s)
- Lelia Duley
- University of NottinghamNottingham Clinical Trials UnitB39, Medical SchoolQueen's Medical Centre CampusNottinghamUKNG7 2UH
| | - A Metin Gülmezoglu
- World Health OrganizationUNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research20 Avenue AppiaGenevaSwitzerland1211
| | - Doris Chou
- World Health OrganizationUNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research20 Avenue AppiaGenevaSwitzerland1211
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