Electroencephalogram and computerised cerebral tomography findings in eclampsia

Anesthetic management for emergency cesarean section in a patient with status epilepticus: A case report

RATIONALE

The presence of clinically significant repeated maternal epilepsies during pregnancy increases the risk of adverse maternal, fetal and neonatal outcomes. However, there are few guidelines for anesthesiologists to deal with this situation.

PATIENT CONCERNS AND DIAGNOSES

A 28-year-old primigravida was transferred to the operating room for emergency cesarean section. Based on the patient's complaints and clinical appearance, provisional diagnosis of preeclampsia at 33 weeks' gestation as well as frequent and repeated grand mal convulsions at 14 years of age were considered. The anesthetic modalities of the disease are also discussed.

INTERVENTIONS AND OUTCOMES

Because the usual antiepileptic therapy had failed, the patient with status epilepticus underwent surgery under general anesthesia. The newborn was handed to the pediatrician and the patient was transferred to the intensive care unit for further observation and discharged 4 days later. No peri-operative or anesthetic complications were observed.

LESSONS

Providing anesthesia to patients undergoing cesarean section poses major challenges for anesthesiologists. Close monitoring and proper treatment can help reduce risks for both the mother and baby.

Specialized Diagnostic Investigations to Assess Ocular Status in Hypertensive Diseases of Pregnancy

This review describes specialized diagnostic investigations to assess ocular status in hypertensive diseases of pregnancy. Ocular assessment can aid in early detection for prompt multidisciplinary treatment, obstetric intervention and follow-up. The investigations accurately predict the possible causes of blindness in hypertensive diseases of pregnancy. The investigations include fluorescein angiography, ophthalmodynamometry, fluorophotometry, imaging modalities, OCT, ultrasonography, doppler velocimetry and blood chemistry analysis. The review includes a summary of imaging techniques and related recent developments to assess the neuro-ophthalmic aspects of the disease. The imaging modalities have been instrumental in understanding the complex neuropathophysiological mechanisms of eclamptic seizures. The importance of blood chemistry analysis in hypertensive diseases of pregnancy has been emphasized. The investigations have made a significant contribution in improving the standards of antenatal care and reducing maternal and fetal morbidity and mortality.

Anesthetic management of a patient presenting with eclampsia

Eclampsia is one of the most common emergencies encountered by anesthesiologists which involve a safe journey of two lives. The definition, etiology, pathophysiology, treatment guidelines along with a special reference to management of labour pain and caesarean section are discussed. Eclampsia is commonly faced challenging case in our day to day anaesthesia practice,but less is discussed in our anaesthesia text books. Lot of controversies with regard to fluid management and monitoring still remain unanswered

The impact of umbilical and uterine artery Doppler indices on antenatal course, labor and delivery in a low-risk primigravid population

AIMS

To evaluate the impact of umbilical and uterine artery Doppler in the second and third trimester on antenatal course, labor and delivery in a low-risk primigravid population.

METHODS

Prospective recruitment of 1011 low-risk primigravidas with uterine and umbilical artery Doppler assessment at 22-24 weeks and 36 weeks. All mothers and infants were reviewed postnatally with a retrospective analysis of ultrasound and clinical outcome data.

RESULTS

Elevated uterine artery indices were associated with increased rates of threatened miscarriage, higher rates of pre-eclampsia (PET) and a higher incidence of fetal birth weight <2nd and 9th centile for gestation. Uterine artery pulsatility index (PI) >95th centile for gestation was associated with statistically higher rates of small-for-gestational age (SGA) infants. Elevated umbilical artery indices were associated with higher rates of induction of labor and a higher incidence of fetal birth weight infants <2nd and 9th centile for gestation. Umbilical artery PI >95th centile for gestation was associated with statistically higher rates of SGA infants.

CONCLUSION

Elevated uterine and umbilical artery indices are associated with higher rates of maternal and fetal disease.

Cerebral magnetic resonance imaging in eclampsia: a series of 12 cases

The object of this study was to assess the ability of magnetic resonance imaging (MRI) to detect the cerebral abnormalities associated with eclampsia and therefore to establish its place in our management of the condition. This study was of particular relevance to our institution because eclampsia is common in our patient population. This was a prospective study in which 13 patients with an initial diagnosis of eclampsia received MRI brain scans. Of 12 patients with a final diagnosis of eclampsia, seven (58.3%) showed the typical MRI changes of eclampsia, namely cerebral hyperintensities representing focal areas of oedema. In five patients (41.6%) the scans were normal. The rate of abnormality detection was surprisingly low. We conclude that the reason for this was the time delay in obtaining the scans. The cerebral changes in eclampsia can be rapidly reversible. Future studies must aim to perform MRI within 48 hours of seizure activity. MRI is more sensitive than computed tomography scanning but has no practical advantages over computed tomography except where the diagnosis is in doubt.

Neurologic complications of pre-eclampsia

Pre-eclampsia is mainly responsible for the world's large maternal mortality rates, mostly due to acute cerebral complications. This review provides insight into the pathogenesis of the neurologic complications of hypertensive disease in pregnancy. In addition, practical relevance for clinical care is highlighted. Pertaining to pregnancy, the blood pressure level at which cerebral autoregulation operates and possible deregulation occurs is unknown, but is likely to be variable. From clinical observation, eclampsia may occur despite a mild clinical picture and before the development of hypertension or proteinuria. Furthermore, failure of cerebrovascular autoregulatory mechanisms in response to either an acute and/or relatively large blood pressure increase may be more important than the absolute blood pressure value. It may be the acuity of the blood pressure rise in the setting of endothelial dysfunction that interrupts the delicate balance between capillary and cellular perfusion pressures that leads to the neurological complications of pre-eclampsia.

A review of the management of eclampsia: practical issues

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

Intrapartum Emergencies

Intrapartum emergencies are challenging to all perinatal nurses because of the increased risk of adverse outcomes for the mother and fetus. Perinatal emergencies, such as seizures, amniotic fluid embolus, hemorrhage, and uterine rupture, create physiological challenges and trigger intrinsic survival techniques. The pregnant uterus becomes a vital source of blood volume during hypovolemic events because it is not considered a vital organ. The pregnancy itself may become burdensome, and birth may occur as an intrinsic maternal compensatory mechanism. The resultant fetal hypoxemia may also stress the fetus into initiating labor. During extensive oxygen desaturation and decompensation, the focus should be on maternal stabilization, which will subsequently enhance fetal stabilization. Clinical assessments, critical thinking, decision making, and resource allocation must be quick and appropriate to increase the likelihood of a positive outcome for the mother, fetus, and neonate.

Hemiparesis following post-partum haemorrhage and eclampsia

A primigravida at 41+ weeks gestation presented with spontaneous rupture of membranes. Labour was induced and later an emergency caesarean section was performed for failure to progress. The patient suffered a per-operative uterine tear and post-partum haemorrhage and required postoperative ventilatory support in the intensive care unit. Following tracheal extubation, she developed a left hemiparesis and grand-mal seizures. The differential diagnosis, diagnostic difficulties, investigations and clinical management of this case are all discussed. An examination of existing literature highlights some of the focal neurological abnormalities that present with eclampsia and the possible need for more sophisticated neuroradiological investigations in these cases. Finally, it is emphasized that anaesthetists and intensivists need to be aware of atypical and delayed presentations of eclampsia.

Single photon emission and cerebral computerised tomographic scan and transcranial Doppler sonographic findings in eclampsia

OBJECTIVE

To define more clearly the neuropathophysiology of eclampsia utilising single-photon emission computed tomography (SPECT), cerebral computerised tomography (CT) and transcranial Doppler (TCD) ultrasonography.

DESIGN

A prospective study

SETTING

The obstetric unit in King Edward VIII Hospital, a large tertiary referral centre in Kwa-Zulu Natal, South Africa.

PARTICIPANTS

Sixty-five women with eclampsia.

INTERVENTIONS

Imaging and ultrasonographic investigations were performed within 48 hours postpartum. Unenhanced cerebral CT scans were performed in all the women and SPECT scans were performed on 63 women using Technetium-99m-hexamethylpropyleneamineoxime (99mTc-HMPAO) as a tracer of regional cerebral blood flow. Middle cerebral artery blood flow velocity waveforms were measured using 2 MHz pulsed Doppler ultrasound via the transtemporal approach.

MAIN OUTCOME MEASURES

Abnormalities in SPECT scan, CT scan and TCD ultrasound findings.

RESULTS

SPECT scanning revealed perfusion deficits in the watershed areas in all women, 75% of whom had concomitant deficits in the parieto-occipital areas of the brain. Hypodensities (cerebral oedema) were reported in 38 CT scans (58.5%), with parieto-occipital involvement in 97.4% of cases. Increased flow velocity measurements in the middle and posterior cerebral arteries were recorded in 36 (85.7%) women in whom TCD ultrasound was performed.

CONCLUSION

The pathophysiological mechanism of eclamptic seizures is primary cerebral vasospasm with resultant ischaemia and cerebral oedema involving mainly the watershed areas and parieto-occipital lobes of the brain. SPECT scanning has been shown to be superior to CT scanning and TCD ultrasonography in detecting neuropathophysiologic alterations in eclampsia. However, each of the three investigative tools provide its own unique information and all three are necessary research techniques to improve our understanding of the neuropathophysiological mechanism of eclamptic seizures.