The changing pattern of eclampsia over a 60-year period

Readmission for postpartum eclampsia in the United States

OBJECTIVE

To characterize the contemporary prevalence of eclampsia in the United States and determine whether eclampsia is taking place during the delivery hospitalization or a postpartum readmission.

STUDY DESIGN

We conducted a retrospective cohort using the 2016 Nationwide Readmission Database, a discharge database of all hospitalizations in 27 states in the U.S. Through the database, we identified women with an admission for delivery of a neonate > 20 weeks gestation. We also identified readmissions that occurred within 6 weeks after discharge from that delivery admission. ICD-10-CM codes were used to identify deliveries, eclampsia and co-morbidities. The primary outcome was timing of eclampsia relative to discharge from the delivery admission.

RESULTS

We identified 1,590,563 deliveries of which 2955 (0.19%) were complicated by eclampsia during the delivery admission or a postpartum readmission. Of these cases of eclampsia, 1575 (53.5%) occurred during the delivery admission, 1354 (45.8%) during a postpartum readmission and 26 (0.88%) during both the delivery and a postpartum readmission. Of the 1380 readmissions with eclampsia, 1117 (81%) occurred within the first week after delivery discharge. Another 194 (14%) occurred in the second week after discharge. Women with readmissions for eclampsia were older (30.1 vs. 28.8 years; p < .01), delivered earlier (37.7 vs. 38.5 weeks; p < .01), and more likely to have a cesarean delivery (48.4 vs. 32.4%; p < .01) or multiple gestation (4.0 vs. 1.8%; p < .01) as compared to those not readmitted for eclampsia and 44% had any hypertensive disorder during the delivery admission (vs. 12.2% without an eclampsia readmission; p < .01).

CONCLUSION

Of the 2955 cases of eclampsia identified, almost half of them occurred after discharge from the delivery admission, 95% of which occurred within the first 2 weeks after discharge, demonstrating the prominence of postpartum eclampsia which may warrant new strategies for prevention and education targeted at postpartum patients after delivery hospitalization.

Comparison of process outcomes, clinical symptoms and laboratory values between patients with antepartum preeclampsia, antepartum with persistent postpartum preeclampsia, and new onset postpartum preeclampsia

OBJECTIVE

There is limited literature on postpartum preeclampsia for process outcomes, clinical symptoms, and laboratory values.

METHOD

Retrospective study comparing 3 groups of antepartum preeclampsia without postpartum preeclampsia (APNP; n = 43), antepartum preeclampsia with persistent postpartum preeclampsia (APYP; n = 59), and new onset postpartum preeclampsia (NEWYP; n = 18).

RESULTS

For process outcomes, NEWYP had higher odds for readmission as compared to APYP [OR: 5.41, 95 % CI: 1.34, 21.56, p = 0.02]. For clinical symptoms of postpartum highest systolic blood pressure NEWYP had greater values as compared to both APYP [B = 19.95, SE = 3.84, p < 0.001] and APNP [B = 23.63, SE = 2.87, p < 0.001]. For laboratory values of serum creatinine, NEWYP had greater values as compared to both APYP [B = 0.15, SE = 0.05, p = 0.01] and APNP [B = 0.17, SE = 0.05, p = 0.002].

CONCLUSION

NEWYP may represent a different disorder from APNP and APYP. We recommend close monitoring of NEWYP by clinicians.

It Takes a System: Magnesium Sulfate for Prevention of Eclampsia in a Resource-Limited Community Setting

Magnesium sulfate is not a silver bullet to reduce maternal mortality associated with preeclampsia/eclampsia. We believe a well-functioning health care system, especially at the hospital level, with competent well-trained providers, adequate equipment, and medications will likely be necessary.

Differences in clinical presentation and pregnancy outcomes in antepartum preeclampsia and new-onset postpartum preeclampsia: Are these the same disorder?

OBJECTIVE

New-onset postpartum preeclampsia is a poorly defined condition that accounts for a significant percentage of eclampsia cases. It is unclear whether new-onset postpartum preeclampsia is a different disorder from or belongs to the same spectrum of classic antepartum preeclampsia. The objective of this study was to compare the clinical presentation and pregnancy outcomes of antepartum preeclampsia and new-onset postpartum preeclampsia.

METHODS

A retrospective study including 92 patients with antepartum preeclampsia and 92 patients with new-onset postpartum preeclampsia was performed. Clinical presentation and pregnancy outcomes were compared. Chi-square test was used to analyze categorical variables, and independent t-test and Mann-Whitney U-test for numerical variables. P-values of <0.05 were used to indicate statistical signifi cance.

RESULTS

Patients with antepartum preeclampsia and new-onset postpartum preeclampsia differ significantly in profile, symptoms at presentation, laboratory markers and pregnancy outcomes.

CONCLUSION

New-onset postpartum preeclampsia has a distinct patient profile and clinical presentation than antepartum preeclampsia, suggesting they may represent different disorders. Characterization of a patient profile with increased risk of developing this condition will help clinicians to identify patients at risk and provide early and targeted interventions to decrease the morbidity associated with this condition.

Diagnosis of Acute Neurologic Emergencies in Pregnant and Postpartum Women

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.

Maternal and perinatal outcome of eclampsia over a decade at a tertiary hospital in Kuwait

AIMS

To determine maternal and perinatal outcome of eclampsia patients over a decade.

METHODS

Analysis of case records of all eclampsia cases from January 2005 to December 2014.

RESULTS

There were 30 cases of eclampsia. The most significant risk factors for developing pre-eclampsia are unbooked cases (97%), nulliparity, young age, marriage ≤4 months, history of pre-eclampsia in previous pregnancy, remarriage, preexisting diabetes mellitus, interval between pregnancies ≥10 years, positive family history. The incidence of eclampsia was 0.05%, antepartum eclampsia 15 (50%), intrapartum 6 (20%) and postpartum 9 (30%) with no maternal deaths, and 1 perinatal death. Perinatal mortality was 33.3/1000. 22 (73%) patients received magnesium sulphate (MgSO4) and 8 patients (27%) received Diazepam, of which 1 had recurrence of convulsions. All 15 antepartum cases were delivered by cesarean section as were 2 intrapartum. 13 (43%) of women delivered vaginally. Only 6 (20%) patients were of low socio-economic status and were primary school educated. Severe maternal complications occurred in 8 (27%), with abruptio placentae being the most common 3 (38%).

CONCLUSIONS

Incidence of eclampsia was low, with no maternal deaths. MgSO4 was found to be highly effective. Lack of antenatal care is a major risk factor.

Formerly eclamptic women have lower nonpregnant blood pressure compared with formerly pre-eclamptic women: a retrospective cohort study

OBJECTIVE

To compare nonpregnant blood pressure and circulating metabolic factors between formerly pre-eclamptic women who did and did not deteriorate to eclampsia.

DESIGN

Retrospective observational cohort study.

SETTING

Tertiary referral centre.

POPULATION

Formerly pre-eclamptic women with (n = 88) and without (n = 698) superimposed eclampsia.

METHODS

Women who experienced pre-eclampsia with or without superimposed eclampsia during their pregnancy or puerperium were tested for possible underlying cardiovascular risk factors at least 6 months postpartum. We measured blood pressure and determined cardiovascular and metabolic risk markers in a fasting blood sample. Groups were compared using Mann-Whitney U test, Spearman's Rho test or Fisher's Exact test (odds ratios).

MAIN OUTCOME MEASURES

Differences in postpartum blood pressures and features of the metabolic syndrome between formerly pre-eclamptic and formerly eclamptic women.

RESULTS

Formerly pre-eclamptic women who developed eclampsia differed from their counterparts without eclampsia by a lower blood pressure (P < 0.01) with blood pressure correlating inversely with the likelihood of having experienced eclampsia (P < 0.001). In addition, formerly eclamptic women had higher circulating C-reactive protein levels than formerly pre-eclamptic women (P < 0.05). All other circulating metabolic factors were comparable. Finally, 40% of all eclamptic cases occurred in the puerperium.

CONCLUSIONS

Formerly pre-eclamptic women with superimposed eclampsia have lower nonpregnant blood pressure compared with their counterparts without neurological sequelae with blood pressure negatively correlated to the occurrence of eclampsia. As about 40% of all eclamptic cases occur postpartum, routine blood pressure monitoring postpartum should be intensified.

Seizures in pregnancy: epilepsy, eclampsia, and stroke

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.

Does preeclampsia predict the risk of late postpartum eclampsia?

Objective To investigate potential predictive symptoms of late postpartum eclampsia (LPE). Study Design Retrospective review of patients delivered at a single academic medical center and diagnosed with eclampsia greater than 48 hours postdelivery. Results Among 19 patients with eclampsia, 5 (26%) patients with confirmed eclampsia seized greater than 48 hours after delivery. None of these patients showed evidence of preeclampsia intrapartum or immediately postpartum and none received intrapartum magnesium sulfate. Prior to seizure activity, 4 of 5 (80%) patients had increased blood pressure and 2 of 5 (40%) had central nervous system symptoms (headache and visual changes). Conclusion Gestational hypertension (GHTN) may be a risk factor for LPE. Consideration of seizure prophylaxis for patients with GHTN may facilitate the prevention of LPE.

Role of neuroimaging in patients with atypical eclampsia

NEED

Despite availability of intensive care units and improved antenatal care, some women still die from Eclampsia. Eclampsia is associated with increased risk of maternal death varying from 1.8 % in developed countries to 14 % in developing countries. Cerebral complications are the major cause of death in eclampsia patients. Eclampsia along with hypercoagulopathy of pregnancy is a high risk fact for patient in respect of development of cerebrovascular thrombosis/ischemic strokes. Eclampsia patients who are refractory to the routine treatment have been found to have various CNS pathological conditions amenable to the medical treatment.

AIMS AND OBJECTIVES

(1) To study the neuropathophysiology behind an eclamptic seizure to reduce the morbidity associated with it. (2) To study the role of neuroimaging in patients with atypical eclampsia.

METHODOLOGY

Prospective study design included 30 patients for the study. All patients were admitted in the eclampsia room with h/o convulsions. All patients were put on MgSO4 therapy and antihypertensives. The patients who are refractory to the treatment such as having recurrent convulsions despite therapy MgSO4 were selected for neuroimaging with CT scan. Neuroimaging is done using Phillips Tomoscan CT scanner where slices of 10-mm thickness were taken through the entire brain in the transaxial plane. Abdomen shielding is done with lead shield to prevent radiation hazard.

RESULT

[Table: see text].

CONCLUSION

Eclampsia patients who were refractory to the treatment with MgSO4 and antihypertensives have been found to have very significant and morbid CNS pathological conditions. Neuroimaging in these patients have done a pivotal role in identifying the abnormality and rectifying it with medical means which had definitely improved patient's condition and have reduced morbidity.

Comparison of outcomes after typical and atypical eclampsia: a retrospective study

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.

Improving patient understanding of preeclampsia: a randomized controlled trial

OBJECTIVE

We developed a standardized educational tool to inform women about preeclampsia. The objective of this study was to assess whether exposure to this tool led to superior understanding of the syndrome.

STUDY DESIGN

This was a randomized controlled trial in which 120 women were assigned to (1) a newly developed preeclampsia educational tool, (2) a standard pamphlet addressing preeclampsia that had been created by the American College of Obstetricians and Gynecologists, or (3) no additional information. Preeclampsia knowledge was assessed with the use of a previously validated questionnaire.

RESULTS

There were no demographic differences among the groups. Patients who received the tool scored significantly better on the preeclampsia questionnaire than those who received the American College of Obstetricians and Gynecologists pamphlet or no additional information (71%, 63%, 49%, respectively; P < .05). This improved understanding was evident equally among women with and without adequate health literacy (interaction: P > .05).

CONCLUSION

Patients who were exposed to a graphics-based educational tool demonstrated superior preeclampsia-related knowledge, compared with those patients who were exposed to standard materials or no education.

Pre-eclampsia-eclampsia admitted to critical care unit

OBJECTIVE

To evaluate women with hypertensive disorder admitted to critical care unit.

METHODS

This study was carried out in Cartagena, Colombia, between January 2006 and December 2009. Patients were divided into 4 groups; severe pre-eclampsia, eclampsia, HELLP syndrome and HELLP with eclampsia (HEEH).

RESULT

A total of 217 cases were admitted. The admitting diagnoses were severe pre-eclampsia without HELLP syndrome (39.2%), HELLP syndrome without eclampsia (33.6%), eclampsia without HELLP syndrome (20.3%) and Eclampsia with HELLP syndrome or HEEH (6.9%). Groups were similar with respect to parity (p = 0.25), gestational age (p = 0.11), cesarean section (p = 0.58), mechanical ventilation (p = 0.54), level of systolic (p = 0.48) and diastolic blood pressure (p = 0.15) and inotropic support (p = 0.32). Average total duration of hospitalization was significantly different among groups, more time in women with HEEH (p = 0.001). Multiple organ dysfunctions was diagnosed > 70% of all women admitted to intensive care, but was significantly more frequent in patients with HELLP syndrome and HEEH (p = 0.001). There were 5 maternal deaths (2.3%). Causes of maternal death were intracranial hemorrhage (3), intra-abdominal bleeding (1) and pulmonary complications (1).

CONCLUSION

Women with HELLP syndrome with or without eclampsia are associated with major morbidity and mortality. Therefore, the maternal outcome in eclampsia is influenced for HELLP syndrome.

Antepartum eclampsia <34 weeks case series: advisable to postpone delivery to administer corticosteroids for fetal pulmonary benefit?

OBJECTIVE

To determine if postponement of delivery to administer fetal lung maturation corticosteroids (PDACs) in mothers with antepartum eclampsia <34 weeks gestation benefits the fetus without compromising the mother.

STUDY DESIGN

A case series of 37 maternal-perinatal pairs over a 9-year period with antepartum eclampsia between 24 and 34 weeks gestation from a single tertiary center were reviewed retrospectively. Duration of PDAC, clinical course and maternal-fetal outcomes, including impact of duration of PDAC on neonatal pulmonary function, were recorded for each case. Group assignment was based on length of corticosteroid treatment course before delivery: Group A, 0 to ≤ 24 h, n=28; B, 24 to <48 h, n=5; C, ≥ 48 h, n=4. Data were collected and analyzed by one-way analysis of variance (ANOVA), ANOVA on ranks, χ(2)-test and Fisher's exact tests where appropriate; statistical significance was determined by a P-value <0.05.

RESULT

Overall, 37 of 68 eclampsia patients in 1999 to 2007 met inclusion criteria. No adverse maternal or fetal event occurred while delivery was postponed. Immediate neonatal intubation or continuous positive airway pressure was required for 23/28 in A, 4/5 in B and 2/4 in C; room air was sufficient at birth for 5/28 in A, 1/5 in B and 2/4 in C. No newborn >33 weeks gestation required INI. Prolonged (that is, >1 day) mechanical ventilation was not required for any infant with a gestational age ≥ 32 weeks or PDAC ≥ 48 h. Two of three neonatal deaths in group A were attributed to pulmonary insufficiency.

CONCLUSION

PDAC for antepartum preterm eclampsia, especially ≤ 32 weeks gestation, appears to offer notable fetal pulmonary benefit without significantly increasing maternal or fetal risk.

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

OBJECTIVE

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

PATIENTS AND METHODS

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

RESULTS

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

DISCUSSION AND CONCLUSION

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

Population-Based Analysis of Hypertensive Disorders in Pregnancy

OBJECTIVE

To determine the population-based incidence of hypertensive diseases in pregnancy in Western New York.

METHODS

A database of 77,358 women with singleton pregnancies was analyzed using birth certificate data. The incidence of pregnancies complicated by gestational hypertension, preeclampsia, and eclampsia was determined.

RESULTS

The overall incidence of pregnancy-associated hypertensive disease varied slightly from 1999 to 2003. The incidence of preeclampsia decreased from 1.8% to 1.1% (p < 0.01). This decrease persisted over time, despite controlling for known risk factors, such as body mass index, age, ethnicity, parity, smoking, diabetes, and chronic hypertension.

CONCLUSION

The incidence of pregnancy-related hypertensive disorders slightly decreased in our population in the last 5 years, with a decline in the rate of preeclampsia accounting for this change. Further analysis may provide additional insights into the population-based incidence of preeclampsia.

One year survey of maternal mortality associated with eclampsia in Dhaka Medical College Hospital

Data was collected prospectively from 763 eclamptic patients hospitalised at Dhaka Medical College Hospital. Comparisons were made between the patients that died and survivors based on determinants already known to be important. The cause of death was taken from the clinical history. The 'Case fatality rate' was 14.7%. The principle mortality risk factors were age, parity, number of convulsions and time between onset of convulsions and admission to hospital. Less than 10% in both groups had received antenatal care. The hospital mortality rate was significantly higher than that found in the Collaborative Eclampsia Study. Urgent interventions are required to increase public awareness of the need for antenatal care, to raise the level of understanding and improve attitudes and practice in relation to eclampsia.

Overlapping features of eclampsia and postpartum angiopathy

INTRODUCTION

Postpartum cerebral angiopathy (PPA) is considered one of a diverse group of rare conditions termed "reversible cerebral vasoconstriction syndromes". Existing literature suggest considerable overlap in the manifestations of eclampsia and PPA.

METHODS

Retrospective case series review of PPA and eclampsia from a single neurosciences intensive care unit patient log identified over a consecutive 18-month period. A MEDLINE search (using OVID) of the English literature from 1950 through October 2008 was also performed.

RESULTS

Four patients who meet the obstetrical criteria for eclampsia and four patients whose clinical and radiographic features were consistent with PPA were identified. Twenty-eight patients with PPA were identified from the literature and showed significant clinical and radiographic overlap without cohort.

CONCLUSION

Given the overlapping clinical, laboratory, and radiographical features of eclampsia and PPA, it is probable they share a similar underlying pathophysiological mechanism and represent different clinical expressions of the same pregnancy-related disorder. The obstetrical definition of eclampsia may be to strict when applied in the neurosciences intensive care unit.

[Eclampsia: retrospective study about 16 cases]

OBJECTIVE

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

PATIENTS AND METHODS

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

RESULTS

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

DISCUSSION AND CONCLUSION

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

Postpartum preeclampsia: emergency department presentation and management

STUDY OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Maternal mortality due to eclamptic and non-eclamptic hypertensive disorders: a challenge

Eclamptic and non-eclamptic hypertensive disorders are responsible for high maternal and perinatal mortality, especially in developing countries. The present study was done in order to understand the trends of maternal deaths due to non-eclamptic and eclamptic hypertensive disorders by analysis of case records of women who died due to these disorders over a period of 20 years. Overall, hypertensive disorders contributed to 31% of maternal deaths, 24.7% due to eclampsia with a decreasing trend from 43% in block A to 8.8% in block E. Case fatality rate (CFR) among eclampsia decreased from 23.3% in block A to 5.7% in block E; 32.7% among ante-partum and 9.9% postpartum and 23.9% in term and 8.9% in pre-term cases. Although the contribution of hypertensive disorders to maternal mortality has reduced significantly (from 43% in block A to 29% in block E), deaths due to non-eclamptic hypertensive disorders have increased from 3% in block C to 23% in block E. Over the years, the contribution of patients<20 years of age has decreased from 8% to 2%, 32% of women who died due to eclampsia were below the age of 20 years. The most common cause of mortality in cases of pre-eclampsia was haemolysis, elevated liver enzymes, and low platelet count (HELLP) or partial HELLP syndrome (83.33%) and in eclampsia, pulmonary oedema. Even with resource constraints, mortality due to eclampsia can be reduced with appropriate and timely therapy. Evidence-based critical care is essential as even seemingly milder forms of pregnancy induced hypertension can lead to mortality.

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

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

A fatal case of postpartum cerebral angiopathy with literature review

INTRODUCTION

Postpartum cerebral angiopathy (PCA) is a rare and pathophysiologically ill-characterized cerebral vasoconstriction syndrome, occurring within 30 days of a usually uncomplicated pregnancy and delivery. Its onset has been associated with the use of vasoactive medications, particularly ergot alkaloids. Other cases have occurred in the absence of these medications, prompting conjecture into possible overlap between PCA and other conditions known to cause cerebral vasoconstriction, including primary angiitis of the central nervous system and postpartum eclampsia. The vast majority of cases follow a relatively benign course; however, a fatal case has been reported. Histopathologic findings in PCA, so far limited to the fatal case and two more recent biopsies, have been nonspecific.

OBJECTIVE

Here we present a second fatal case of PCA, including pre- and post-mortem histopathologic analysis. We also include a review of all PCA cases reported in the English literature.

METHODS

Criteria for the clinical diagnosis of PCA are proposed and used to select case reports from the medical literature. Data pertaining to patient characteristics, clinical symptomatology, cerebral imaging findings, and clinical outcomes are compared between cases associated with the postpartum use of vasoactive medications and spontaneous cases.

CONCLUSIONS

We conclude that histopathologic findings in PCA are nonspecific and secondary to ischemic brain injury. Functional vasoconstriction is the most likely primary pathophysiologic process in PCA. The etiology in cases associated with medications may be due to idiosyncratic reactions to these agents. Significant overlap in symptomatology and clinical features exists between spontaneous cases and late postpartum eclampsia.

Late Postpartum Eclampsia: Examples and Review

Eclampsia, defined as the occurrence of seizures in pregnant women, usually in the setting of preeclampsia and in the absence of other neurologic disorders, occurs mainly before, during , or within 48 hours after delivery. When convulsions occur later postpartum, diagnosis is difficult and treatment disputed. We review the entity of late postpartum eclampsia and report 2 examples in which the serum levels of antiangiogenic and angiogenic proteins were measured.

Cerebrovascular accident with quadriplegia following postpartum eclampsia

A 26-year-old woman (para 1 + 0) was managed at the National Hospital, Abuja, Nigeria for postpartum eclampsia with quadriplegia following referral from a peripheral hospital with a history of a solitary tonic/clonic seizure and unconsciousness. Her antenatal period had been uneventful until she presented with labour pains, where examination revealed an elevated blood pressure. She fitted once after delivery and remained unconscious for more than 12 h, hence the referral. The patient was managed in the intensive care unit (ICU), where she was found to be quadriplegic. She received mechanical ventilation for 21 days as part of her management in the ICU. Despite multidisciplinary care, she remained quadriplegic until a doctors' strike precluded further in-patient management. This rare complication of eclampsia is discussed, together with the patient's management.

Postpartum Eclampsia Complicated by Reversible Cerebral Herniation

BACKGROUND

Preeclampsia and eclampsia have been associated with significant morbidity and mortality. Posterior reversible encephalopathy syndrome is a neuroradiologic entity that has been previously reported to occur in patients with preeclampsia and eclampsia. We present, to our knowledge, the first reported case of late postpartum eclampsia complicated by posterior reversible encephalopathy syndrome and reversible cerebral herniation.

CASE

A 39-year-old woman (para 1) presented with late postpartum preeclampsia on postpartum day 4. She developed eclampsia and posterior reversible encephalopathy syndrome, which was diagnosed by magnetic resonance imaging. She subsequently developed clinical and radiologic evidence of reversible cerebral herniation.

CONCLUSION

Postpartum preeclampsia and eclampsia that is complicated by posterior reversible encephalopathy syndrome can result in cerebral herniation. Neuroradiologic imaging may be a useful adjunctive diagnostic tool in the setting of preeclampsia and eclampsia to predict disease severity.

Diagnosis, prevention, and management of eclampsia

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

Delayed postpartum preeclampsia: an experience of 151 cases

OBJECTIVE

Preeclampsia affects 6% to 8% of pregnancies. There are few data regarding hypertensive disorders that are diagnosed in the postpartum period. Our purpose was to determine the demographics, outcomes, and treatment of this complication.

STUDY DESIGN

This was a multicenter retrospective study of women who had received a diagnosis of hypertension/preeclampsia in the postpartum period. Inclusion criteria were readmission of a patient with this diagnosis (<or=6 weeks after the delivery).

RESULTS

Data from 151 women were studied. Complications included 24 cases (15.9%) of eclampsia, 9 cases (5.9%) of pulmonary edema, 6 cases (3.9%) of endomyometritis, 2 cases (1.3%) of thromboembolism, and 1 case of maternal death. Seventy-eight patients required antihypertensive medications on discharge. Subanalysis performed between the eclamptic and non-eclamptic women showed no difference among groups.

CONCLUSION

Delivery does not eliminate the risk for preeclampsia and its complications. Efforts should be directed at the continued monitoring, reporting, and evaluating of the symptoms of preeclampsia during the postpartum period.

Prolongation of pregnancy following eclampsia

Eclampsia is a serious complication of preeclampsia with high maternal and perinatal mortality and morbidity rates. The recommended management is induction of labour when convulsions are controlled and the women's condition is stabilised. Here, we report about stabilisation after eclampsia followed by prolongation of a preterm pregnancy for 11 days within early gestational weeks.

Eclampsia at a tertiary hospital 1973-99

BACKGROUND

To investigate changes in incidence, patient characteristics, comorbidity and in the care provided in cases of eclampsia at a tertiary hospital during the period 1973-99.

METHODS

Thirty-nine cases were identified through the Swedish National Birth Registry. Incidences and rates regarding patient characteristics and outcomes (duration of intensive care unit surveillance, assisted ventilation, multiple seizures, predefined major complications, perinatal mortality, small for gestational age, and neonatal intensive care surveillance) were compared between the time periods 1973-79, 1980-89 and 1990-99 with trend analysis.

RESULTS

The incidences in the three time periods were 3.0/10,000 births [95% confidence interval (CI) 0.1-5.9], 6.2/10,000 births (95% CI 2.7-9.7) and 10.9/10,000 births (95% CI 6.4-15.4), respectively, which constitutes a significant difference according to trend analysis (p = 0.006). There were no differences in patient characteristics or comorbidity. Onset occurred in hospital in 85% of the cases.

CONCLUSIONS

The increase in the incidence of eclampsia reported here is contrary to international trends up until the early 1990s. The incidence in 1990-99 is also higher than the reported national incidence in Sweden 1976-80, which was 2.9/10,000 births. Despite successful identification of women at risk for eclampsia and hospital surveillance, several cases were not prevented. Better prognostic tests that identify impending eclampsia are needed to bring the incidence down further.

Late postpartum eclampsia: a common presentation of an uncommon diagnosis

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

A current concept of eclampsia

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

A Review of Eclampsia in Qatar 1991: 2000

Objective: To measure the incidence and risk factors of eclampsia, establish how often it is preceded by preeclampsia, detect the clinical characteristics of women developing eclampsia, document the morbidity associated with eclampsia, determine the maternal case fatality rate and review the clinical features and management of this condition.

Method: A retrospective review of all cases of eclampsia which were managed in the Women's Hospital in the State of Qatar in the period between January 1991 to December 2000. Details were collected by reviewing the files of the patients from the medical record. Data were analyzed by either x2 analysis or the unpaired student “t” test as appropriate.

Result: Thirty nine cases of eclampsia were notified. The incidence of eclampsia in Qatar was 4.1 /10,000 maternities. Fourteen women (36%) had no antenatal care (ANC). However most convulsions occurred despite ANC (64%) and within one week of the woman's last visit to a doctor (58%). Thirty nine percent of the first seizures occurred in hospital, of which 23% developed before both proteinuria and hypertension had been developed. Twenty three percent of eclampsia occurred postpartum (PP), 51% antepartum (AP), and the remainder (26%) intrapartum (IP). There was no maternal fatality in Qatar but 23% of all women had at least one major complication. The rate of still birth (SB) andfirst week neonatal death (NND) was 76.2/1000 and 83.6/1000 respectively and the perinatal mortality rate (PNMR) was 153.8/1000. Preterm eclampsia was more common than term eclampsia (74% V 26%). Preterm eclampsia occurred more commonly AP (66%) and was associated with more maternal complications (26%) and fetuses that were small for gestational age (34%) as well as with higher rates of SB (10%) and first week NNDs (14%).

Conclusion: Eclampsia occurs in nearly one in 4000 maternities in Qatar and is associated with high incidence of maternal and neonatal morbidity and mortality. Antepartum onset carries greater risks and preterm eclampsia is particularly dangerous to both mother and fetus.