Maternal ascites an independent prognostic factor in severe preeclampsia: a matched cohort study

Pathophysiology and pregnancy outcomes of ascites in preeclampsia-a scoping review

Preeclampsia is a multisystem disorder associated with defective trophoblast invasion, maternal syndrome, and capillary endothelial leak. The presence of ascites/third space fluid accumulation increases the risk of maternal morbidity and mortality. The current criteria/guidelines of preeclampsia do not establish the presence of ascites as a marker of severity or recognize the timing and need for early delivery despite associated complications. Medline and Embase databases were searched to identify relevant literature, reported up to December 2023, regarding the pathophysiology, pregnancy outcome, and management of preeclampsia complicated with ascites. A total of 5 studies on pathophysiology and eight on pregnancy outcomes met the inclusion criteria, with 41 case reports on ascites in preeclampsia. The etiopathogenesis for the development of ascites in preeclampsia includes endothelial damage, capillary hyperpermeability, release of vasoconstrictive agents, reduced intravascular oncotic pressure, and raised intraabdominal pressure. The presence of ascites represents the extreme form of microvascular damage, which also correlates with the raised sFlt-1 levels in this condition. The adverse pregnancy outcomes include increased risk of congestive heart failure, eclampsia, renal failure, disseminated intravascular coagulation, acute respiratory distress syndrome, and maternal death. The presence of ascites in preeclampsia is associated with the deterioration of the maternal condition. Hence, it is indicative of preeclampsia with severe features and requires vigilant monitoring, and prompt delivery may be considered.

Possible additional criteria for the diagnosis of preeclampsia with severe features

Preeclampsia is a disorder affecting multiple organ systems. Preeclampsia with severe features may prompt consideration of delivery. The diagnostic criteria for preeclampsia with severe features, while focusing upon maternal cardiopulmonary, neurological, hepatic, renal and haematological systems, vary considerably in international practice guidelines. In the absence of alternative causes, severe hyponatraemia, pleural effusions and ascites, and abrupt severe maternal bradycardia are proposed as possible additional criteria for the diagnosis of preeclampsia.

A Case of Preeclampsia with Uterine Necrosis after Uterine Artery Embolization for Postpartum Hemorrhage

Uterine necrosis is a rare complication in uterine artery embolization (UAE) for postpartum hemorrhage (PPH). Preeclampsia (PE) is a condition characterized with systemic endothelial damage and intravascular volume depletion. Whether a patient with PE is at high risk for uterine necrosis after UAE for PPH has been unknown. A 30-year-old primipara woman was diagnosed with PE based on hypertension and proteinuria during delivery. UAE was performed for PPH after forceps delivery. After UAE, the patient presented with pleural effusion and massive ascites as well as persistent fever unresponsive to antibiotics. Ultrasonography and contrast-enhanced magnetic resonance imaging (MRI) led to the diagnosis of uterine necrosis, for which we performed total laparoscopic hysterectomy. It should be kept in mind that patients with PE associated with massive ascites may be at high risk for uterine necrosis after UAE due to decreased uterine perfusion. Therefore, it is important to pay attention to persistent symptoms such as fever and abdominal pain after UAE to diagnose uterine necrosis.

A case of preeclampsia developing massive ascites after delivery

We experienced a case of preeclampsia in which massive ascites became apparent in the postpartum period. The patient had isolated proteinuria without hypertension before delivery. The infant had fatal growth restriction and neonatal distress. Massive ascites and isolated proteinuria are important symptoms for predicting the aggravation of PE.

Massive ascites due to lupus peritonitis in a patient with pre-eclampsia and systemic lupus erythematosus: a case report

BACKGROUND

Patients with systemic lupus erythematosus (SLE) are associated with pre-eclampsia. Pre-eclampsia can have systemic manifestations, such as ascites. Lupus peritonitis, a rare condition in patients with SLE, can also cause ascites.

CASE PRESENTATION

A 31-year-old woman, primigravida, with SLE had a blood pressure of 170/110 mmHg and proteinuria at 29 weeks of gestation. She was diagnosed with pre-eclampsia. Her blood pressure was stabilized by an antihypertensive drug. At 30 weeks of gestation, a cesarean section was performed for maternal safety because of decreased urine output and massive ascites. Postoperatively, re-accumulation of ascites was observed. On the fourth postoperative day, ascites (approximately 3 L) was discharged from the cesarean section wound. A decrease in serum complement concentrations was observed, and she was diagnosed as having lupus peritonitis. The steroid dose was increased and she recovered well thereafter.

CONCLUSIONS

Ascites occurs in pre-eclampsia and SLE, but determining which of these conditions causes ascites can be difficult. However, careful observation is necessary because of the differences in treatment of these two conditions.

Gallbladder wall thickening in a woman with postpartum preeclampsia: A case report

Background

Preeclampsia (PE) is hallmarked by dysfunction of various organs; therefore, its diagnosis can be challenging, especially when patients present with right upper abdominal pain. Herein, we present a case of postpartum gallbladder wall thickening (GBWT) that led to a diagnosis of PE, rather than hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome or gallbladder and biliary disease.

Case Presentation

A 31-year-old postpartum woman presented with a fever, hypertension, headache, and right upper abdominal pain. HELLP syndrome and intracranial hemorrhage were initially suspected, due to the combination of symptoms and elevated levels of aspartate transaminase, alanine transaminase, and lactate dehydrogenase. However, hemolysis and thrombocytopenia were absent, and a computed tomography (CT) scan of the head did not indicate the presence of intracranial hemorrhage. Further, transabdominal ultrasound and CT revealed GBWT (edematous gallbladder); CT also revealed an enlarged heart, lung edema, pleural effusion, and ascites. Thus, PE, rather than HELLP syndrome or gallbladder or biliary disease, was diagnosed based on gestational hypertension and proteinuria, new-onset headache, liver dysfunction, and edema in several organs, including the lung. Nicardipine treatment quickly improved hypertension and headache, and, over time, the patient's urination increased, and edema subsided throughout the body. Furthermore, laboratory results improved, and the patient was discharged on postpartum day 11.

Conclusion

Postpartum gallbladder wall thickening can be a diagnostic sign of PE.

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Preeclampsia can cause edema in several organs.

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We present a case of postpartum gallbladder wall thickening.

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Gallbladder wall thickening can aid in the diagnosis of preeclampsia in cases with right upper abdominal pain.

Point of care ultrasound: does the presence of ascites in severe pre-eclampsia correlate with poor maternal and neonatal outcome?

OBJECTIVE

Ascites in severe pre-eclampsia may impact foetal and maternal outcomes. The objective was to determine the prevalence of ascites in women with severe pre-eclampsia by point of care (POC) ultrasound and to determine whether it correlates with higher perinatal risks.

METHODS

Prospective cohort study of patients admitted with severe pre-eclampsia at 2 teaching hospitals in Kigali, Rwanda. Serial POC ultrasound was performed to document ascites. Patients were stratified by the presence of ascites in perinatal period. Maternal demographics and complications were recorded and compared between groups.

RESULTS

There were 112 patients with severe pre-eclampsia, and ascites was found in 53.5% (76.7% antepartum, and 23.3% postpartum). Antepartum ascites correlated with an earlier delivery (32.2 ± 0.51 vs. 33.8 ± 0.47 weeks, P = 0.022) as well as lower birthweight (1587.3 ± 77.03 vs. 2011.6 ± 103.5 g, P = 0.002). Antepartum ascites was associated with higher stillbirth rates (P = 0.034) and NICU admission (87.2% vs. 68%, P = 0.034). Maternal hospital stay was increased in the ascites group (P < 0.0001).

CONCLUSIONS

Ascites is common in severe pre-eclampsia in Rwanda and maybe a prognosticator for poor outcomes. A larger sample is necessary to determine whether ascites is independently associated with maternal morbidity and mortality and whether documenting its presence aids in the management of the foetus and mother.

Re-evaluation of abruptio placentae and other maternal complications during expectant management of early onset pre-eclampsia

OBJECTIVE

Expectant management of appropriately selected cases of early pre-eclampsia in a dedicated, tertiary in-patient setting with frequent non-invasive maternal and fetal surveillance, prolongs pregnancy, improves perinatal outcome and mitigates the impact of maternal complications. As the rate of abruptio placentae in a large descriptive study performed nearly 20 years ago was 20%, a study to re-evaluate the rate of abruptio placentae and other maternal complications was performed.

STUDY DESIGN

A retrospective study that included all women admitted for expectant management with stable early pre-eclampsia (≥24 and <34 weeks' gestation) was performed at Tygerberg Hospital, a secondary and tertiary referral centre in South Africa over a period of 12 months.

MAIN OUTCOME MEASURES

Abruptio placentae and other maternal complications.

RESULTS

During the study period, 9137 women were delivered at the study institution. The data of 102 of 106 women admitted for expectant management of early pre-eclampsia were available. Thirty-four (33%) reached the elective delivery threshold of 34 weeks. Seventeen women (17%) experienced ≥1 complication. There were four cases (4%) each with abruptio placentae, HELLP syndrome and renal insufficiency. Three of the cases with abruptio placentae were asymptomatic, only being diagnosed at caesarean section for fetal distress. Nine women developed mild/moderate ascites. There were no admissions to the critical care unit and no deaths.

CONCLUSIONS

Abruptio placentae occurred in 4% of women managed expectantly with early pre-eclampsia and was most often asymptomatic before delivery.