Posterior reversible encephalopathy syndrome in 46 of 47 patients with eclampsia

High risk and low incidence diseases: Aneurysmal subarachnoid hemorrhage

INTRODUCTION

Aneurysmal subarachnoid hemorrhage (aSAH) is a serious condition that carries a high rate of morbidity.

OBJECTIVE

This review highlights the pearls and pitfalls of aSAH, including presentation, diagnosis, and management in the emergency department based on current evidence.

DISCUSSION

aSAH is a type of hemorrhagic stroke, most commonly from rupture of a saccular aneurysm, which results in leakage of blood into the subarachnoid space. It presents acutely and has many mimics, making the diagnosis difficult. Patients who present with either sentinel or acute presentation of a headache that is described as sudden or severe, has associated neck stiffness, cranial nerve deficits, syncope, seizure, and/or coma should raise suspicion for the diagnosis. Non-contrast head computed tomography is the imaging modality of choice for evaluation and diagnosis of the disease in patients who present acutely. Further diagnostic testing with lumbar puncture or advanced neuroimaging may be required in patients who present >6 h after symptom onset. Patients with aSAH require critical, multidisciplinary care, with particular attention to management of airway, breathing, and circulation; expeditious referral for neurosurgical intervention; coagulopathy reversal; and prophylaxis against downstream complications.

CONCLUSION

An understanding of aSAH can assist emergency clinicians in diagnosing and managing this disease.

Surgery or Not? A Retrospective Observational Study in Eclamptic Patients with Malignant Posterior Reversible Encephalopathy Syndrome and Intracerebral Hemorrhage

OBJECTIVE

The study aims to evaluate the outcomes of surgical intervention in eclamptic patients with malignant posterior reversible encephalopathy syndrome (PRES) complicated by intracerebral hemorrhage (ICH).

METHODS

A retrospective review of 22 eclamptic women diagnosed with PRES between January 2013 and November 2023 was conducted. Patients were categorized into 4 groups: group 1 (no ICH, Glasgow Coma Scale 15, and no signs of increased intracranial pressure [IICP]), group 2 (no ICH, Glasgow Coma Scale <15, with neurological deficits), group 3 (ICH <10 ml, no mass effect, and no signs of IICP), and group 4 (ICH >10 ml, with mass effect and signs of IICP). Patient demographics, obstetrical outcomes, radiological findings, and functional recovery (measured by modified Rankin Scale [mRS]) were analyzed.

RESULTS

No patients in groups 1 or 2 required surgery, while all patients in group 4 underwent surgical intervention. At presentation, group 4 exhibited significantly worse mRS scores (mean 4.4) compared to groups 1 (mean 1.2) and 2 (mean 2.29, P < 0.001). However, at the 1- and 2-year follow-ups, mRS scores were comparable across all groups (P = 0.458 and P = 0.883, respectively), reflecting substantial recovery regardless of initial severity.

CONCLUSIONS

Eclamptic women with malignant PRES and ICH can achieve long-term outcomes comparable to those without hemorrhagic transformation through timely surgical intervention following American Heart Association guidelines, though the natural course of such cases remains unclear.

An Organ-Specific Approach to the Management of Gestational Hypertension: Evidence versus Tradition

The management of hypertensive disease in pregnancy is currently guided by practice recommendations based largely on observational data from a half century ago and has changed only superficially since that time. These recommendations are both narrowly prescriptive (women without traditional features of severe disease should all be delivered at exactly 370/7 weeks) and at the same time frustratingly ambiguous (the presence of epigastric pain unresponsive to repeat analgesics precludes expectant management at any gestational age, regardless of laboratory studies). Guidelines that ignore recent data from the obstetric, pediatric, and internal medicine literature too often lead practitioners to be more aggressive than necessary in the delivery of very premature pregnancies, and, conversely, more complacent than patient safety would support in prolonging pregnancy with advanced fetal maturity. We present here an alternative, organ-specific-based approach to the management of gestational hypertension that allows and encourages practitioners to formulate a management plan based on a thoughtful and, when possible, evidence-based synthesis of the continuous variables of blood pressure, degree of organ dysfunction and response to treatment, gestational age, and patient balancing of maternal and fetal/neonatal risks. Such clinical care is more complex and nuanced than simply basing life-altering critical management decisions, including timing of delivery, on whether the patient does, or does not have any one of the conditions described by box 4 of the current American College of Obstetricians and Gynecologists practice guidelines. Nonetheless, we believe this approach will not only improve care but will also open the door to useful investigations into prevention and management of the various entities traditionally considered as the same disease process. KEY POINTS: · Traditional approaches to preeclampsia are not evidence based.. · The use of such approaches has resulted in stagnant maternal morbidity and mortality ratios.. · The consideration of disease severity as binary is particularly counterproductive.. · An organ-based approach will facilitate evidence-based individualization of care..

High prevalence of neuroimaging abnormalities in eclampsia: Justifying the routine use of non-contrast CT in resource-limited settings

OBJECTIVES

Eclampsia remains a principal cause of maternal mortality, especially in low- and middle-income countries. The frequent association with Posterior Reversible Encephalopathy Syndrome (PRES) underscores the critical role of neuroimaging in clinical assessment. We aimed to evaluate tomographic findings in women with eclampsia and analyze clinical factors associated with these abnormalities.

STUDY DESIGN

This descriptive, retrospective study was conducted at the Hospital Universitario San Vicente Fundación in Medellín, Colombia. A mandatory registry identified women diagnosed with eclampsia between 2011 and 2023. Non-contrast cranial tomography results and clinical data were analyzed using univariate and multivariate logistic regression to determine factors associated with imaging abnormalities.

MAIN OUTCOME MEASURES

The primary outcomes were the presence of abnormalities on non-contrast cranial CT scans and their association with clinical factors such as antepartum eclampsia and HELLP syndrome.

RESULTS

Of the eighty-one women with eclampsia, sixty-seven underwent non-contrast cranial tomography. Abnormal findings were observed in 52% of cases, with 74% consistent with PRES and 22% showing evidence of hemorrhage. Antepartum eclampsia and HELLP syndrome are significantly associated with abnormal imaging findings, with odds ratios of 11,72 (2.34 - 106,23) and 9,14 (1.72 - 85,72), respectively, after adjusting for potential confounding variables.

CONCLUSION

Given the high prevalence of tomographic abnormalities, non-contrast cranial tomography should be considered for all women with eclampsia, particularly those with antepartum presentations or HELLP syndrome. These findings support the need for revising neuroimaging guidelines to improve the diagnosis and management of neurological complications associated with eclampsia, especially in resource-limited settings.

A (PRES)sing Matter: Two Cases of Posterior Reversible Encephalopathy Syndrome (PRES) in Pregnancy and Postpartum

Posterior reversible encephalopathy syndrome (PRES) is a rare but serious neurological condition characterized by headaches, seizures, vision disturbances, and altered mental status. While it is commonly associated with hypertensive disorders, including preeclampsia and eclampsia, its exact pathophysiology remains unclear. We discuss the cases of two obstetric patients diagnosed with PRES: one in antepartum and the other during postpartum. Both exhibited severe hypertension and neurological symptoms, confirmed with neuroimaging, requiring urgent intervention with blood pressure control and seizure prophylaxis. Despite the reversible nature of PRES, a delay in diagnosis can lead to significant morbidity. These cases highlight the diverse clinical presentations of PRES and underscore the importance of early diagnosis and aggressive management to prevent complications. Through a discussion of potential underlying mechanisms, imaging findings, and treatment strategies, this report contributes to the growing understanding of PRES in pregnancy and postpartum, emphasizing the need for continued research and awareness.

Approach to Altered Mental Status in Pregnancy and Postpartum

The evaluation and diagnosis of altered mental status in the pregnant or postpartum patient largely parallels the approach used for any other patient; however, there are several critical differences including that some neuroobstetric diagnoses require emergent delivery of the fetus. Being familiar with the physiological changes and medical complications of pregnancy and delivery is therefore essential. This review first addresses pregnancy-specific disorders that may result in altered mental status, such as the hypertensive disorders of pregnancy and pregnancy-related metabolic and endocrinopathies. The focus then shifts to the complex physiologic changes in pregnancy and how these changes contribute to the distinct epidemiology of pregnancy-related cerebrovascular complications like intracranial hemorrhage, ischemic stroke, and reversible cerebral vasoconstriction syndrome. Medical disorders that are not unique to pregnancy, such as infections and autoimmune conditions, may present de novo or worsen during pregnancy and the peripartum period and require a thoughtful approach to diagnosis and management. Finally, the unique nervous system complications of obstetric anesthesia are explored. In each section, there is a focus not only on diagnosis and syndrome recognition but also on the emergent treatment needed to reverse these complications, bearing in mind the unique physiology of the pregnant patient.

Fetomaternal outcome in preeclampsia and eclampsia with posterior reversible encephalopathy syndrome

Introduction

Preeclampsia and eclampsia are hypertensive disorders of pregnancy associated with significant maternal and fetal morbidity and mortality. Posterior reversible encephalopathy syndrome (PRES) is a neurological complication observed in these conditions, yet its impact on fetomaternal outcomes remains underexplored. The aim of this study is to investigate the association between PRES and fetomaternal outcomes in women with preeclampsia and eclampsia.

Methods

This prospective cohort study enrolled 64 singleton pregnant women beyond 20 weeks of gestation with preeclampsia and eclampsia having neurological symptoms. Participants underwent clinical evaluation and radiological assessment, including non-contrast computed tomography (NCCT) and magnetic resonance imaging (MRI). Maternal outcomes, including high dependency unit (HDU)/intensive care unit (ICU) stay, intubation, mode of delivery and maternal mortality. Fetal outcomes, i.e., stillbirth, prematurity, and neonatal intensive care unit (NICU) stay, were recorded. Statistical analysis was performed to compare outcomes between PRES and non-PRES groups.

Results

The majority (92.18%) of participants were unscheduled and (56.2%) were primigravida. PRES was diagnosed in 62.5% of cases, predominantly associated with antepartum eclampsia (47.5%). Neurological symptoms such as headache (85.9%) and blurring of vision (68.8%) were common in PRES cases. Cesarean section rate was significantly higher in PRES group (75%), along with adverse outcomes including increased HDU/ICU stay, intubation, postpartum haemorrhage (PPH), abruption, maternal mortality, stillbirth, prematurity, fetal growth restriction (FGR), meconium-stained liquor (MSL), and NICU stay, which were observed significantly higher in women with PRES (p < 0.001) and low Appearance, Pulse, Grimace, Activity, and Respiration (APGAR) scores (p < 0.05). However, no significant association was observed between PRES and early neonatal death (ENND).

Conclusion

PRES is associated with adverse fetomaternal outcomes in women with preeclampsia/eclampsia, including higher cesarean section rate and increased maternal and neonatal morbidity. Early recognition and management of PRES are crucial for improving outcomes in these high-risk pregnancies. Further research with larger sample sizes is warranted to validate these findings and explore potential interventions.

Hypertensive Disorders and Cardiovascular Severe Maternal Morbidity in the US, 2015-2019

Importance

The incidence of severe maternal morbidity (SMM)-and particularly cardiovascular SMM (cvSMM), the first cause of pregnancy-related mortality-has been rising in North America. Although hypertensive disorders of pregnancy (HDP) are common, their association with cvSMM specifically remains unclear.

Objective

To assess the association between individual subtypes of HDP and cvSMM, in addition to overall SMM, in a large, nationally representative sample.

Design, Setting, and Participants

A population-based cohort study using the United States National Inpatient Sample was conducted. Individuals with obstetric deliveries between 2015 and 2019 were included. Data analysis was performed from October 2023 to February 2024.

Exposure

HDP subtypes included gestational hypertension, chronic hypertension, preeclampsia without severe features, severe preeclampsia, and HELLP (hemolysis, elevated liver enzymes, and low platelet) syndrome.

Main Outcomes and Measures

The primary outcome was a composite of cvSMM (including conditions such as pulmonary edema, stroke, and acute myocardial infarction) and the secondary outcome was a composite of overall SMM (including cvSMM and other conditions such as respiratory failure, severe postpartum hemorrhage, and sepsis). Adjusted risk ratios (aRRs) for the association between HDP subtypes and the outcomes were estimated using modified Poisson regression models adjusted for demographic and clinical characteristics.

Results

Among 15 714 940 obstetric deliveries, 2 045 089 (13.02%) had HDP, 23 445 (0.15%) were affected by cvSMM, and 282 160 (1.80%) were affected by SMM. The mean (SD) age of the cohort was of 29 (6) years. The incidence of cvSMM was higher in participants with HDP than those without HDP (0.48% [9770 of 2 045 089] vs 0.10% [13 680 of 13 669 851]; P < .001). Participants with HELLP syndrome had the highest risk for cvSMM (aRR, 17.55 [95% CI, 14.67-21.01]), followed by severe preeclampsia (aRR, 9.11 [95% CI, 8.26-10.04]), and chronic hypertension (aRR, 3.57 [95% CI, 3.15-4.05]). Although HDP subtypes were also associated with overall SMM, the association with HELLP syndrome (aRR, 9.94 [95% CI, 9.44-10.45]), severe preeclampsia (aRR, 3.66 [95% CI, 3.55-3.78]), and chronic hypertension (aRR, 1.96 [95% CI, 1.88-2.03]) was attenuated compared with cvSMM.

Conclusions and Relevance

In this cohort study, a graded relationship by severity characterized the association between HDP and cvSMM. Although all HDP subtypes were associated with an increased risk of overall SMM, the risk was more pronounced for cvSMM.

Association between hypertensive disorders and Bell's palsy in pregnancy: protocol for a systematic review and meta-analysis

BACKGROUND

Bell's palsy is an idiopathic peripheral nerve palsy involving the facial nerve. Pregnancy, diabetes mellitus and hypertension are the risk factors for Bell's palsy. However, the association between hypertensive disorders and Bell's palsy during pregnancy or the puerperium remains unclear. This systematic review will comprehensively summarise the literature and evaluate the association between Bell's palsy and hypertensive disorders during pregnancy or the puerperium.

METHODS AND ANALYSIS

Systematic searches of PubMed, MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials will be undertaken using prespecified search strategies. Observational studies (cross-sectional studies, cohort studies, case reports and series case reports) written in English that investigate the association between hypertensive disorders of late pregnancy and Bell's palsy during pregnancy or the puerperium will be included. Different authors will independently conduct the eligible study selection, perform data extraction and appraise the quality of included studies. Subgroup analysis will be carried out based on the age of pregnant women (≤35 years old, >35 years old), parity (primipara, multipara) and fetus number (singleton or multiple-gestation pregnancy).

ETHICS AND DISSEMINATION

This review will be based on published literature, and thus there is no requirement for ethics approval. The results of this study will aid in the knowledge of the relationship between Bell's palsy during pregnancy or the puerperium and hypertensive disorders of late pregnancy. The results of this systematic review will be shared through publication in a peer-reviewed journal with good visibility for the field of obstetrics and presentations at academic conferences.

PROSPERO REGISTRATION NUMBER

CRD42023422902.

Clinical relevance of reversible cerebral vasoconstriction syndrome in pregnant women with posterior reversible encephalopathy syndrome: review of case reports in Japan

We systematically reviewed case reports of posterior reversible encephalopathy syndrome (PRES), and investigated the characteristics of PRES in pregnant Japanese women and the clinical relevance of reversible cerebral vasoconstriction syndrome (RCVS) in pregnant women with PRES. Articles were collected using the PubMed/Medline and Ichushi-Web databases. This review was ultimately conducted on 121 articles (162 patients). The clinical characteristics of PRES, individual sites of PRES lesions, edema types, and clinical characteristics of RCVS in PRES cases were examined. The most common individual site of PRES lesion was the occipital lobe (83.3%), followed by the basal ganglia, parietal lobe, frontal lobe, brain stem, cerebellum, temporal lobe, thalamus, and splenium corpus callosum (47.5, 42.6, 24.7, 16.1, 9.3, 5.6, 4.3, and 0.0%, respectively). Edema types in 79 cases with PRES were mainly the vasogenic edema type (91.1%), with very few cases of the cytotoxic edema type (3.8%) and mixed type (5.1%). Among 25 PRES cases with RCVS, RCVS was not strongly suspected in 17 (68.0%) before magnetic resonance angiography. RCVS was observed at the same time as PRES in 13 cases (approximately 50%), and between days 1 and 14 after the onset of PRES in the other 12. These results suggest that the basal ganglia is a frequent site of PRES lesions in pregnant women. RCVS may occur at or after the onset of PRES, even if there are no symptoms to suggest RCVS.

Posterior Reversible Encephalopathy Syndrome in a Late Postpartum Patient With a Rare Complication of Subarachnoid Hemorrhage

Posterior reversible encephalopathy syndrome (PRES) is considered a neuroclinical syndrome of headache, confusion, visual changes, and seizures associated with neuroimaging findings of posterior cerebral white matter edema. Although the incidence of the syndrome is largely unknown, this condition is becoming increasingly recognized. The prognosis is generally good with most symptoms resolving within one week and lesions on imaging resolving in two weeks. Death and significant neurological disability have been reported but are relatively rare. In this report, we present a 10-day postpartum patient with an atypical history of headache and seizure-like activity. Neuroimaging revealed findings consistent with PRES as well as a rare complication of subarachnoid hemorrhage. This case highlights the importance of clinicians considering preeclampsia/eclampsia-induced PRES when encountering a postpartum patient with headache and hypertension to further reduce morbidity and mortality in this patient population.

The diagnostic approach and management of hypertension in the emergency department

Hypertension urgency and emergency represents a challenging condition in which clinicians should determine the assessment and/or treatment of these patients. Whether the elevation of blood pressure (BP) levels is temporary, in need of treatment, or reflects a chronic hypertensive state is not always easy to unravel. Unfortunately, current guidelines provide few recommendations concerning the diagnostic approach and treatment of emergency department patients presenting with severe hypertension. Target organ damage determines: the timeframe in which BP should be lowered, target BP levels as well as the drug of choice to use. It's important to distinguish hypertensive emergency from hypertensive urgency, usually a benign condition that requires more likely an outpatient visit and treatment.

Posterior Reversible Encephalopathy Syndrome and Eclampsia in the Setting of Magnesium Toxicity: A Case Report

Posterior reversible encephalopathy syndrome (PRES) is a rare neurologic condition and a feared complication of eclampsia. It is evidenced by acute neurologic dysfunction secondary to cerebral edema and is typically reversible in nature. Although it is a relatively new diagnosis, an increasing amount of literature has described its occurrence, including an association with hypomagnesemia. We present a case wherein a 24-year-old parturient developed PRES and eclampsia in the setting of symptomatic hypermagnesemia, requiring management with lorazepam after seizures developed. Here we detail her clinical course, including the unique challenges of treating eclampsia and PRES in the setting of magnesium toxicity.

Labor Induction After Severe Preeclampsia With Maternal Posterior Reversible Encephalopathy Syndrome Complications Leading to Intrauterine Fetal Death: A Case Report

Posterior reversible encephalopathy syndrome (PRES) is a clinical imaging syndrome characterized by vasogenic edema in the posterior cerebral circulation, with severe preeclampsia (PE) and eclampsia as major etiologies. Posterior reversible encephalopathy syndrome lesions are often reversible, but they can be potentially fatal in obstetric crises, causing serious complications such as cerebral hemorrhage, confusion, headache, visual symptoms, and stroke if not treated immediately. Neurological sequelae and even death may occur in a minority of these cases. In this paper, we report the case of a 26-year-old primigravida at 25 weeks of gestation who was irregular with obstetric visits. The patient presented with edema, nausea and vomiting, dizziness, blurry vision, falling down, and a maximum blood pressure of 190/85 mmHg. A brain MRI revealed PRES. Approximately 10 hours after admission, intrauterine fetal death occurred. After treatment, the patient was in stable condition and successfully induced for delivery.

Status Epilepticus as a Presenting Feature in Posterior Reversible Encephalopathy Syndrome: Tertiary Care Center Experience

Background

Though epileptic seizures are common in posterior reversible encephalopathy syndrome (PRES), status epilepticus (SE) as the presenting feature is rare.

Objective

To study the clinical spectrum and outcome of patients with SE as presenting feature of PRES.

Methods

This is a retrospective study. PRES was diagnosed based on the clinical features and imaging findings on brain MRI (n = 40) which became normal after 6 months follow-up imaging. Patients with SE as the initial manifestation of PRES were identified. Baseline information regarding the clinical presentation, etiology, past history of illness, treatment history, imaging findings, EEG and long-term clinical outcome.

Result

Seizure was the most common presentation seen in 31 patients (77.5%). The etiologies in PRES were preeclampsia, or eclampsia [n = 33 (82.5%)], hypertensive encephalopathy [n = 3 (7.5%)], systemic lupus erythematosus (SLE), AIP, and chronic renal failure (CRF) in one patient each [n = 01 (2.5%)]. Brain MRI showed the involvement of parieto-occipital lobes (n = 33 [82.5%]) mostly. Status epilepticus (generalized convulsive) was the presenting feature in eight cases (20%). Among them, five cases (0.5%) had a history of chronic epilepsy. In the remaining three patients, SLE and acute intermittent porphyria, CRF precipitated the SE.

Conclusion

The study highlights the clinico-etiological spectrum of PRES and the identification of SE within its context leading to the early diagnosis and management if treated early. The role of antenatal care is important for the identification and treatment of etiologies, blood pressure, proper antiepileptic drug compliance and appropriate counseling.

How to cite this article

Prasad P. Status Epilepticus as a Presenting Feature in Posterior Reversible Encephalopathy Syndrome: Tertiary Care Center Experience. Indian J Crit Care Med 2023;27(7):488-492.

Magnetic resonance spectroscopy and liquid chromatography-mass spectrometry metabolomics study may differentiate pre-eclampsia from gestational hypertension

OBJECTIVE

To investigate the findings of magnetic resonance imaging (MRI), magnetic resonance spectroscopy (MRS), and serum metabolomics for differentiating pre-eclampsia (PE) from gestational hypertension (GH).

METHODS

This prospective study enrolled 176 subjects including a primary cohort with healthy non-pregnant women (HN, n = 35), healthy pregnant women (HP, n = 20), GH (n = 27), and PE (n = 39) and a validation cohort with HP (n = 22), GH (n = 22), and PE (n = 11). T1 signal intensity index (T1SI), apparent diffusion coefficient (ADC) value, and the metabolites on MRS were compared. The differentiating performances of single and combined MRI and MRS parameters for PE were evaluated. Serum liquid chromatography-mass spectrometry (LC-MS) metabolomics was investigated by sparse projection to latent structures discriminant analysis.

RESULTS

Increased T1SI, lactate/creatine (Lac/Cr), and glutamine and glutamate (Glx)/Cr and decreased ADC value and myo-inositol (mI)/Cr in basal ganglia were found in PE patients. T1SI, ADC, Lac/Cr, Glx/Cr, and mI/Cr yielded an area under the curves (AUC) of 0.90, 0.80, 0.94, 0.96, and 0.94 in the primary cohort, and of 0.87, 0.81, 0.91, 0.84, and 0.83 in the validation cohort, respectively. A combination of Lac/Cr, Glx/Cr, and mI/Cr yielded the highest AUC of 0.98 in the primary cohort and 0.97 in the validation cohort. Serum metabolomics analysis showed 12 differential metabolites, which are involved in pyruvate metabolism, alanine metabolism, glycolysis, gluconeogenesis, and glutamate metabolism.

CONCLUSIONS

MRS is expected to be a noninvasive and effective tool for monitoring GH patients to avoid the development of PE.

KEY POINTS

• Increased T1SI and decreased ADC value in the basal ganglia were found in PE patients than in GH patients. • Increased Lac/Cr and Glx/Cr, and decreased mI/Cr in the basal ganglia were found in PE patients than in GH patients. • LC-MS metabolomics showed that the major differential metabolic pathways between PE and GH were pyruvate metabolism, alanine metabolism, glycolysis, gluconeogenesis, and glutamate metabolism.

Preeclampsia and the Kidney: Pathophysiology and Clinical Implications

Preeclampsia and other hypertensive disorders of pregnancy are major contributors to maternal morbidity and mortality worldwide. This group of disorders includes chronic hypertension, gestational hypertension, preeclampsia, preeclampsia superimposed on chronic hypertension, and eclampsia. The body undergoes important physiological changes during pregnancy to allow for normal placental and fetal development. Several mechanisms have been proposed that may lead to preeclampsia, including abnormal placentation and placental hypoxia, impaired angiogenesis, excessive pro-inflammatory response, immune system imbalance, abnormalities of cellular senescence, alterations in regulation and activity of angiotensin II, and oxidative stress, ultimately resulting in upregulation of multiple mediators of endothelial cell dysfunction leading to maternal disease. The clinical implications of preeclampsia are significant as there are important short-term and long-term health consequences for those affected. Preeclampsia leads to increased risk of preterm delivery and increased morbidity and mortality of both the developing fetus and mother. Preeclampsia also commonly leads to acute kidney injury, and women who experience preeclampsia or another hypertensive disorder of pregnancy are at increased lifetime risk of chronic kidney disease and cardiovascular disease. An understanding of normal pregnancy physiology and the pathophysiology of preeclampsia is essential to develop novel treatment approaches and manage patients with preeclampsia and hypertensive disorders of pregnancy. © 2023 American Physiological Society. Compr Physiol 13:4231-4267, 2023.

A systematic review of posterior reversible encephalopathy syndrome in pregnant women with severe preeclampsia and eclampsia

Background

The association of posterior reversible encephalopathy syndrome (PRES) and severe preeclampsia/eclampsia has been established but the frequency is uncertain.

Objectives

To determine the frequency of PRES in severe preeclampsia or eclampsia.

Methods

We searched published articles in PubMed, Cochrane library, Embase, and CINAHL from 1990 to 2020. We included articles that reported on six or more cases of PRES with eclampsia or severe preeclampsia who underwent neuroimaging during pregnancy or up to 6 weeks postpartum.

Results

We identified 29 studies presenting data on 1519 women with eclampsia or severe preeclampsia. Among 342 women with eclampsia who had neuroimaging, 176 (51.4%) were diagnosed with PRES. Of 121 women with severe preeclampsia, 24 (19.8%) had PRES. The pooled maternal death rate was 5.3% (21/395).

Conclusion

PRES is commonly reported on neuroimaging of women with eclampsia/ severe preeclampsia. The role of neuroimaging in eclampsia and especially in women with severe preeclampsia requires re-evaluation as further management is often dictated by this finding.

Sequential measurement of the neurosensory retina in hypertensive disorders of pregnancy: a model of microvascular injury in hypertensive emergency

Optical coherence tomography of the eye suggests the retina thins in normal pregnancy. Our objectives were to confirm and extend these observations to women with hypertensive disorders of pregnancy (HDP). Maternal demographics, clinical/laboratory findings and measurements of macular thickness were repeatedly collected at gestational ages <20 weeks, 20-weeks to delivery, at delivery and postpartum. The primary outcome was the change in macular thickness from non-pregnant dimensions in women with incident HDP compared to non-hypertensive pregnant controls. Secondary outcomes were the relationship(s) between mean arterial pressure (MAP) and macular response. Data show macular thicknesses diminished at <20 weeks gestation in each of 27 pregnancies ending in HDP (mean 3.94 µm; 95% CI 4.66, 3.21) and 11 controls (mean 3.92 µm; 5.05, 2.79; P < 0.001 versus non-pregnant dimensions in both; P = 0.983 HDP versus controls). This thinning response continued to delivery in all controls and in 7 women with HDP superimposed on chronic hypertension. Macular thinning was lost after 20 weeks gestation in the other 20 women with HDP. MAP at loss of macular thinning in women without prior hypertension (n = 12) was identical to MAP at enrollment. However, mean MAP subsequently rose 19 mmHg (15, 22) leading to de novo HDP in all 12 women. Loss of thinning leading to a rise in MAP was also observed in 8 of 15 women with HDP superimposed on chronic hypertension. We conclude the macula thins in most women in early pregnancy. Those who lose this early macular thinning response often develop blood pressure elevations leading to HDP.

Early Readmissions After Hospitalization for Posterior Reversible Encephalopathy Syndrome

BACKGROUND AND OBJECTIVES

To evaluate the frequency, etiologies, and risk factors for 90-day readmissions after hospitalization for posterior reversible encephalopathy syndrome (PRES).

METHODS

Data were obtained from the Nationwide Readmissions Database 2016-2018. Patients with a primary diagnosis of PRES, survival to discharge, and known discharge disposition were included. The primary outcome was nonelective readmission within 90 days of discharge. Survival analysis was performed, and independent predictors of readmission were analyzed using multivariable Cox proportional hazards regression.

RESULTS

Based on the study inclusion criteria, 6,155 eligible patients were included (mean ± SD age: 55.9 ± 17.3 years, female: 71.0%). Nonelective readmission within 90 days of discharge occurred for 1,922 (31.2%) patients. Of these, 617 readmissions were due to PRES-related or neurologic etiologies and the remaining 1,305 readmissions were due to non-neurologic conditions. In multivariable analysis, age was inversely associated with the risk of readmission (hazards ratio [HR] 0.92 for every 10 years increase in age, 95% CI 0.88-0.97). Patients with diabetes (HR 1.21, 95% CI 1.04-1.42), systemic lupus erythematosus (HR 1.42, 95% CI 1.03-1.96), acute kidney injury (HR 1.28, 95% CI 1.11-1.47), and a higher Charlson comorbidity index score (HR 1.09, 95% CI 1.06-1.13) were more likely to be readmitted. Furthermore, patients admitted at large bed size hospitals (HR 1.19, 95% CI 1.03-1.39), those with a longer length of stay (HR 1.01, 95% CI: 1.00-1.02), and those not discharged to home (HR 1.33, 95% CI: 1.14-1.55) during the index hospitalization were also at a higher risk for readmission.

DISCUSSION

Nearly one-third of patients hospitalized because of PRES are readmitted within 90 days of discharge, and approximately one-third of these readmissions are due to PRES-related or neurologic etiologies. Younger age, a higher comorbidity burden, a longer length of hospital stay, and discharge disposition other than to home are independently associated with the risk of readmission.

Posterior reversible encephalopathy in a pregnant woman without preeclampsia or eclampsia: A case report

BACKGROUND

We report a case of a pregnant woman who presented posterior reversible encephalopathy syndrome (PRES) without pre-eclampsia, eclampsia, or any other common causes of PRES.

METHODS

A 32-year-old primigravida at 25 weeks and 4 days of gestation was admitted to neurology department because of suffering intermittent headache, hearing loss, memory loss with mental and behavioral disorder, and blurred vision for 1 month. She was healthy before without hypertension, migraine, or other medical or family history. Brain magnetic resonance imaging (MRI) revealed diffuse symmetrical high-signal intensity lesions in the white matter, medulla oblongata, without enhancement. After completely multidisciplinary discussion and with the family of the patient, she accepted termination of pregnancy.

RESULTS

After the operation, the patient improved symptomatically. The follow-up MRI showed a decrease of the white matter lesion after 3 months and complete recovery at postoperative 6 months. The patient returned to work without any neurological sequelae.

CONCLUSION

It might widen the cause spectrum of PRES that pregnancy itself without pre-eclampsia, eclampsia, or any other known risk factors could cause PRES. Pregnancy with acute or subacute leukoencephalopathy should be screened related causes and risk factors carefully. Hormonal fluctuations during the pregnancy might account for pregnancy-related PRES.

Prediction of pre-eclampsia by using radiomics nomogram from gestational hypertension patients

Background

Pre-eclampsia (PE) is the main cause of death in maternal and prenatal morbidity. No effective clinical tools could be used for the prediction of PE. A radiomics nomogram based on diffusion-weighted imaging (DWI) and apparent diffusion coefficient (ADC) maps was established to predict PE from gestational hypertension (GH).

Materials and methods

A total of 138 patients with hypertensive disorders of pregnancy were continuously enrolled in the study prospectively, namely, 58 patients with PE and 80 patients with GH. The patients were randomly divided into a training cohort (n = 97) and a test cohort (n = 41). Radiomics features were extracted from DWI and ADC maps. The radiomics signature was constructed using a least absolute shrinkage and selection operator (LASSO) algorithm in the training cohort. A radiomics nomogram was developed by combining the radiomics signature with the selected clinical risk factors. The area under the receiver operating characteristic (ROC) curves (AUC), specificity, sensitivity, accuracy, positive predictive value, and negative predictive values of the radiomics signature, clinical risk factors, and radiomics nomogram were calculated. Decision curve analysis (DCA) was performed to determine the clinical usefulness of the radiomics nomogram.

Results

The LASSO analysis finally included 11 radiomics features, which were defined as the radiomics signature. The individualized prediction nomogram was constructed by integrating the radiomics signature, maternal age, and body mass index (BMI). The nomogram exhibited a good performance both in the training cohort [AUC of 0.89 (95% CI, 0.82–0.95)] and test cohort [AUC of 0.85 (95% CI, 0.73–0.97)] for predicting PE from GH. The DCA indicated that clinicians and patients could benefit from the use of radiomics nomogram.

Conclusion

The radiomics nomogram could individually predict PE from GH. The nomogram could be conveniently used to facilitate the treatment decision for clinicians and patients.

High risk and low prevalence diseases: Eclampsia

INTRODUCTION

Eclampsia is a rare partum and puerperal condition that carries a high rate of morbidity and mortality.

OBJECTIVE

This review highlights the pearls and pitfalls of the care of patients with eclampsia, including presentation, evaluation, and evidence-based management in the emergency department (ED).

DISCUSSION

Eclampsia is a hypertensive disease of pregnancy defined by new onset tonic-clonic, focal, or multifocal seizures or unexplained altered mental status in a pregnant or postpartum patient in the absence of other causative etiologies. However, signs and symptoms of preeclampsia and prodromes of eclampsia are often subtle and non-specific, making the diagnosis difficult. Thus, it should be considered in pregnant and postpartum patients who present to the ED. Laboratory testing including complete blood cell count, renal and liver function panels, electrolytes, glucose, coagulation panel, fibrinogen, lactate dehydrogenase, uric acid, and urinalysis, as well as imaging to include head computed tomography, can assist, but these evaluations should not delay management. Components of treatment include emergent obstetric specialist consultation, magnesium administration, and blood pressure control in patients with hypertension. Definitive treatment of eclampsia requires emergent delivery in pregnant patients. If consultants are not in-house, emergent stabilization and immediate transfer are required.

CONCLUSIONS

An understanding of eclampsia can assist emergency clinicians in rapid recognition and timely management of this potentially deadly disease.

Headaches in Pregnancy and Postpartum: ACOG Clinical Practice Guideline No. 3

PURPOSE

To provide updated evidence-based recommendations for the evaluation and treatment of primary and secondary headaches in pregnancy and postpartum.

TARGET POPULATION

Pregnant and postpartum patients with a history of or experiencing primary or new secondary headaches.

METHODS

This guideline was developed using an a priori protocol in conjunction with a writing team consisting of two specialists in obstetrics and gynecology appointed by the ACOG Committee on Clinical Practice Guidelines-Obstetrics and one external subject matter expert. ACOG medical librarians completed a comprehensive literature search for primary literature within Cochrane Library, Cochrane Collaboration Registry of Controlled Trials, EMBASE, PubMed, and MEDLINE. Studies that moved forward to the full-text screening stage were assessed by two authors from the writing team based on standardized inclusion and exclusion criteria. Included studies underwent quality assessment, and a modified GRADE (Grading of Recommendations Assessment, Development, and Evaluation) evidence-to-decision framework was applied to interpret and translate the evidence into recommendation statements.

RECOMMENDATIONS

This Clinical Practice Guideline includes recommendations on interventions to prevent primary headache in individuals who are pregnant or attempting to become pregnant, postpartum, or breastfeeding; evaluation for symptomatic patients presenting with primary and secondary headaches during pregnancy; and treatment options for primary and secondary headaches during pregnancy and lactation. Recommendations are classified by strength and evidence quality. Ungraded Good Practice Points are included to provide guidance when a formal recommendation could not be made because of inadequate or nonexistent evidence.

Headache in Pregnancy

Headache is a common symptom in pregnancy. The differential diagnosis for headache in pregnancy is broad and includes conditions that range in acuity and severity. Most headaches in pregnancy are migraine or tension-type headaches. However, pregnant women are at an increased risk of vascular causes of headache due to hormone changes and increased hypercoagulability in pregnancy. A careful history, physical examination, and possible diagnostic workup should be performed. Treatment of headache in pregnancy varies according to the etiology, but care should be taken when performing diagnostic studies and considering pharmacologic treatments, given the possible risk to the mother and fetus.

Maternal Stroke Associated With Pregnancy

PURPOSE OF REVIEW

This article summarizes current knowledge of the epidemiology, pathophysiology, prevention, and treatment of cerebrovascular disease in pregnant and postpartum women.

RECENT FINDINGS

Stroke is a leading cause of maternal morbidity and mortality, and most fatal strokes are preventable. Adaptive physiologic changes of pregnancy, including hemodynamic changes, venous stasis, hypercoagulability, and immunomodulation, contribute to increased maternal stroke risk. The highest-risk time period for maternal stroke is the immediate postpartum period. Migraine and hypertensive disorders of pregnancy, including gestational hypertension and preeclampsia, are major risk factors for maternal stroke. Adverse pregnancy outcomes, including gestational hypertension, preeclampsia, preterm delivery, and fetal growth restriction, are important risk factors for cerebrovascular disease later in life.

SUMMARY

Many catastrophic maternal strokes could be avoided with targeted prevention efforts, early recognition of warning signs, and rapid evaluation of neurologic symptoms. Neurologists play a central role in the care of pregnant patients with cerebrovascular disease, whether acute or chronic, and should be familiar with the unique and complex physiology of pregnancy and its complications, particularly hypertensive disorders of pregnancy.

Eclampsia in the 21st century

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.

Hypertension in Pregnancy: Diagnosis, Blood Pressure Goals, and Pharmacotherapy: A Scientific Statement From the American Heart Association

Hypertensive disorders of pregnancy (HDP) remain one of the major causes of pregnancy-related maternal and fetal morbidity and mortality worldwide. Affected women are also at increased risk for cardiovascular disease later in life, independently of traditional cardiovascular disease risks. Despite the immediate and long-term cardiovascular disease risks, recommendations for diagnosis and treatment of HDP in the United States have changed little, if at all, over past decades, unlike hypertension guidelines for the general population. The reasons for this approach include the question of benefit from normalization of blood pressure treatment for pregnant women, coupled with theoretical concerns for fetal well-being from a reduction in utero-placental perfusion and in utero exposure to antihypertensive medication. This report is based on a review of current literature and includes normal physiological changes in pregnancy that may affect clinical presentation of HDP; HDP epidemiology and the immediate and long-term sequelae of HDP; the pathophysiology of preeclampsia, an HDP commonly associated with proteinuria and increasingly recognized as a heterogeneous disease with different clinical phenotypes and likely distinct pathological mechanisms; a critical overview of current national and international HDP guidelines; emerging evidence that reducing blood pressure treatment goals in pregnancy may reduce maternal severe hypertension without increasing the risk of pregnancy loss, high-level neonatal care, or overall maternal complications; and the increasingly recognized morbidity associated with postpartum hypertension/preeclampsia. Finally, we discuss the future of research in the field and the pressing need to study socioeconomic and biological factors that may contribute to racial and ethnic maternal health care disparities.

Posterior reversible encephalopathy syndrome (PRES): diagnosis and management

Posterior reversible encephalopathy syndrome (PRES) may present with diverse clinical symptoms including visual disturbance, headache, seizures and impaired consciousness. MRI shows oedema, usually involving the posterior subcortical regions. Triggering factors include hypertension, pre-eclampsia/eclampsia, renal failure, cytotoxic agents and autoimmune conditions. The mechanism underlying PRES is not certain, but endothelial dysfunction is implicated. Treatment is supportive and involves correcting the underlying cause and managing associated complications, such as seizures. Although most patients recover, PRES is not always reversible and may be associated with considerable morbidity and even mortality.

Posterior Reversible Encephalopathy Syndrome: A Review of the Literature

Posterior reversible encephalopathy syndrome (PRES) is a group of clinical syndromes typically characterized by bilateral reversible vasogenic edema of the subcortical white matter in the parieto-occipital region on neuroimaging that causes a wide variety of acute or subacute neurological symptoms, including headache, mental status alteration, seizures, and visual dysfunction. PRES is classically suspected in patients with severe hypertension, renal failure, autoimmune disorders, eclampsia, or immunosuppressant medications. Frequent neurological evaluations and neuroimaging examinations by computed tomography or magnetic resonance imaging are required for both the diagnosis and assessment of the condition. Early detection of the disease is key for a rapid recovery and good prognosis.

Clinical and Imaging Data-Based Model for Predicting Reversible Posterior Leukoencephalopathy Syndrome (RPLS) in Pregnant Women With Severe Preeclampsia or Eclampsia and Analysis of Perinatal Outcomes

OBJECTIVE

This study aimed to investigate the risk factors of reversible posterior leukoencephalopathy syndrome (RPLS) in pregnant women with severe preeclampsia or eclampsia (SPE/E) based on a predicting model and to analyze the perinatal outcomes.

METHODS

From January 2015 to March 2020, 78 pregnant women data diagnosed with severe preeclampsia or eclampsia with cranial magnetic resonance imaging (MRI) and transcranial Doppler (TCD) screening in Xiangyang No. 1 People's Hospital and Jiangsu Province Hospital of Chinese Medicine were analyzed retrospectively. They were divided into the RPLS group (n = 33) and non-RPLS group (n = 45) based on the MRI results. The general clinical data (blood pressure, BMI, symptoms, and so forth), laboratory examination, TCD results, and perinatal outcomes in the two groups were compared. The risk factors of severe preeclampsia or eclampsia complicated with RPLS were analyzed by multivariate logistic regression. The prediction model and decision curve (DCA) were established according to the clinical-imaging data.

RESULTS

The univariate analysis showed that poor placental perfusion, hypertension emergency, use of two or more oral antihypertensive drugs, headache, white blood cell (WBC) count, platelet (PLT) count, lactate dehydrogenase (LDH), alanine aminotransferase (ALT), uric acid (UA), serum albumin (ALB), average flow velocity, and resistance index of the posterior cerebral and basilar arteries were significantly different in the RPLS group compared with the non-RPLS group (all P < 0.05). The multivariate logistic regression analysis showed that hypertensive emergency, headache, WBC, PLT, ALT, and average flow velocity of the basilar artery (BAAFV) were the risk factors in the RPLS group. The aforementioned clinical-imaging data modeling (general data model, laboratory examination model, TCD model, and combined model) showed that the combined model predicted RPLS better. DCA also confirmed that the net benefit of the combined model was higher. In addition, the incidence of postpartum hemorrhage, stillbirth, and preterm infants was higher in the RPLS group than in the non-RPLS group (all P < 0.05).

CONCLUSIONS

More postpartum complications were detected in pregnant women with severe preeclampsia or eclampsia complicated with RPLS. Hypertensive emergency, headache, WBC, PLT, ALT, and BAAFV were the important risk factors for RPLS. The combined model had a better effect in predicting RPLS.

Evaluation of QOL in Patients with Dyspeptic Symptoms Who Meet or Do Not Meet Rome IV Criteria

Health related quality of life (HR-QOL) of functional dyspepsia (FD) patients is impaired. However, the QOL of such patients has not been fully examined. Accordingly, we examined the QOL of Rome IV defined FD, endoscopic negative dyspeptic patients who do not meet the criteria, (non-FD patients) and healthy subjects, and investigated the factors that influence HR-QOL. This was a multicenter, prospective, observational study. Two hundred thirty-five patients (126 FD, 87 non-FD) and 111 healthy subjects were investigated, and non-FD patients were subdivided into three groups: 17 patients failing to meet only the disease duration criterion (Group A), 53 patients failing to meet only disease frequency criterion (Group B) and 17 patients failing to meet both the disease duration and frequency criteria (Group C). They completed a questionnaire survey regarding gastrointestinal symptoms (GSRS), QOL and psychological factors, which were compared among three groups. The total GSRS score was significantly higher in FD patients than non-FD patients (p = 0.012), which was higher than the healthy subjects (p < 0.0001). Furthermore, the total GSRS score of FD patients was comparable to that of Group A (p = 0.885), which was significantly higher than that of the Group B and C (p = 0.028, p = 0.014, respectively). HR-QOL is more impaired in FD patients than non-FD patients, which was significantly lower than the healthy subjects. That GSRS score in FD and Group A was comparable suggesting that an increased frequency of symptoms may have impact on the impairment of patient’s QOL.

The pathophysiologic, diagnostic, and therapeutic aspects of posterior reversible encephalopathy syndrome during pregnancy

Posterior reversible encephalopathy syndrome (PRES) is a neurological condition with a wide range of symptoms, including visual disturbances, headache, vomiting, seizures, and altered consciousness. This review describes the pathophysiology of PRES, as well as the clinical, diagnostic, and therapeutic intervention during pregnancy. The gold standard for diagnosis of PRES is Magnetic Resonance Imaging (MRI), helping to differentiate it from other similar conditions. The aim of this paper is to review the principal aspects of PRES, general care, blood pressure control, and seizures prevention while avoiding potential injuries to the mother and fetus in the event of pregnancy. We concluded that PRES can be effectively treated and reversed if prompt diagnostic action is made, and adequate care is initiated.

Rheumatic Diseases Associated With Posterior Reversible Encephalopathy Syndrome

OBJECTIVE

Posterior reversible encephalopathy syndrome (PRES) is an acute neurological syndrome. There are many reports of PRES occurring in the setting of rheumatic diseases. However, it remains uncertain whether rheumatic diseases are truly a risk factor for PRES, as the literature consists of case reports and small clinical series. Here, we evaluated the relationship between PRES and the rheumatic diseases, using a large population-based data set as the reference.

METHODS

We conducted a medical records review of hospitalizations in the United States during 2016 with a diagnosis of PRES. Hospitalizations were selected from the National Inpatient Sample. International Classification of Diseases, 10th Revision, Clinical Modification codes were used to identify rheumatic diseases. A multivariate logistic regression analysis was used to calculate odds ratios (ORs) for the association of PRES and rheumatic diseases.

RESULTS

There were 3125 hospitalizations that had a principal billing diagnosis of PRES. Multivariate logistic regression revealed the multiple independent associations with PRES. The demographic and nonrheumatic associations included acute renal failure (OR, 1.52), chronic renal failure (OR, 12.1), female (OR, 2.28), hypertension (OR, 8.73), kidney transplant (OR, 1.97), and preeclampsia/eclampsia (OR, 11.45). Rheumatic associations with PRES included antineutrophil cytoplasmic antibody-associated vasculitis (OR, 9.31), psoriatic arthritis (OR, 4.61), systemic sclerosis (OR, 6.62), systemic lupus erythematosus (SLE) nephritis (OR, 7.53), and SLE without nephritis (OR, 2.38).

CONCLUSIONS

This analysis represents the largest sample to date to assess PRES hospitalizations. It confirms that several rheumatic diseases are associated with PRES, including antineutrophil cytoplasmic antibody-associated vasculitis, systemic sclerosis, SLE, and psoriatic arthritis. Acute and unexplained central nervous system symptoms in these patient populations should prompt consideration of PRES.

Study protocol: establishment of a multicentre pre-eclampsia database and biobank in Sweden: GO PROVE and UP MOST, a prospective cohort study

INTRODUCTION

Pre-eclampsia, a multisystem disorder in pregnancy, is one of the most common causes of maternal morbidity and mortality worldwide. However, we lack methods for objective assessment of organ function in pre-eclampsia and predictors of organ impairment during and after pre-eclampsia. The women's and their partners' experiences of pre-eclampsia have not been studied in detail. To phenotype different subtypes of the disorder is of importance for prediction, prevention, surveillance, treatment and follow-up of pre-eclampsia.The aim of this study is to set up a multicentre database and biobank for pre-eclampsia in order to contribute to a safer and more individualised treatment and care.

METHODS AND ANALYSIS

This is a multicentre cohort study. Prospectively recruited pregnant women ≥18 years, diagnosed with pre-eclampsia presenting at Sahlgrenska University Hospital, Uppsala University Hospital and at Södra Älvsborgs Hospital, Sweden, as well as normotensive controls are eligible for participation. At inclusion and at 1-year follow-up, the participants donate biosamples that are stored in a biobank and they are also asked to participate in various organ-specific evaluations. In addition, questionnaires and interviews regarding the women's and partner's experiences are distributed at follow-up.

ETHICS AND DISSEMINATION

By creating a database and biobank, we will provide the means to explore the disorder in a broader sense and allow clinical and laboratory discoveries that can be translated to clinical trials aiming at improved care of women with pre-eclampsia. Further, to evaluate experiences and the psychological impact of being affected by pre-eclampsia can improve the care of pregnant women and their partners. In case of incidental pathological findings during examinations performed, they will be handled in accordance with clinical routine. Data are stored in a secure online database. Biobank samples are identified through the women's personal identification number and pseudonymised after identification in the biobank before analysis.This study was approved by the regional ethical review board in Gothenburg on 28 December 2018 (approval number 955-18) and by the Swedish Ethical Review Authority on 27 February 2019 (approval number 2019-00309).Results from the study will be published in international peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ISRCTN13060768.

Posterior Reversible Encephalopathy Syndrome: A Narrative Review for Emergency Clinicians

BACKGROUND

Posterior reversible encephalopathy syndrome (PRES) is a clinicoradiologic disorder characterized by seizures, headache, altered mental status, and visual disturbances, and is often associated with acute hypertension.

OBJECTIVE

This narrative review provides a focused description of the presentation, diagnostic evaluation, and management of PRES.

DISCUSSION

PRES is associated with a variety of factors, including acute rise in blood pressure, renal disease, preeclampsia/eclampsia, and immunosuppressive therapy. The pathophysiology is theorized to involve dysfunction of cerebral autoregulation leading to vascular leak or endothelial dysfunction resulting in vasogenic edema. In the emergency department (ED), clinical findings suggestive of PRES should prompt diagnostic testing focused on confirming the diagnosis and excluding other conditions that may present similarly. Laboratory studies are primarily useful for excluding alternative diagnoses. Computed tomography (CT) and, in particular, magnetic resonance imaging (MRI) are the recommended neuroimaging modalities for diagnosis. CT and MRI may demonstrate cerebral vasogenic edema, most often in the distribution of the posterior circulation. Treatment involves management of seizures, control of blood pressure if elevated, and treatment of any underlying trigger.

CONCLUSION

PRES is a neurological disorder that is typically reversible if recognized on presentation and promptly and appropriately managed. This narrative review characterizes this condition for emergency clinicians.

Eclampsia and posterior reversible encephalopathy syndrome (PRES): A retrospective review of risk factors and outcomes

Posterior reversible encephalopathy syndrome (PRES) is a clinical and radiological entity initially described in 1996. PRES frequently develops in patients with preeclampsia and eclampsia. There is not much literature on risk factors causing PRES in pregnant patients with eclampsia. This study aimed to determine the incidence of PRES in eclampsia, its association with pregnancy, risk factors, and maternal and perinatal outcomes.

Patients and methods: All patients who were admitted with eclampsia and developed PRES in an intensive care unit of a tertiary medical facility between 1997 and 2017 were included in the study. Patients’ demographics, pregnancy and gestational data, treatment mode, and outcomes were retrospectively obtained from their medical charts/files. Data were entered using SPSS program version 23. Chi-square test was used to compare the variables, and a p value of < 0.05 was considered statistically significant.

Results: A total of 151 patients were admitted during the study period, and 25 developed PRES. The diagnosis was common in patients older than 25 years. Eclampsia patients who developed PRES were without any pregnancy-associated comorbidities (p < 0.08). At the time of diagnosis, their gestational age was more than 36 weeks, which was significant (p < 0.04). Incidence was significantly higher in patients presenting with eclampsia and had recurrent seizures (p < 0.01 and 0.002, respectively). Its incidence was significantly higher in postpartum eclampsia patients (p < 0.01). It was also significantly higher in patients who had cesarean section and hypertension treated with labetalol (p < 0.001 and 0.02, respectively). Overall, the maternal mortality rate of eclampsia patients complicated with PRES was 4% in our population.

Conclusion: Of eclampsia patients, 16% developed PRES, which is on the lower side than the reviewed literature (10%–90%). Eclampsia on presentation, recurrent seizures, postpartum eclampsia, cesarean delivery, and labetalol use were associated with increased risk of PRES development.

Coexisting posterior reversible encephalopathy syndrome and ischemic hepatopathy: A case report

Posterior reversible encephalopathy syndrome (PRES) is acute neurologic symptoms with specific radiologic findings. This unique case shows coexisting PRES with acute liver injury, which could suggest common pathophysiologic process.

Stroke in Pregnancy: A Multidisciplinary Approach

Pregnancy confers a substantially increased risk of stroke, especially during the third trimester and until 6 weeks postpartum. Hypertensive disorders of pregnancy and gestational hypercoagulability are important contributors to obstetric stroke. Preeclampsia and eclampsia confer risk for future cardiovascular disease. Hemorrhagic stroke is the most common type of obstetric stroke. Ischemic stroke can result from cardiomyopathy, paradoxical embolism, posterior reversible encephalopathy, reversible cerebral vasoconstriction syndrome, and dissections. Cerebral venous sinus thrombosis is a frequent complication of pregnancy.

Maternal microvascular dysfunction during preeclamptic pregnancy

Preeclampsia is a hypertensive disorder of pregnancy effecting ∼5-8% of pregnancies in the United States, and ∼8 million pregnancies worldwide. Preeclampsia is clinically diagnosed after the 20th week of gestation and is characterized by new onset hypertension accompanied by proteinuria and/or thrombocytopenia, renal insufficiency, impaired liver function, pulmonary edema, or cerebral or visual symptoms. This broad definition emphasizes the heterogeneity of the clinical presentation of preeclampsia, but also underscores the role of the microvascular beds, specifically the renal, cerebral, and hepatic circulations, in the pathophysiology of the disease. While the diagnostic criteria for preeclampsia relies on the development of de novo hypertension and accompanying clinical symptoms after 20-week gestation, it is likely that subclinical dysfunction of the maternal microvascular beds occurs in parallel and may even precede the development of overt cardiovascular symptoms in these women. However, little is known about the physiology of the non-reproductive maternal microvascular beds during preeclampsia, and the mechanism(s) mediating microvascular dysfunction during preeclamptic pregnancy are largely unexplored in humans despite their integral role in the pathophysiology of the disease. Therefore, the purpose of this review is to provide a summary of the existing literature on maternal microvascular dysfunction during preeclamptic pregnancy by reviewing the functional evidence in humans, highlighting potential mechanisms, and providing recommendations for future work in this area.

Neurology of Preeclampsia and Related Disorders: an Update in Neuro-obstetrics

PURPOSE OF REVIEW

Preeclampsia and related hypertensive disorders of pregnancy affect up to 10% of pregnancies. Neurological complications are common and neurologists often become involved in the care of obstetric patients with preeclampsia. Here, we review the definition(s), epidemiology, clinical features, and pathophysiology of preeclampsia, focusing on maternal neurological complications and headache as a common presenting symptom of preeclampsia.

RECENT FINDINGS

Neurological symptoms are early and disease-defining features of preeclampsia. Neurological complications of preeclampsia may include headaches, visual symptoms, cerebral edema, seizures, or acute cerebrovascular disorders such as intracerebral hemorrhage or reversible cerebral vasoconstriction syndrome. A history of migraine is an independent risk factor for vascular diseases during pregnancy, including preeclampsia and maternal stroke. The pathophysiology of both preeclampsia and migraine is complex, and the mechanisms linking the two are not fully understood. Overlapping clinical and pathophysiological features of migraine and preeclampsia include inflammation, vascular endothelial dysfunction, and changes in vasoreactivity. Neurological complications are recognized as a major contributor to maternal morbidity and mortality. Pregnant and postpartum women commonly present with headache, and red flags in the clinical history and examination should prompt urgent neuroimaging and laboratory evaluation. A focused headache history should be elicited from patients as part of routine obstetrical care to identify patients at an increased risk of preeclampsia and related hypertensive disorders of pregnancy. Collaborative models of care and scientific investigation in the emerging field of neuro-obstetrics have the common goal of reducing the risk of maternal neurological morbidity and mortality from preeclampsia.

Posterior Reversible Encephalopathy Syndrome

Purpose of Review

This review provides an updated discussion on the clinical presentation, diagnosis and radiographic features, mechanisms, associations and epidemiology, treatment, and prognosis of posterior reversible encephalopathy syndrome (PRES). Headache is common in PRES, though headache associated with PRES was not identified as a separate entity in the 2018 International Classification of Headache Disorders. Here, we review the relevant literature and suggest criteria for consideration of its inclusion.

Recent Findings

COVID-19 has been identified as a potential risk factor for PRES, with a prevalence of 1–4% in patients with SARS-CoV-2 infection undergoing neuroimaging, thus making a discussion of its identification and treatment particularly timely given the ongoing global pandemic at the time of this writing.

Summary

PRES is a neuro-clinical syndrome with specific imaging findings. The clinical manifestations of PRES include headache, seizures, encephalopathy, visual disturbances, and focal neurologic deficits. Associations with PRES include renal failure, preeclampsia and eclampsia, autoimmune conditions, and immunosuppression. PRES is theorized to be a syndrome of disordered autoregulation and endothelial dysfunction resulting in preferential hyperperfusion of the posterior circulation. Treatment typically focuses on treating the underlying cause and removal of the offending agents.

Endothelial cell disruption drives increased blood-brain barrier permeability and cerebral edema in the Dahl SS/jr rat model of superimposed preeclampsia

Preeclampsia is characterized by increases in blood pressure and proteinuria in late pregnancy, and neurological symptoms can appear in the form of headaches, blurred vision, cerebral edema, and, in the most severe cases, seizures (eclampsia). The causes for these cerebral manifestations remain unknown, so the use of animal models that mimic preeclampsia is essential to understanding its pathogenesis. The Dahl salt-sensitive (Dahl SS/jr) rat model develops spontaneous preeclampsia superimposed on chronic hypertension; therefore, we hypothesized that the Dahl SS/jr rat would display cerebrovascular features similar to those seen in human preeclampsia. Furthermore, we predicted that this model would allow for the identification of mechanisms underlying these changes. The pregnant Dahl SS/jr rat displayed increased cerebral edema and blood-brain barrier disruption despite tighter control of cerebral blood flow autoregulation and vascular smooth muscle myogenic tone. Analysis of cerebral endothelial cell morphology revealed increased opening of tight junctions, basement membrane dissolution, and vesicle formation. RNAseq analysis identified that genes related to endothelial cell tight junctions and blood-brain barrier integrity were differentially expressed in cerebral vessels from pregnant Dahl SS/jr compared with healthy pregnant Sprague Dawley rats. Overall, our data reveal new insights into mechanisms involved in the cerebrovascular dysfunction of preeclampsia.NEW & NOTEWORTHY This study uses the Dahl SS/jr rat as a preclinical model of spontaneous superimposed preeclampsia to demonstrate uncoupling of cerebral vascular permeability and blood-brain barrier disruption from cerebral blood flow autoregulatory dysfunction and myogenic tone. Additionally, the data presented in this study lay the foundational framework on which future experiments assessing specific transcellular transport components such as individual transporter protein expression and components of the vesicular transport system (caveolae) can be built to help reveal a potential direct mechanistic insight into the causes of cerebrovascular complications during preeclamptic pregnancies.