Posterior encephalopathy syndrome in women with eclampsia: Predictors and outcome

Gestational Hypertension, Preeclampsia, and Eclampsia and Future Neurological Disorders

Importance

Gestational hypertension, preeclampsia, and eclampsia are established risk factors for stroke and dementia later in life. Whether these pregnancy complications are associated with an increased risk of new-onset neurological disorders within months to years after giving birth is not known.

Objective

To explore whether gestational hypertension, preeclampsia, and eclampsia are associated with new-onset migraine, headache, epilepsy, sleep disorder, or mental fatigue within months to years after giving birth.

Design, Setting, and Participants

In this register-based cohort study, exposures were identified in the Swedish Medical Birth Register from 2005 to 2018. Follow-up was conducted using the National Patient Register, containing diagnoses from specialized inpatient and outpatient care. Follow-up started 42 days after delivery and continued until the first event, death, emigration, or the end of the follow-up period (2019). The risk was calculated with Cox regression analysis and expressed as adjusted hazard ratio (aHR) with a 95% CI. Through the Swedish Medical Birth Register, 659 188 primiparous women with singleton pregnancies between 2005 and 2018 were identified. Women with a diagnosis of chronic hypertension (n = 4271) or a prepregnancy neurological disorder (n = 6532) were excluded. The final study population included 648 385 women. Data analyses were conducted in 2023.

Exposures

Gestational hypertension, preeclampsia, and eclampsia.

Main outcome

The primary outcome was a composite neurological outcome of migraine, headache, epilepsy, sleep disorder, or mental fatigue.

Results

The study included 648 385 women with a mean age of 28.5 (SD, 5.0) years at the time of their first pregnancy. Women with gestational hypertension (n = 11 133), preeclampsia (n = 26 797), and eclampsia (n = 625) all had an association with increased risk for a new-onset neurological disorder compared with women with normotensive pregnancies. The aHR for gestational hypertension was 1.27 (95% CI, 1.12-1.45), 1.32 (95% CI, 1.22-1.42) for preeclampsia, and 1.70 (95% CI, 1.16-2.50) for eclampsia. When exploring individual outcomes, women with eclampsia were associated with more than a 5 times increased risk of epilepsy (aHR, 5.31; 95% CI, 2.85-9.89).

Conclusion and Relevance

In this study, gestational hypertension, preeclampsia, and eclampsia were associated with an increased risk of new-onset migraine, headache, epilepsy, sleep disorder, or mental fatigue within months to years after giving birth. Guidelines recommend follow-up after delivery for women with gestational hypertension and preeclampsia for their increased risk of cardiovascular disease. At these visits, caregivers should also pay attention to persisting or new-onset of neurological symptoms, since this group of women appears to be vulnerable to developing or experiencing neurological disorders.

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.

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.

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.

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.

Predictors of posterior reversible encephalopathy syndrome in women with hypertension in pregnancy: A prospective observational study

OBJECTIVES

Posterior reversible encephalopathy syndrome (PRES) is a clinical neuro-radiologic abnormality associated with eclampsia and is diagnosed with magnetic resonance imaging (MRI). However, MRI scans to detect PRES may be difficult to obtain routinely. Thus, it would be useful to see whether standard demographic, clinical and laboratory parameters are predictive of PRES.

STUDY DESIGN

Prospective observational cohort study.

MAIN OUTCOME MEASURE

Prediction of PRES with standard parameters.

RESULTS

30 hypertensive pregnant women were enrolled. Brain MRI scans were performed after delivery till 7 days post-partum. Area under curves (AUC)s for clinical and laboratory parameters were generated for PRES prediction. A total of 8 women (5 with eclampsia and 3 with preeclampsia with features of severity) had PRES features in MRI. The most specific parameters for predicting PRES were age (<24 years), platelet count (<0.69 lacs/mm³), serum ALT (>129 IU/L) and AST (>55 IU/L), total bilirubin (>1.3 mg/dl), low hemoglobin (<8.7 g/dl) and presence of seizures. The most sensitive predicting parameters were serum uric acid > 5.2 mg/dl, systolic blood pressure (SBP) > 164 mm Hg, diastolic blood pressure > 100 mmHg and serum creatinine > 0.8 mg/dl. The best AUCs > 70% and good Youden indices were obtained for age < 24 years, SBP > 164 mm Hg, total bilirubin > 1.3 mg/dl, AST > 55 IU/L, hemoglobin < 8.7 mg/dl and uric acid > 5.2 mg/dl.

CONCLUSION

In women with preeclampsia, younger age, raised SBP, elevated serum total bilirubin, uric acid and AST and low hemoglobin best predict PRES.

Simultanagnosia as a cause of visual disturbance following Posterior Reversible Encephalopathy Syndrome (PRES): A case report

Simultanagnosia resulting from dorsal stream dysfunction is an under recognized condition. In this case report we describe the case of a young woman who developed posterior reversible encephalopathy syndrome (PRES), and who recovered visual acuities of 20/20 in each eye, along with normal visual fields and contrast sensitivities, yet experienced persistent symptoms of perceptual dysfunction. Detailed and systematic history taking revealed consistent visual difficulties typical of dorsal stream dysfunction. After a detailed explanation of her symptomatology and training in a range of strategies to cope, the patient experienced a great improvement in her day-to-day functioning.

Migraine and other headache disorders in pregnancy

Migraine prevalence is three times higher in women than in men during fertile years, which is mainly due to sex hormone differences. The majority of women suffering from migraine without aura report improvement of their migraine attacks during pregnancy. Migraine attacks with aura can also improve during pregnancy, but more often remain the same or worsen. Anovulation caused by lactation is generally associated with a decrease in migraine attacks in breastfeeding women. This chapter describes the current knowledge on acute and prophylactic treatment options of migraine and other primary headache disorders during pregnancy and lactation. Further, clinical profiles of secondary headaches during pregnancy and the postpartum period are summarized.

Posterior reversible encephalopathy syndrome associated with reversible cerebral vasoconstriction syndrome in a patient presenting with postpartum eclampsia: A case report

Posterior reversible encephalopathy syndrome (PRES) and reversible cerebral vasoconstriction (RCVS) are rare neurological disorders with complex physiopathology which is not yet fully understood. We present here the case of a 31-year-old woman with a bi-amniotic bi-chorial pregnancy who developed immediate postpartum eclampsia after vaginal delivery, associated with RCVS and PRES. Although post-partum is a well-known precipitating factors for these diseases, to our knowledge, there are only few similar cases reported with the association of these syndromes. Repeated MRI scans were instrumental in the final diagnosis of RCVS associated with PRES, allowing us to give the patient the appropriate treatment. These two syndromes have similar symptoms but may have different treatments, thus highlighting the importance of a correct diagnosis.

Concomitant Acute Toxic Leukoencephalopathy and Posterior Reversible Encephalopathy Syndrome

BACKGROUND AND PURPOSE

Posterior reversible encephalopathy syndrome (PRES) and acute toxic leukoencephalopathy (ATL) are both potentially reversible clinicoradiologic entities. Although their magnetic resonance imaging (MRI) findings differ, rarely both may occur simultaneously in acutely encephalopathic patients. Our aim was to determine the incidence and causes of concomitant "ATL-PRES."

METHODS

Retrospective search of suspected acutely encephalopathic adults since 1998 throughout our picture archiving and communication system revealed 167 patients with PRES and 106 patients with ATL. Images of these patients were retrospectively evaluated by two neuroradiologists and a fellow to identify the cases which carry both features of PRES and ATL. Imaging findings were scored based on previously reported scoring system as mild, moderate, and severe. The clinical outcome of the patients was determined according to the modified Rankin scale.

RESULTS

Our search revealed a series of 6 patients (%2.2) in 273 patients who presented acutely with either encephalopathy or seizures, caused by various etiologies, including immunosuppression following transplantation (n = 2), hypertensive crisis (n = 2), chemotherapy (n = 1), and sepsis (n = 1). MRI demonstrated findings consistent with both PRES and ATL simultaneously on FLAIR and diffusion weighted imaging. Severity of imaging findings of concomitant "ATL-PRES" was concordant with each other (rho ≈ 1.0, P < .00001), and each patient eventually returned to clinical baseline. This finding, along with their similar etiologies, raises the possibility of an underlying common pathophysiologic thread, perhaps being endothelial toxicity.

CONCLUSIONS

Concomitant "ATL-PRES" was found in 2.2% of the patients in a large cohort of ATL and PRES. Etiologies varied. Clinical symptoms and MRI findings were potentially reversible.