Late postpartum eclampsia

Posterior reversible encephalopathy syndrome in postpartum patients with gestational hypertension: A case report emphasizing early recognition and management

Posterior reversible encephalopathy syndrome (PRES) is a rare neuroradiological condition causing headaches, altered mental status, seizures, visual disturbances, and focal deficits. It is often associated with preeclampsia and eclampsia in pregnancy, but can also occur in patients with other medical conditions, such as hypertension, autoimmune diseases, renal dysfunction etc. This case report highlights the importance of recognizing PRES in postpartum patients with hypertension and the need for prompt diagnosis and management to prevent potential complications. A 30-year-old woman with gestational hypertension underwent scheduled induction of labor. After a successful delivery, she experienced a sudden headache but no other neurological symptoms. Imaging showed bilateral frontoparietal white matter edema, consistent with PRES. She was closely monitored, treated with analgesics, and improved within a week. The case highlights the rarity of PRES in postpartum patients without preeclampsia or eclampsia. It underscores the importance of considering PRES as a possible diagnosis in postpartum patients with hypertension, even in the absence of typical risk factors. Prompt control of blood pressure and careful monitoring are essential to ensure a positive outcome, as PRES can lead to life-threatening complications if not managed appropriately. The study highlights the importance of heightened awareness of PRES in postpartum patients with gestational hypertension. Early detection and timely management can improve prognosis, even in atypical cases. Healthcare professionals should be vigilant in assessing hypertension patients to diagnose and manage PRES, preventing neurological sequelae. Further research is needed to better understand PRES pathophysiology and risk factors in postpartum patients.

Cerebral vasospasm syndromes and postpartum eclampsia associated with post-dural puncture headache

Headache is common in the puerperium, with a wide variety of underlying aetiologies. We describe a unique case of postpartum headache after accidental dural puncture with a Tuohy needle in a previously healthy woman during a combined spinal-epidural for labour analgesia. Initially, a post-dural puncture headache was diagnosed. Eclampsia was subsequently suspected after the development of complex partial seizures and proteinuria 5 days postpartum. After neurological examination and neuroimaging, however, the diagnoses of reversible cerebral vasoconstriction syndrome and posterior reversible encephalopathy syndrome were confirmed. We hypothesise that accidental dural puncture which resulted in post-dural puncture headache may have delayed the diagnosis of other headache aetiologies and may have acted as a trigger for the development of cerebral vasospasm syndromes. This case demonstrates the importance of a careful assessment of postpartum headaches and the need for a high degree of diagnostic suspicion in cases of refractory post-dural puncture headache. In these cases, neurological referral and neuroimaging evaluation should be considered. We highlight the importance of multidisciplinary team including anaesthetists, obstetricians and other clinicians.

An unusual presentation of posterior reversible encephalopathy syndrome—a case report

Background

Acute neurological emergencies in pregnant and postpartum women presenting as headache, visual disturbances, seizures, and elevated blood pressure are usually attributed to preeclampsia and eclampsia. However cerebral venous sinus thrombosis (CVST) and posterior reversible encephalopathy syndrome (PRES) are two important, rare conditions which should be considered. PRES is a rare neuroradiological syndrome characterised by vasogenic oedema of subcortical white matter, commonly involving posterior cerebral hemispheres. Preeclampsia and eclampsia are the common causes of PRES. However, late postpartum eclampsia concurrent to PRES is rare. Here, we report a rare case of PRES secondary to late postpartum eclampsia with atypical radiological findings.

Case presentation

A 25-year-old married woman with prior history of two spontaneous abortions presented to us on day 5 postpartum, post lower segment caesarean section (LSCS) with complaints of headache followed by one episode of new onset generalised tonic-clonic seizures. There was no history of seizures prior to the pregnancy and no history of hypertension or diabetes during any of her pregnancies. On examination, BP was 140/90 mm Hg and PR 98 bpm. Systemic examination revealed GCS 15/15, no focal neurological deficits, and bilateral flexor plantar response. Fundus examination was normal with no evidence of hypertensive retinopathy. Preliminary haematological and biochemical tests including antiphospholipid antibody (APLA) profile were done in view of prior abortions and were within normal limits. Lumbar puncture was done—normal study. EEG was normal. MRI with MRV was suggestive of atypical posterior encephalopathy. In view of late onset postpartum seizure, the patient was started on injection of magnesium sulphate, anti-hypertensives, and antiepileptics; following which, she improved and was discharged.

Conclusion

Though preeclampsia and eclampsia are usually screened entities, we should also follow women in puerperium for late postpartum eclampsia which is defined as seizures beyond 48 h of delivery up to 4 weeks postpartum. So it is important to follow-up postpartum women for complications like PRES because early detection and treatment can lessen the morbidity and mortality as they are completely reversible. Thus, health care professionals should be educated about the same. Apart from antenatal and intrapartum care, postpartum care should also be given equal importance.

Atypical case of posterior reversible encephalopathy syndrome related to late onset postpartum eclampsia: A case report

RATIONALE

Eclampsia, an obstetric emergency frequently seen in pregnant or puerperal women, is a risk factor for posterior reversible encephalopathy syndrome (PRES). Most cases of eclampsia occur postpartum. We report a woman with PRES associated with eclampsia 10 weeks post-delivery, the latest onset ever reported.

PATIENT CONCERNS

A 23-year-old healthy woman presented headache and nausea 10 weeks after delivery. Two days later, she generalized tonic-clonic seizure. Her brain MRI presented the foci which is typical of PRES.

DIAGNOSIS

The patient was diagnosed as PRES associated with eclampsia.

INTERVENTIONS

The patient received levetiracetam and edaravone.

OUTCOMES

Her clinical course was uneventful and she fully recovered without neurological complications LESSONS:: The possible diagnosis of late onset postpartum eclampsia, even weeks post-delivery, should be considered, since initiation of early treatment averts severe complications and decreases mortality. Sharing our experience may increase awareness of PRES induced by late-onset postpartum eclampsia.

Preeclampsia: Disease biology and burden, its management strategies with reference to India

Preeclampsia is the cause of significant maternal and fetal mortality and morbidity. It is characterized by new-onset hypertension and proteinuria after 20 weeks of gestation. Preeclamptic women and children born from preeclamptic pregnancies are at greater risk to develop severe cardiovascular complications and metabolic syndromes later in life. The incidence of preeclampsia is estimated to be seven times higher in developing countries as compared to the developed countries. This review summarizes the pathophysiology of preeclampsia, emerging new hypothesis of its origin, risk factors that make women susceptible to developing preeclampsia and the potential of various biomarkers being studied to predict preeclampsia. The health care of developing countries is continuously challenged by substantial burden of maternal and fetal mortality. India despite being a fast developing country, is still far behind in achieving the required maternal mortality rates as per Millennium Development Goals set by the World Health Organization. Further, this review discusses the prevalence of preeclampsia in India, health facilities to manage preeclampsia, current guidelines and protocols followed and government policies to combat this complication in Indian condition.

Postpartum Headache

Approximately 40% of all women report experiencing headaches during the postpartum period, regardless of a previous headache history. This case narrative describes the clinical case of a 22-year-old woman who presented for the evaluation of an intractable headache for 2½ weeks. It demonstrates the inherent difficulty in diagnosing patients not presenting with "textbook" symptoms and highlights the fact that signs and symptoms of eclampsia/preeclampsia, such as elevated blood pressure, may fall below the threshold for hypertensive emergencies and not be considered in the differential. Emergency department providers must possess a strong knowledge base and skill set to recognize subtle presentations and direct care accordingly to ensure positive patient outcomes.

Labor therapeutics and BMI as risk factors for postpartum preeclampsia: A case-control study

OBJECTIVES

This study aims at identifying associations between therapeutics used during labor and the occurrence of postpartum preeclampsia (PPPE), a poorly understood entity.

STUDY DESIGN AND MAIN OUTCOME MEASURES

This is a case-control study of women who received an ICD-9 code for PPPE (cases) during the years 2009-2011, compared to women with a normotensive term pregnancy, delivery and postpartum period until discharge (controls), matched on age (±1year) and delivery date (±3months). Cases were defined as women having a normotensive term pregnancy, delivery and initial postpartum period (48h post-delivery) but developing hypertension between 48h and 6weeks postpartum. Single variable and multiple variable models were used to determine significant risk factors.

RESULTS

Forty-three women with PPPE were compared to 86 controls. Use of vasopressors and oxytocin did not differ between cases and controls, but rate of fluids administered during labor (OR=1.68 per 100cc/h; 95% CI: 1.09-2.59, p=0.02) and an elevated pre-pregnancy/first trimester BMI (OR=1.18 per kg/m², 95% CI: 1.07-1.3, p=0.001) were identified as significant risk factors in multivariate analysis.

CONCLUSIONS

We identified two potentially modifiable risk factors for PPPE; further studies are needed to better define the role of these two variables in the development of PPPE.

Clinical and Biomarkers Difference in Prepartum and Postpartum Eclampsia

Background

There is a large body of literature which assessed the incidence and risk factors of eclampsia, but little was done in assessing the association of clinical features and biological markers with prepartum and postpartum eclampsia.

Methods

A total of 361 eclamptic women admitted to three teaching hospitals between 2008 and 2013 were included in this analysis. A comparative analysis was done for several clinical and biological variables to assess their association with prepartum and postpartum eclampsia.

Results

The overall incidence of eclampsia was 1.2% (prepartum 71% and postpartum 29%). The majority of women with prepartum eclampsia were young, primigravida, more hypertensive, symptomatic and proteinuric. Conversely, the majoritys of the women with post-partum eclampsia were adult, multiparous, carrying pregnancy to term, anemic, thrombocytopenic, and with hepatic dysfunction. The commonest severity symptom (headache) was less common in postpartum eclamptic women.

Conclusion

The incidence of eclampsia was among the highest in the world. And, the analysis has shown that the clinical and biochemical spectrum of prepartum and postpartum eclampsia were apparently different. The majority of the women who developed postpartum eclampsia were multiparous and adult. Derangement of biomarkers was also more common in women with postpartum eclampsia.

No Hypertensive Disorder of Pregnancy; No Preeclampsia-eclampsia; No Gestational Hypertension; No Hellp Syndrome. Vascular Disorder of Pregnancy Speaks for All

Hypertensive disorders complicate 5%-10% of pregnancies with increasing incidence mainly due to upward trends in obesity globally. In the last century, several terminologies have been introduced to describe the spectrum of this disease. The current and widely used classification of hypertensive pregnancy disorders was introduced in 1972 and in 1982, but has not been free of controversy and confusion. Unlike other diseases, the existing terminology combines signs and symptoms, but does not describe the underlying pathology of the disease itself. In this commentary, a detailed account is given to vascular disorder of pregnancy (VDP) as an inclusive terminology taking into account the underlying pathology of the disease on affected organs and systems. A simple and uniform classification scheme for VDP is proposed.

Late postpartum eclampsia complicated with posterior reversible encephalopathy syndrome: a case report and a literature review

Posterior reversible encephalopathy syndrome (PRES) is a rare but serious clinical-neuroradiological entity characterized by headache, vomiting, visual disturbances, altered mental status, seizures, and unconsciousness associated with the characteristic imaging findings including sub-cortical vasogenic edema at the bilateral parietal and occipital lobes. We describe a case of 28-year-old PRES patient secondary to delayed maternal postpartum eclampsia. This patient was not initially diagnosed with pre-eclampsia and PRES. The diagnosis was established after magnetic resonance imaging. After treatment this patient's PRES resolved. Early diagnosis and treatment are the keys to reverse PRES. A literature review for PRES is provided in this report.

Blood pressure assessment and first-line pharmacological agents in women with eclampsia

BACKGROUND

Eclampsia is a life-threatening complication of pregnancy. Timely blood pressure assessment and administration of magnesium sulphate are essential management. In this retrospective single-centre study we examined the timing and magnitude of maternal blood pressure before eclampsia, and whether magnesium sulphate was administered as the first agent for treatment.

METHODS

We conducted a five-year review of eclampsia in a tertiary referral obstetric hospital. Using data from electronic birthing records and hospital coding (ICD-10AM) we identified patients with the diagnostic criteria for eclampsia and assessed patient characteristics, blood pressure and pharmacological treatment.

RESULTS

There were 33812 births from July 2008 to June 2013 with 19 cases of eclampsia (1:1780). Patients were 32±5.9years of age, 36±3.9weeks of gestation, 63% were nulliparous and all had a singleton pregnancy. Antepartum eclampsia occurred in 74%. In the four hours before a fit, 47% of patients had blood pressure recorded, of whom 78% were hypertensive. Magnesium sulphate was administered as first therapy in 47% of patients but it was not given to any patient transferred to hospital by ambulance. Of the patients who fitted antenatally, 86% underwent caesarean section, of whom 25% received neuraxial anaesthesia.

CONCLUSIONS

Our study highlights the need for vigilance when managing pregnant women with hypertension, especially in the third trimester as eclampsia is most likely preceded by raised blood pressure. It also highlights the need for timely commencement of magnesium sulphate in the community and during transfer to hospital for the treatment of eclampsia, and for prevention of eclampsia in hospital when thresholds for severe preeclampsia are met.

Posterior reversible encephalopathy syndrome (PRES) in a patient with late postpartum eclampsia

Posterior reversible encephalopathy syndrome (PRES) is a reversible neurological entity characterised by seizure, headaches, visual symptoms, impaired consciousness and other focal neurological findings. It is caused by a wide variety of causes ultimately leading to a vasogenic cerebral oedema of occipital and parietal lobes of the brain. We present here a young woman with headache, generalised tonic-clonic seizures and cortical blindness in a late postpartum stage. Reversibility of the symptoms and characteristic imaging findings led us to a diagnosis of PRES in our patient.

Preeclampsia 2012

Preeclampsia is a common complication of pregnancy associated with high maternal morbidity and mortality and intrauterine fetal growth restriction. There is extensive evidence that the reduction of uteroplacental blood flow in this syndrome results from the toxic combination of hypoxia, imbalance of angiogenic and antiangiogenic factors, inflammation, and deranged immunity. Women treated for preeclampsia also have an increased risk for cardiovascular and renal disease. At present it is unclear if the increased cardiovascular and renal disease risks are due to residual and or progressive effects of endothelial damage from the preeclampsia or from shared risk factors between preeclampsia and cardiac disease. Moreover, it appears that endothelin-1 signaling may play a central role in the hypertension associated with preeclampsia. In this paper, we discuss emerging data on the pathogenesis of preeclampsia and review therapeutic options.