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This case report describes an atypical presentation of eclampsia. A 26-year-old lady presented 5 days' postpartum with a series of grand mal seizures after an uneventful pregnancy and delivery. An MRI scan of the brain showed areas of low signal involving cerebral white matter and right cerebellum. Within 2 weeks, all symptoms and radiologic abnormalities had resolved.

We present our anaesthetic management of a 27-year-old woman with antepartum eclampsia, mild thrombocytopenia, difficult airway and clinical evidence of impending upper airway obstruction. She required urgent delivery by caesarean section, which was conducted uneventfully under spinal anaesthesia. We discuss the management conundrums presented by this case and why we chose spinal anaesthesia over other anaesthetic options.

A previously healthy female sustained bilateral subcapital femur fractures during an eclamptic seizure. This complication has not been previously described in association with eclampsia. Clinicians need to be aware of this potential complication and investigate postseizure hip pain appropriately.

Objective: This study was undertaken to characterize the neuroimaging findings of cerebral edema associated with eclamptic seizures by use of diffusion-weighted magnetic resonance imaging (MRI)., Study Design: During the 3-year period ending March 2002, 27 nulliparous women with eclampsia were evaluated with diffusion-weighted MRI and apparent diffusion coefficient mapping. Those with findings of restricted diffusion suggestive of cytotoxic edema underwent neuroimaging again 6 weeks post partum., Results: All but 2 of these 27 women (93%) had reversible vasogenic edema. Six were also found to have areas of cytotoxic edema consistent with cerebral infarction. Five of these 6 women had persistent imaging findings of infarction when studied post partum, however, without clinical neurologic deficits., Conclusion: The spectrum of cerebral lesions in eclampsia as seen with MRI varies from initially reversible areas of vasogenic edema that may progress to cytotoxic edema and infarction in up to a fourth of women.

Objective: The purpose of this study was to validate diffusion-weighted magnetic resonance imaging in the prediction of the evolutive course of brain edema and to establish its pathophysiologic presence in patients with eclampsia/severe preeclampsia., Study Design: Seventeen patients with a clinical diagnosis of severe eclampsia/preeclampsia and T2 hyperintense brain lesions on routine magnetic resonance imaging were evaluated at hospital admission and 8 weeks later., Results: Brain edema was reversible in 13 patients and irreversible in 4 patients, as indicated on follow-up magnetic resonance imaging. Sixteen of 17 patients were differentiated accurately into reversible and irreversible groups on the basis of diffusion imaging on hospital admission. Diffusion-weighted magnetic resonance imaging demonstrated a significant increase in water mobility in abnormal regions compared with normal-appearing brains in patients in the reversible group (1.34+/-0.10 mm(2) vs 0.79+/-0.08 mm(2)/s x 10(-3), P<.001). In the irreversible group, restricted water diffusion was present, which was consistent with cytotoxic edema and early brain infarction in 3 of 4 patients., Conclusion: Diffusion-weighted magnetic resonance imaging can predict successfully the evolutive course of brain edema in an acute setting in these patients. Our findings indicate that brain edema is vasogenic, although ischemic/cytotoxic edema was observed less commonly.

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

Objective: To evaluate the predictability of eclampsia and explore the role for seizure prophylaxis in a population with a low frequency of seizure prophylaxis., Methods: A retrospective review was conducted of all women with eclampsia registered at the Foothills Hospital in Calgary, Alberta, between 1991 and 2000. The data collected included timing of seizure in relation to diagnosis of gestational hypertension (GHTN) and delivery, method of seizure prophylaxis (if any), and maternal characteristics., Results: During the study period, 3075 of 38,577 women (8.0%) were diagnosed with GHTN, with or without proteinuria or adverse conditions. Three percent had received magnesium sulfate for seizure prophylaxis. Of these 3075 women, 17 (0.6%) developed eclampsia, none of whom was receiving magnesium sulfate for seizure prophylaxis at the time. Of these, 10 women (59%) exhibited GHTN prior to their first seizure, including 6 women with GHTN with adverse conditions, 3 with GHTN with proteinuria but without adverse conditions, and 1 with GHTN without proteinuria or adverse conditions. Five of the 17 women had seizures that occurred prior to labour, 6 were intrapartum, and 6 were postpartum. Nine (53%) of the 17 women with eclampsia had their initial seizure after the diagnosis of GHTN and before 24 hours postpartum., Conclusion: Seizure prophylaxis for all the women with GHTN, from the time of diagnosis through 24 hours postpartum, may have been able to prevent as many as 53% of eclamptic episodes. Three hundred and seven women with GTHN would have to receive seizure prophylaxis to prevent one seizure.

Objective: To study the specific management problems of severe eclampsia under tropical latitudes., Study Design: A two years retrospective study in a University hospital in the tropics., Patients and Methods: In all patients admitted for eclampsia between January 1997 et December 1999, the following parameters were studied: age, parity, interval between disease et admission, post-eclampsia Glasgow Coma Scale (GCS), time of occurrence of eclampsia during pregnancy, delivery route, blood pressure data at admission, the occurrence of complications at admission or during hospital stay., Results: Twenty-eight mainly primiparous patients (mean age: 26 +/- 6) were admitted with an average delay of 8.5 +/- 10.2 hours after the first symptoms. The time of occurrence was prepartum in 6, perpartum in 14 and postpartum in 8 cases. All patients were hypertensive and comatose with an average GCS of 8 +/- 2.2. Twenty patients had been previously intubated and ventilated. Delivery was natural in 22 and by caesarean section in 6 patients. The following complications were found: acute oliguric renal failure (9), HELLP-syndrome (4), cerebral haemorrhage (4), acute lung oedema (3) and acute respiratory distress syndrome (1). Maternal and child mortality were 35 and 42.8% respectively., Conclusion: Eclampsia is a major cause of both maternal and infantile mortality in developing countries. The authors insist that prevention and management require speedy transfers to adapted specialized obstetrical intensive care structures.

Objective: To study the factors of risk of complications and evaluate the quality of medical and obstetrical management of eclampsia., Methodology: We performed a retrospective analysis of all cases of eclampsia recorded during the ante- or per partum period from January 1, 2000 to December 31, 2001 at the gynecological and obstetrical clinic at Dakar University Teaching Hospital., Results: Eclampsia had concerned 78 patients, with an incidence of 8 per 1000 childbirth. The epidemiological profile was primipara (68%), young (average age: 20 years), 36 weeks pregnancy or more (60,3%), evacuation in a state of post critical coma (74.3%), on average after 2 seizures, without medical assistance (64%) with an average diastolic blood pressure of 100 mm Hg. Examinations with strong prognosis value like blood count, creatininemia, coagulation, hepatic transaminases and uricemia were not available in emergency (only 24% of all cases). Medicines prescribed included, nicardipine (63%) and magnesia sulfate (53%); this medical treatment was satisfactory in 34.6% of the cases. Cesarean section was performed in 50%. The prognosis was marked by 17.9% maternal mortality and a perinatal mortality of 359 per 1000 births. The principal risk factors of maternal and perinatal complications were early-onset eclampsia, large number of seizures and late obstetrical treatment., Conclusion: Prehospital treatment and availability of early cesarean section must be better organized to improve the prognosis of eclampsia.

Objective: Current treatment of preeclampsia no longer mandates delivery for proteinuria of >5 g per 24 hours. We sought to determine whether delayed delivery of preeclampsia with massive proteinuria (>10 g/24 h) increased maternal or neonatal morbidity., Study Design: Records of all women with preeclampsia who were delivered at <37 weeks of gestation between January 1, 1997, and June 30, 2001, were reviewed. Patients with underlying renal disease or multiple gestation were excluded. Patients were characterized as having mild (<5 g/24 h), severe (5-9.9 g/24 h), or massive (>10 g/24 h) proteinuria. Outcomes were compared using the chi(2) test, one-way analysis of variance, or Fisher exact test., Results: Two hundred nine patients met the inclusion criteria: 125 patients had mild proteinuria, 43 patients had severe proteinuria, and 41 patients had massive proteinuria. No significant differences in maternal morbidity were seen. Massive proteinuria was associated with earlier onset of preeclampsia, earlier gestational age at delivery, and higher rates of prematurity complications. After correction for prematurity, massive proteinuria has no significant effect on neonatal outcomes., Conclusion: Women with preeclampsia and massive proteinuria did not have increased maternal morbidity compared with women with severe or mild proteinuria. Massive proteinuria appears to be a marker for early-onset disease and progression to severe preeclampsia. Neonatal morbidity appears to be a function of prematurity rather than of massive proteinuria itself.

Objective: The purpose of this study was to determine whether there is a shift in the timing of eclampsia in relation to delivery and whether traditional symptoms precede impending postpartum eclampsia., Study Design: A multicenter analysis of data from patients with eclampsia from March 1996 through February 2001 at the University of Cincinnati, the University of Tennessee, Memphis, and Central Baptist Hospital, Lexington. Data were collected regarding the relationship of the patient's first seizure to delivery, prodromal symptoms, neuroimaging studies, use of magnesium sulfate, antihypertensive therapy, and follow-up medical care. The analysis focused on women who had late postpartum eclampsia., Results: During the study period, 89 patients were diagnosed with eclampsia. Twenty-nine women (33%) had postpartum eclampsia, of whom 23 women (79%) had late onset (>48 hours). Interestingly, only 5 of these 23 women (22%) had been previously diagnosed with preeclampsia. Twenty-one patients (91%) with late postpartum eclampsia had at least 1 prodromal symptom, and 12 patients (52%) had >1 symptom that heralded the seizure: 20 women (87%) had headache; 10 women (44%) had visual changes; 5 women (22%) had nausea or vomiting; and 2 women (9%) experienced epigastric pain. Only 7 of these 21 women (33%) sought care for their symptoms, of whom 6 women (86%) had clinical evidence of preeclampsia that was not considered by the treating physician. Among all patients with eclampsia, there were 7 cases of aspiration pneumonia, 3 cases of pulmonary edema, 3 cases of pleural effusion, 2 cases of disseminated intravascular coagulation, and no cases of maternal death., Conclusion: Current obstetric treatment in the United States has resulted in a shift of eclampsia toward the postpartum period, with most cases being seen as late post partum. To reduce the rate of late postpartum eclampsia, efforts should be directed to the education of the health care providers and patients regarding the importance of prompt reporting and evaluation of symptoms of preeclampsia during the postpartum period.

Objective: We sought to determine risk factors for deep vein thrombosis and pulmonary embolism during pregnancy or post partum., Study Design: We performed a population-based case-control study. All Olmsted County, Minnesota, residents with a first lifetime deep vein thrombosis or pulmonary embolism during pregnancy or post partum from 1966 to 1990 were identified (N = 90). Where possible, a resident without deep vein thrombosis or pulmonary embolism was matched to each patient by date of the first live birth after the patient's child. The medical records of all remaining patients and all control subjects were reviewed for >25 baseline characteristics, which were tested as risk factors for deep vein thrombosis or pulmonary embolism., Results: In multivariate analysis smoking (odds ratio, 2.4) and prior superficial vein thrombosis (odds ratio, 9.4) were independent risk factors for deep vein thrombosis or pulmonary thrombosis during pregnancy or post partum., Conclusion: Venous thromboembolism prophylaxis may be warranted for pregnant women with prior superficial vein thrombosis. Smoking cessation should be recommended, especially during pregnancy and the postpartum period.

Objective: The purpose of this study was to examine the effect of gestational hypertension and preeclampsia on fetal growth., Study Design: A retrospective cohort study was conducted on the basis of 97,270 pregnancies delivered between 1991 and 1996 in 35 hospitals in northern and central Alberta, Canada. Univariate and multivariate logistic analyses were performed to examine the impact of preeclampsia and gestational hypertension on high-birth-weight (> or =4200 g), large-for-gestational-age, low-birth-weight (<2500 g), and small-for-gestational-age babies., Results: The rate of high-birth-weight fetuses in women with gestational hypertension (7. 3%) was higher than in those with normal blood pressure (5.6%). After we controlled for confounders, the adjusted odds ratio of high birth weight was 1.44 (95% confidence interval, 1.21-1.70) in women with gestational hypertension. Preeclampsia was also associated with a statistically nonsignificant (P =.054) increased risk of high birth weight (adjusted odds ratio, 1.40; 95% confidence interval 0. 99-1.98). The rate of large-for-gestational-age babies was significantly higher in women with gestational hypertension (4.5%) and preeclampsia (4.7%) than in those with normal blood pressure (2. 2%), with adjusted odds ratios of 1.50 (95% confidence interval, 1. 22-1.85) for gestational hypertension and 1.87 (95% confidence interval, 1.31-2.67) for preeclampsia. Concurrently, women who had gestational hypertension were also at higher risk of having low-birth-weight (adjusted odds ratio, 2.4; 95% confidence interval, 2.13-2.93) and small-for-gestational-age (adjusted odds ratio, 2.04; 95% confidence interval, 1.68-2.48) babies. Women with preeclampsia were also at markedly higher risk of having low-birth-weight (adjusted odds ratio, 4.14; 95% confidence interval, 3.32-5.15) and small-for-gestational-age (adjusted odds ratio, 2.56; 95% confidence interval, 1.92-3.41) babies., Conclusions: There is a significant association of preeclampsia and gestational hypertension with large-for-gestational-age infants, in addition to a significant association with low-birth-weight and small-for-gestational-age infants. This study challenges the currently held belief that reduced uteroplacental perfusion is the unique pathophysiologic process in preeclampsia.

Objective: This study was undertaken to describe and correlate clinical findings with computed tomographic and magnetic resonance imaging scan results in 10 women with eclampsia and widespread cerebral edema., Study Design: This was a clinical descriptive study of 10 women with eclampsia and symptomatic cerebral edema who were encountered at Parkland Hospital from 1986 through 1998. During this 13-year period nearly 175 women had eclampsia from a total of >160, 000 women delivered. The clinical courses of these 10 women with eclampsia and symptomatic cerebral edema are described, along with findings from computed tomographic and magnetic resonance imaging scans., Results: In 3 cases symptoms followed an acute and severe elevation of blood pressure while the patient was being treated for eclampsia. All 3 of these women had severe generalized edema with radiographic findings of impending transtentorial herniation. Herniation did occur in 1 of these women, and she died. The other 7 women had central nervous system symptoms that persisted after an initial eclamptic convulsion. Symptoms ranged from lethargy, confusion, and blurred vision to obtundation and blindness. Five of these women had multiple areas of edema mostly apparent at the gray matter-white matter junction. Two women demonstrated extensive unilateral brain involvement; however, their symptoms were similar to those of the women with multifocal areas of cerebral edema., Conclusion: Symptomatic cerebral edema developed in almost 6% of women with eclampsia. Its genesis probably represents a continuum of central nervous system lesions that result from eclampsia. We postulate that women with symptoms of extensive cerebral edema have a cytotoxic edema caused by ischemia that is intensified by a vasogenic edema associated with sudden or severe hypertension.

Objective: We sought to examine risk factors for urinary tract infection in postpartum women., Study Design: Subjects (n = 931) with maternal urinary tract infections and control subjects (n = 1862) were identified by using a linked Washington State birth certificate and Birth Events Records Database for the years 1987-1993; stratified analysis was performed by using Mantel-Haenszel procedures., Results: Increased risk for postpartum urinary tract infection was associated with black, Native American, or Hispanic race-ethnicity (odds ratio, 1.30; 95% confidence interval, 1.03-1.64) and unmarried status (odds ratio, 1.33; 95% confidence interval, 1.11-1.58). Cesarean delivery (odds ratio, 2.70; 95% confidence interval, 2.27-3.20) and tocolysis (odds ratio, 3.30; 95% confidence interval, 2.15-5.06) also contributed to maternal risk of acquiring a urinary tract infection. Maternal risk factors included renal disease (adjusted odds ratio, 3.89; 95% confidence interval, 1.80-8.41) and preeclampsia-eclampsia (adjusted odds ratio, 3.21; 95% confidence interval, 2.36-4.38). Among women undergoing vaginal delivery, renal disease (odds ratio, 5.47; 95% confidence interval, 2.04-14.64) and abruptio placentae (odds ratio, 5.02; 95% confidence interval, 1.84-13.64) were risk factors. Length of hospital stay was significantly associated with urinary tract infection., Conclusion: Maternal medical conditions and procedures that predispose to urinary tract infections are those that also are associated with urethral catheterization. In addition, maternal urinary tract infections may contribute significantly to duration of postpartum hospital stay.

Objective: This study was undertaken to explore the spectrum of maternal disease with a triple classification system of HELLP (hemolysis, elevated liver enzyme levels, and low platelet count) syndrome and compare these classes with severe preeclampsia without HELLP syndrome., Study Design: In this retrospective analytic study the pregnancies of 777 patients with class 1, 2, or 3 HELLP syndrome were compared and contrasted with those of 193 women with severe preeclampsia but without HELLP syndrome., Results: Eclampsia, epigastric pain, nausea and vomiting, significant proteinuria, major maternal morbidity, and stillbirth increased as HELLP syndrome worsened from class 3 to class 1. In contrast, headache and diastolic hypertension were more common among the significantly heavier patients with severe preeclampsia without HELLP syndrome. Approximately half of pregnancies complicated by class 1 HELLP syndrome exhibited significant maternal morbidity, compared with only 11% of those complicated by severe preeclampsia without HELLP syndrome. Although a significant trend was apparent in increasing levels of lactate dehydrogenase, aspartate aminotransferase, and uric acid as HELLP syndrome worsened, there was considerable variation within groups., Conclusion: Laboratory and clinical indices of disease severity in patients with severe preeclampsia or eclampsia generally were highest with class 1 HELLP syndrome and were lowest when HELLP syndrome was absent. Class 3 HELLP syndrome is considered a clinically significant transitional group.

Objective: Our purpose was to characterize the clinical presentation or laboratory variables predictive of either abruptio placentae or eclampsia in women with severe preeclampsia., Study Design: Prospective collection of perinatal data from 445 consecutively managed women with severe preeclampsia and eclampsia. Univariate analysis was used to determine which of the independent variables were significantly different between the groups (abruptio placentae vs no abruptio placentae; eclampsia vs no eclampsia). Those with significant differences were then entered into multiple logistic regression analysis to determine those characteristics that were independently related to the outcome variable (abruptio placentae or eclampsia). Before multivariate analysis, the independent variables with an interval scale of measurement were converted to a dichotomous scale, with the receiver-operator characteristic curve used to determine a cutoff level., Results: Univariate analysis revealed statistical significance for the following variables associated with eclampsia: uric acid concentration, > 8.1 mg/dL; proteinuria (>3+); headache; visual symptoms; deep tendon reflexes >3+; serum albumin concentration, <3 mg/dL; and serum creatinine concentration, >1.3 mg/dL. However, with subsequent multivariate analysis, only headache and deep tendon reflexes >3+ remained significant. Univariate analysis for variables associated with abruptio placentae revealed an association between bleeding and platelet count <60,000/mm3. There was no association between abruptio placentae and eclampsia and systolic, diastolic, or mean arterial pressure, quantitative proteinuria, epigastric pain, bleeding, gestational age at delivery, history of preeclampsia, or chronic hypertension., Conclusion: Quantitative proteinuria and degree of blood pressure elevation were not predictive of either abruptio placentae or eclampsia, as has previously been suggested. The greatest morbidity associated with eclampsia occurred in women with preterm gestations not receiving medical attention.

Objective: In patients with a history of severe preeclampsia, an increased frequency of hemostatic abnormalities has recently been suggested in small studies without control groups. Our purpose was to investigate the prevalence of such abnormalities in a large patient group with a history of severe hypertensive disorder in pregnancy, in comparison with an appropriate control group., Study Design: A total of 345 patients with a history of severe preeclampsia were investigated at a minimum of 10 weeks post partum for the presence of activated protein C resistance, the associated factor V mutation, hyperhomocysteinemia and anticardiolipin antibodies. The control group consisted of 67 healthy women with a history of uncomplicated pregnancies only. Blood was obtained during the second half of a normal menstrual cycle, and none of the patients or control subjects used oral contraceptives., Results: Of all patients, 11.3% had activated protein C resistance (control subjects 1.5%, P =.025). Only half of these patients had the factor V mutation. Hyperhomocysteinemia was present in 12.1% of all patients, in comparison with 4.5% in the control group (P =.115). Anticardiolipin antibodies were observed in 20.9% of the patients, whereas these antibodies were found in 7.5% of the control subjects (P =.016). In general, the prevalence of these abnormalities was 1.5 to 2 times higher in patients who were delivered before 28 weeks, in comparison with patients who were delivered after 28 weeks., Conclusions: Hemostatic abnormalities, associated with an increased risk of thrombosis, are present in approximately 40% of patients with a history of severe preeclampsia, which is almost 4 times higher than in control subjects. These findings might suggest a cause of preeclampsia and could have implications in subsequent pregnancies and general health.

Objective: Study of hemostatic disorders during eclampsia, their risk factors, maternal complications and associated mortality., Methods: Retrospective study concerning 106 cases of severe eclampsia treated in intensive care between September 1992 and December 96. Patients with or without hemostatic disorders were compared for laboratory findings, maternal complications and mortality., Results: Forty patients had hemostasis disorders as follows: isolated thrombopenia in 19 cases, disseminated intravascular coagulation (DIC) in 5 cases, Hellp syndrome associated to DIC in 7 cases and Hellp syndrome in 9 cases. Hemostasis disorders were associated to maternal advanced age, but not with gestational age or blood pressure in admission or time of convulsions. Complications and mortality associated with hemostasis disorders were more frequent compared to patients without hemostasis disorders. Among the 17 deaths of our series, 10 had hemostasis disorders., Conclusion: Hemostasis disorders were prognosis factors in eclampsia requiring systematic laboratory tests at admission and immediate delivery.

Objective: The purpose of this study was to determine whether there are demonstrable alterations in uterine artery blood flow in pregnant women with müllerian duct anomaly., Study Design: Flow velocity waveforms obtained from the placental and nonplacental uterine arteries were studied at 18 to 24 weeks' gestational age in 15 pregnant women with müllerian duct anomaly and in 30 controls. The systolic/diastolic ratios were compared and correlated with the degree of placental laterality and perinatal outcome., Results: Systolic/diastolic ratio in the uterine artery was abnormal in 80% of the cases and in 10% of controls (p < 0.0001). A completely lateral placenta was found in 10 of 15 women of the study group and only in 1 of the 30 controls (p < 0.0001). Women with müllerian duct anomaly had higher systolic/diastolic ratios in the nonplacental uterine artery than those with a normal uterus (median 4.3, range 2.0 to 7.4 vs median 2.8, range 2.0 to 4.0; p < 0.001). Twelve of 15 women of the study group had poor perinatal outcome compared with 4 of the 30 controls (p < 0.001). Among those women with poor perinatal outcome, 11 of 12 (92%) in the study group and only 1 of the 4 (25%) in the control group had an abnormal systolic/diastolic ratio in the uterine arteries (p < 0.05)., Conclusion: There is a clear association between placental laterality and high systolic/diastolic ratio in the nonplacental uterine artery in pregnant women with müllerian duct anomaly who had poor perinatal outcome. This finding suggests that unilateral placental implantation could lead to functional exclusion of one uterine artery from the uteroplacental circulation and could explain pregnancy complications in women with developmental fusion defects of the uterus.

Eclampsia accounts for a third of maternal mortality in developing countries. The neurological manifestations of eclampsia consist of seizures and alteration of sensorium or coma on a background of pre-eclampsia. Occasionally there can be focal neurological deficits too. Recent studies with CT scan and MRI have demonstrated the presence of cerebral edema and/or cerebral hemorrhage in eclampsia. EEG in patients with eclampsia has revealed evidence of diffuse cerebral dysfunction (delta waves) and epileptiform transients (spikes or sharp waves). There is also evidence of extensive vasculopathy within the brain parenchyma. A variety of mechanisms have been suggested to explain these changes, the most important being failure of autoregulation of cerebral blood flow that leads to cerebral edema and hemorrhage. There is considerable controversy regarding the treatment of seizures in eclampsia. Recent studies have shown that magnesium sulfate is superior to phenytoin or diazepam in the treatment of eclamptic seizures and prevention of eclamptic seizures in women with pre-eclampsia.

A case of preeclampsia-eclampsia leading to acute edematous pancreatitis is reported, probably related to microvascular abnormalities and splanchnic ischemia. Recovery was uneventful.

We describe hepatic rupture in a 37-yr-old woman admitted to the intensive care unit after an eclamptic convulsion. The intensive care and surgical management are discussed.

We have measured platelet count, bleeding time and thrombelastography (TEG) variables and the correlation between these variables in 49 pregnant patients presenting with pre-eclampsia or eclampsia. Eighteen patients (37%) had a platelet count < or = 150 x 10(9) litre-1 and seven (14%) had a platelet count < or = 100 x 10(9) litre-1. Bleeding time was prolonged > 9.5 min in 13 (27%) patients and the TEG was abnormal in four (8%). The TEG variables, k time and maximum amplitude (MA) had a strong correlation with platelet count (k time-platelet count < or = 150 x 10(9) litre-1, r = -0.68, P = 0.003, platelet count < or = 100 x 10(9) litre-1, r = -0.84, P = 0.02; MA--platelet count < or = 150 x 10(9) litre-1, r = 0.72, P = 0.001, platelet count < or = 100 x 10(9) litre-1, r = 0.78, P = 0.04). There was no correlation between bleeding time and thrombocytopenia (platelet count < or = 150 x 10(9) litre-1, r = -0.18, ns; platelet count < or = 100 x 10(9) litre-1, r = 0.09, ns). There was no correlation between bleeding time and any measured TEG variable. Of the 10 (20%) patients with an adequate platelet count (> 100 x 10(9) litre-1) but prolonged bleeding time, the TEG was normal, suggesting adequate haemostasis. An MA of 53 mm, which is the lower limit for normal pregnancy, correlated with a platelet count of 54 x 10(9) litre-1 (95% confidence limits 40-75 x 10(9) litre-1). Although the number of patients with severe thrombocytopenia was small, a platelet count of 75 x 10(9) litre-1 should be associated with adequate haemostasis.

Eclampsia, or toxemia of pregnancy, is a disorder of pregnancy characterized by seizures associated with hypertension, edema, and proteinuria. Toxemia of pregnancy carries significant maternal and fetal morbidity and mortality. Eclampsia most commonly occurs in the antepartum period. A minority of cases, however, may initially manifest in the postpartum period. We present the case of a 28-year-old female with postpartum eclampsia presenting to the Emergency Department with altered mental status. A review of the literature concerning postpartum toxemia and a discussion of appropriate management strategies follows.

Eclampsia, the occurrence of a seizure in association with pre-eclampsia, remains an important cause of maternal mortality. Although it is standard practice to use an anticonvulsant for management of eclampsia, the choice of agent is controversial and there has been little properly controlled evidence to support any of the options. 1687 women with eclampsia were recruited into an international multicentre randomised trial comparing standard anticonvulsant regimens. Primary measures of outcome were recurrence of convulsions and maternal death. Data are available for 1680 (99.6%) women: 453 allocated magnesium sulphate versus 452 allocated diazepam, and 388 allocated magnesium sulphate versus 387 allocated phenytoin. Most women (99%) received the anticonvulsant that they had been allocated. Women allocated magnesium sulphate had a 52% lower risk of recurrent convulsions (95% CI 64% to 37% reduction) than those allocated diazepam (60 [13.2%] vs 126 [27.9%]; ie, 14.7 [SD 2.6] fewer women with recurrent convulsions per 100 women; 2p < 0.00001). Maternal mortality was non-significantly lower among women allocated magnesium sulphate. There were no significant differences in other measures of serious maternal morbidity, or in perinatal morbidity or mortality. Women allocated magnesium sulphate had a 67% lower risk of recurrent convulsions (95% CI 79% to 47% reduction) than those allocated phenytoin (22 [5.7%] vs 66 [17.1%] ie, 11.4 [SD 2.2] fewer women with recurrent convulsions per 100 women; 2p < 0.00001). Maternal mortality was nonsignificantly lower among women allocated magnesium sulphate. Women allocated magnesium sulphate were also less likely to be ventilated, to develop pneumonia, and to be admitted to intensive care facilities than those allocated phenytoin. The babies of women who had been allocated magnesium sulphate before delivery were significantly less likely to be intubated at the place of delivery, and to be admitted to a special care nursery, than the babies of mothers who had been allocated phenytoin. There is now compelling evidence in favour of magnesium sulphate, rather than diazepam or phenytoin, for the treatment of eclampsia.

Objective: Over a 14-year period at Parkland Hospital, the clinical courses of 15 women with severe preeclampsia or eclampsia were further complicated by blindness. Our purpose is to describe their management and outcome, as well as to offer insight to the pathophysiologic characteristics of blindness complicating pregnancy-induced hypertension., Study Design: Prospective ascertainment of women with blindness and pregnancy-induced hypertension was done. These cases were managed according to the standardized preeclampsia-eclampsia regimen used at our hospital since 1955. Briefly, this regimen includes magnesium sulfate given intramuscularly to prevent or control seizures, hydralazine to lower dangerously elevated blood pressure, intravenous fluid restriction, and delivery., Results: There were 15 women with blindness that persisted from 4 hours to 8 days; it subsequently resolved completely in all. Of the 13 women who underwent computed tomography, 8 had low-density areas localized predominantly in the occipital lobes. Five of these 13 subsequently underwent magnetic resonance imaging and 2 showed corresponding hyperintense lesions in the occipital areas., Conclusions: On the basis of previously published experiences with computed tomography in women with eclampsia, as well as the experiences described here, we conclude that cortical blindness associated with preeclampsia-eclampsia results from petechial hemorrhages and focal edema in the occipital cortex. These lesions are likely stimulated by disparity in cerebral regional blood flow that is characterized by vasospasm and diminished flow primarily affecting the posterior circulation.

An unusual case of a 40-year-old woman with eclampsia and the HELLP syndrome associated with brainstem dysfunction is presented. The patient made a progressive neurological recovery. A follow-up magnetic resonance image (MRI) demonstrated complete resolution of the multiple foci. The MRI of the brainstem was found to correlate far more closely with neurological findings than with computed tomography (CT scan).

Perinatal losses have been studied in 37 pre-eclamptic/eclamptic patients: 13 of them exhibited a HELLP syndrome. Only 23 newborns survived (62.5%); after deduction of 4 pregnancies of less than 28 weeks, the perinatal mortality was 27%. Comparison with the local perinatal mortality showed a 6-fold higher risk for the fetus when pregnancy was complicated by pre-eclampsia/eclampsia, regardless of a superimposed HELLP syndrome. For reasons beyond our understanding the fetal losses with HELLP syndrome are much higher in primigravidae.

The early recognition of elevated blood pressure in pregnancy is still considered the most critical step in preventing the maternal and perinatal morbidity and mortality associated with preeclampsia-eclampsia. The recognition of hypertension is enhanced by an initial assessment of a women's risk for developing high blood pressure during pregnancy, correct blood pressure measurement, and early prenatal care. The care of the woman with hypertension preceding a pregnancy or during a previous pregnancy includes not only early prenatal care but also pre- or interconceptual care that might minimize the risk of further blood pressure elevation during pregnancy, as well as later in life. Tests to predict preeclampsia, such as the "roll" test and the use of the mean arterial pressure during midpregnancy, have been found to be invalid because of poor predictive validity. Relative increases in blood pressure during pregnancy are also no longer considered diagnostic for preeclampsia, however, consideration of relative increases is still "prudent" in assessing signs and symptoms of this disease. The development of preeclampsia is thought to occur very early in pregnancy as a result of imbalances between vasoconstrictive and vasodilatory factors, probably accompanying implantation and placentation. The use of aspirin to prevent the development of hypertension and preeclampsia is currently being studied because it has been shown to shift the balance toward the metabolism of the vasodilatory prostaglandin, prostacycline. At this time, aspirin is only advised for women at high risk for developing preeclampsia. Calcium may also be a preventative mineral, and a diet that is adequate during pregnancy is advised.

Many brain complications occur during eclampsia with various degree of gravity. The pathogenesis of these lesions continues to be a source of considerable controversy. Five cases of eclampsia with severe neurologic manifestations were treated in our surgical intensive care unit. The CT image appeared to be related to haemorrhagic lesions (3 cases) and ischaemic lesions (2 cases). The clinical course was favourable, often reversible, in cases with oedema and ischaemia maternal prognosis was poor in the case with haemorrhage.

Color flow Doppler ultrasonography was used to demonstrate a significant and sustained reduction in the central retinal artery pulsatility index after administration of the calcium antagonist nimodipine to a patient with eclampsia. Nimodipine is an effective cerebral vasodilator and may be useful in the management of eclamptic patients with severe vasospasm.

Objective: Our purpose was to describe maternal-perinatal outcome, subsequent pregnancy outcome, and long-term prognosis after hemolysis, elevated liver enzymes, and low platelets and acute renal failure., Study Design: Thirty-two patients with this complication were studied in the index pregnancy and were subsequently followed for an average of 4.5 years. Six patients had preexisting hypertension, and 26 were normotensive during the index pregnancy., Results: There were four maternal deaths (13%), 27 (84%) had disseminated intravascular coagulation, 14 (44%) had pulmonary edema, and 10 (31%) required dialysis. The perinatal mortality rate was 34%, and 72% of births were preterm. Eight normotensive women had 11 subsequent pregnancies, only one complicated by preeclampsia. Four hypertensive women had six subsequent pregnancies; three were complicated by severe preeclampsia and fetal death (one complicated by hemolysis, elevated liver enzymes, and low platelets and one by renal failure). None of 23 surviving normotensive women had residual renal damage or hypertension on follow-up, whereas two of five hypertensive women required chronic dialysis., Conclusion: These findings should be used in counseling these patients regarding the index pregnancy and future pregnancies.

Objective: Our aim was to assess the impact of beta-adrenergic blockade during the peripartum period on the previously observed high incidence of ventricular arrhythmias in eclamptic parturients., Study Design: An open, randomized comparison of intravenous labetalol versus dihydralazine was conducted in 40 eclamptic subjects in the peripartum period. Cardiac rhythm was assessed by blinded analysis of a 24-hour Holter record by means of the Lown classification of arrhythmias., Results: There was a significantly higher incidence of serious ventricular arrhythmias in patients receiving dihydralazine (81%) than in those receiving labetalol (17%, p < 0.0001). Patients receiving labetalol showed a significant decrease in mean heart rate (p < 0.0001), whereas patients receiving dihydralazine showed a significant increase (p < 0.0001)., Conclusion: The introduction of beta-adrenergic blockade into peripartum hypertensive management of eclampsia significantly reduced the incidence of dangerous ventricular arrhythmias. Myocardial oxygen supply/demand ratio may be improved by beta-blockade.

Through a series of 76 cases of jaundice observed in pregnant women, the authors emphasize on the biggest frequency of viral hepatitis among the all of etiology. In fact that one represents the 2/3 of cases. They insist on the graves forms of the diseases which are responsible of a high maternal mortality and big foetal complications.

Objectives: Our goal was to report pregnancy outcome and long-term prognosis after eclampsia., Study Design: Women whose pregnancies were managed at the E.H. Crump Women's Hospital between August 1977 and April 1989 were studied. A total of 223 women with eclampsia underwent follow-up for an average of 7.2 years. Thirteen had preexisting hypertension and 210 were normotensive (31 were multiparous and 179 were nulliparous)., Results: Among these women 23 who were multiparous and 159 who were nulliparous had 366 subsequent pregnancies: 22% of pregnancies were complicated by preeclampsia, 1.9% by eclampsia, and 2.5% by abruptio placentae; 2.7% resulted in perinatal death. Within the nulliparous group, women who had eclampsia before 37 weeks' gestation in the index pregnancy had significantly higher incidences of preeclampsia and poor perinatal outcome in subsequent pregnancies as compared with those who had eclampsia at greater than or equal to 37 weeks' gestation; the highest incidence of obstetric complications occurred in those having eclampsia at less than or equal to 30 weeks. Twenty of the 210 normotensive women (9.5%) had chronic hypertension on follow-up; the highest incidence (17.9%) being in those with eclampsia at less than or equal to 30 weeks and the lowest incidence (4.8%) in those having eclampsia at greater than or equal to 37 weeks. Women with eclampsia who had preeclampsia in subsequent pregnancies had a higher incidence of chronic hypertension as compared with those who were normotensive in subsequent pregnancies (25% vs 2%, p less than 0.0001). Long-term maternal complications included dialysis required in one patient and one case of cardiomyopathy in women with chronic hypertension; there was one maternal death in a women with chronic hypertension. None of the women had evidence of neurologic deficit or seizures during follow-up., Conclusions: These findings should be used in counseling women who have had eclampsia and are considering future pregnancies.

Eclampsia has been traditionally divided in three types: antepartum, intrapartum, and postpartum. Several authors consider two more subtypes, early cases and intercurrent eclampsia. The clinical analysis of 990 patients with eclampsia divided according to such classification revealed numerous significant differences that could give grounds for the interpretation of conflicting results in medical research. Maternal and perinatal mortality, types and incidence of complications, obstetric and eclamptic profiles, and incidence of underlying diseases were strikingly higher in antepartum eclampsia, especially in early cases. The features of intrapartum eclampsia were closer to those of the postpartum group than to those of antepartum cases, and intercurrent eclampsia was oddly benign for the mother but not for the fetuses. These findings indicate that a more precise classification of eclampsia must consider seven differential facts: (1) timing of convulsions, (2) length of pregnancy, (3) complications , (4) underlying diseases, (5) maternal age, (6) number of index pregnancy, and (7) single or multiple gestation.

Twenty-four patients first seen with hypertensive crises during pregnancy were studied by continuous electrocardiographic monitoring for a period of 24 hours to detect the presence of serious ventricular arrhythmias. Three patients were excluded from analysis because of low serum potassium levels. Thirteen of the remaining 21 patients had ventricular tachycardia on subsequent analysis of the electrocardiogram. These arrhythmias subsided after induction of anesthesia when blood pressure control was optimal. This finding may be implicated in the pathogenesis of pulmonary edema and sudden death in these patients.

It has never been formally established whether eclampsia can come on more than 48 hours after delivery. We report a case of a patient who had convulsions together with transitory raised blood pressure coming on 14 days after her delivery. MRI was carried out 24 hours after the attack and showed pathological sub-cortical images and there was a hyper signal at T2. This is now a well known feature and has been described in the course of typical eclampsia fits. On the other hand MRI is able to eliminate a certain number of differential diagnoses such as cerebral thrombophlebitis, cerebral vascular accidents and tumours. A cerebral blood flow study and a trans-cranial Doppler flow study showed (as far as we know for the first time) a lessening in perfusion and in speed of flow giving rise to lowered blood circulation in that part of the brain and suggestive of vascular spasm. This observation makes it very likely that eclamptic crises can occur two weeks after delivery and favours a vascular spasm being the origin of these crises.

Severe bilateral visual loss attributable to multiple retinal arteriolar occlusions occurred in four young women within 24 hours after childbirth. In two patients, labor was complicated by preeclampsia requiring cesarean section. One patient was suffering from pancreatitis. None had connective tissue disease or antecedent trauma. Ophthalmoscopy and fluorescein angiography revealed evidence of multiple superficial peripapillary and macular patches of ischemic retinal whitening simulating Purtscher's retinopathy. By 8 weeks, the white patches were resolving in all eyes and visual acuity had significantly improved in three of the four patients. The pathogenesis of this disorder is unknown but may involve arteriolar obstruction by complement-induced leukoemboli formed during parturition.

During a 12-year period, 254 cases of eclampsia were managed at this center. Eighty patients (32%) did not have edema, 58 (23%) had "relative hypertension," and 49 (19%) did not have proteinuria at the time of convulsions. Eclampsia developed at less than or equal to 20 weeks in 6 patients and beyond 48 hours post partum in 40 (16%). Convulsions developed in 33 while they were receiving standard doses of magnesium sulfate for preeclampsia during or after birth, and subsequent seizures developed in 36 (14%) after magnesium sulfate therapy was started. There was one maternal death (0.4%) and morbidity was frequent (acute renal failure, 4.7%; pulmonary edema, 4.3%; cardiorespiratory arrest, 3.1%; and aspiration, 2%. The use of multiple drug therapy was associated with significant maternal and neonatal complications. The total perinatal mortality was 11.8%, with the majority of them related to either abruptio placentae or extreme prematurity. These findings emphasize the need for intensive monitoring of women with preeclampsia throughout hospitalization and underscore the importance of maternal stabilization before and during transfer.