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High blood pressure in the postpartum period is most commonly seen in women with antenatal hypertensive disorders, but it can develop de novo in the postpartum time frame. Whether postpartum preeclampsia or eclampsia represents a separate entity from preeclampsia or eclampsia with antepartum onset is unclear. Although definitions vary, the diagnosis of postpartum preeclampsia should be considered in women with new-onset hypertension 48 hours to 6 weeks after delivery. New-onset postpartum preeclampsia is an understudied disease entity with few evidence-based guidelines to guide diagnosis and management. We propose that new-onset hypertension with the presence of any severe features (including severely elevated blood pressure in women with no history of hypertension) be referred to as postpartum preeclampsia after exclusion of other etiologies to facilitate recognition and timely management. Older maternal age, black race, maternal obesity, and cesarean delivery are all associated with a higher risk of postpartum preeclampsia. Most women with delayed-onset postpartum preeclampsia present within the first 7 to 10 days after delivery, most frequently with neurologic symptoms, typically headache. The cornerstones of treatment include the use of antihypertensive agents, magnesium, and diuresis. Postpartum preeclampsia may be associated with a higher risk of maternal morbidity than preeclampsia with antepartum onset, yet it remains an understudied disease process. Future research should focus on the pathophysiology and specific risk factors. A better understanding is imperative for patient care and counseling and anticipatory guidance before hospital discharge and is important for the reduction of maternal morbidity and mortality in the postpartum period., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Hypertensive disorders in pregnancy (HDP) are associated with increased risk of offspring neurodevelopmental disorders, suggesting long-term adverse impacts on fetal brain development. However, the relationship between HDP and deficits in general child development is unclear. Our objective was to assess the association between HDP and motor and cognitive developmental delay in children at 36 months of age. We analyzed data from the All Our Families community-based cohort study (n = 1554). Diagnosis of HDP-gestational or chronic hypertension, preeclampsia, or eclampsia-was measured through medical records. Child development was measured by maternal-report on five domains of the Ages and Stages Questionnaire (ASQ-3). Standardized cut-off scores were used to operationalize binary variables for any delay, motor delay, and cognitive delay. We calculated adjusted risk ratios (aRRs) and 95% confidence intervals (CIs) using logistic regression, sequentially controlling for potential confounders followed by factors suspected to lie on the causal pathway. Overall, 8.0% of women had HDP and hypertension-exposed children had higher prevalence of delay than unexposed children. Hypertension-exposed children had elevated risk for developmental delay, but CIs crossed the null. The aRRs quantifying the fully adjusted effect of HDP on child development were 1.19 (95% CI 0.92, 1.53) for any delay, 1.18 (95% CI 0.86, 1.61) for motor delay, and 1.24 (95% CI 0.83, 1.85) for cognitive delay. We did not find a statistically significant association between HDP and developmental delay. Confidence intervals suggest that children exposed to HDP in utero have either similar or slightly elevated risk of any, motor, and cognitive delay at 36 months after controlling for maternal and obstetric characteristics. The observed direction of association aligns with evidence of biological mechanisms whereby hypertensive pathology can disrupt fetal neurodevelopment; however, more evidence is needed. Findings may have implications for early developmental monitoring and intervention following prenatal hypertension exposure., Competing Interests: The authors have declared that no competing interests exist.

Objective: To investigate the association between hypothyroxinemia and the risk of preeclampsia-eclampsia and gestational hypertension., Design: Historical cohort study., Methods: The study included pregnant individuals who delivered live-born singletons and had at least one thyroid function assessment during pregnancy at a tertiary hospital. Hypothyroxinemia was defined as thyroid-stimulating hormone (TSH) levels within the normal reference range and free thyroxine (FT4) levels lower than the tenth percentile. Risk ratios (RRs) with 95% confidence intervals (95% CIs) for preeclampsia-eclampsia and gestational hypertension between women with and without a diagnosis of hypothyroxinemia during pregnancy were estimated using a generalized estimating equation model., Results: A total of 59,463 women with live-born singletons were included in the analysis. Logistic regression models with restricted cubic spline suggested that there was a U-shaped association between FT4 levels and preeclampsia-eclampsia risk. Compared with euthyroid women, those with hypothyroxinemia had an increased risk of preeclampsia-eclampsia (RR = 1.16, 95% CI: 1.02-1.31), and the risk increased with the increasing severity of hypothyroxinemia ( p for trend < 0.001). Moreover, persistent hypothyroxinemia from the first to second trimesters was associated with an increased risk of preeclampsia-eclampsia (RR = 1.37, 95% CI: 1.03-1.83), especially for women with severe hypothyroxinemia (RR = 1.70, 95% CI: 1.12-2.58). In contrast, there was no association between hypothyroxinemia and gestational hypertension., Conclusion: Our study suggested that hypothyroxinemia was only associated with an increased risk of preeclampsia-eclampsia, especially in women with persistent hypothyroxinemia in the first half of pregnancy. Analyses of the associated risk of gestational hypertension with hypothyroxinemia were not significant., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Su, Liu, Li, Liu, Huang, Duan and Du.)

Objective: To examine temporal trends of eclampsia by plurality in the US spanning three decades (1989-2018); and to investigate risk factors for eclampsia among singleton and multiple pregnancies in the US during the study period., Study Design: We conducted a retrospective cohort study using the Natality data files, including information on all births within the gestational age of 20-42 weeks from 1989 through 2018. We used joinpoint regression analysis to evaluate trends in rates of eclampsia over the study period. We employed logistic regression models to examine the association between plurality and eclampsia after adjusting for socio-demographic and gestational factors., Main Outcome Measures: The primary outcome was eclampsia among singleton and multiple pregnancies., Findings: There was a 2.8% (95% CI: -5.4, -0.1) average annual reduction in eclampsia rates among singletons, whereas among multiples there was a decline of about 3.7% (95% CI: -6.4, -1.0) annually. Mothers with multiple pregnancies had three-fold increased adjusted odds (OR = 95% CI: 2.95-3.21) of experiencing eclampsia when compared to those with singleton gestations. Non-Hispanic (NH) Black mothers with singletons had 37% greater adjusted odds of developing eclampsia than their NH-White peers (95%CI: 1.33-1.42)., Conclusion: There was an overall decreasing trend in eclampsia incidence in the US from 1989 to 2018, regardless of plurality. The occurrence of eclampsia was associated with plurality, race/ethnicity, maternal age and maternal BMI. Given the heterogeneity in clinical presentations of eclampsia, personalized/standardized risk prediction models are needed to enable consistent diagnosis and timely intervention., (Copyright © 2021 International Society for the Study of Hypertension in Pregnancy. Published by Elsevier B.V. All rights reserved.)

Hypertensive disorders in pregnancy pose a huge challenge to the socioeconomic stability of a community; being a major cause of maternal and neonatal morbidity and mortality during delivery. Although there have been recent improvements in management strategies, still, the diversified nature of the underlying pathogenesis undermines their effectiveness. Generally, these disorders are categorized into two; hypertensive disorders of pregnancy with proteinuria (pre-eclampsia and eclampsia) and hypertensive disorders of pregnancy without proteinuria (gestational and chronic hypertension). Each of these conditions may present with unique characteristics that have interwoven symptoms. However, the tendency of occurrence heightens in the presence of any pre-existing life-threatening condition(s), environmental, and/or other genetic factors. Investigations into the cerebrovascular system demonstrate changes in the histoarchitectural organization of neurons, the proliferation of glial cells with an associated increase in inflammatory cytokines. These are oxidative stress indicators which impose a deteriorating impact on the structures that form the neurovascular unit and the blood-brain barrier (BBB). Such a pathologic state distorts the homeostatic supply of blood into the brain, and enhances the permeability of toxins/pathogens through a process called hyperperfusion at the BBB. Furthermore, a notable aspect of the pathogenesis of hypertensive disorders of pregnancy is endothelial dysfunction aggravated when signaling of the vasoprotective molecule, nitric oxide, amongst other neurotransmitter regulatory activities are impaired. This review aims to discuss the alterations in cerebrovascular regulation that determine the incidence of hypertension in pregnancy., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Importance: Previous efforts to examine severe maternal morbidity (SMM) in the US have focused on delivery hospitalizations. Little is known about de novo SMM that occurs after delivery discharge., Objective: To investigate the incidence, timing, factors, and maternal characteristics associated with de novo SMM after delivery discharge among women in the US., Design, Setting, and Participants: In this retrospective cohort study, data from the IBM MarketScan Multi-State Medicaid database and the IBM MarketScan Commercial Claims and Encounters database were used to construct a sample of women aged 15 to 44 years who delivered between January 1, 2010, and September 30, 2014. Severe maternal morbidity was reported by the timing of diagnosis, and the associated maternal characteristics were examined. Women in the Medicaid and commercial insurance sample were classified into 3 distinct outcome groups: (1) those without any SMM during the delivery hospitalization and the postdelivery period (reference group), (2) those who exhibited at least 1 factor associated with SMM during the delivery hospitalization, and (3) those who exhibited any factor associated with de novo SMM after delivery discharge (defined as SMM that was first diagnosed in the inpatient setting during the 6 weeks [or 42 days] after discharge from the delivery hospitalization, conditional on no factor associated with SMM being identified during delivery). Data were analyzed from February to July 2020., Exposures: Timing of SMM diagnosis., Main Outcomes and Measures: Women with SMM were identified using diagnosis and procedure codes from the International Classification of Diseases, Ninth Revision, Clinical Modification for the 21 factors associated with SMM that were developed by the Centers for Disease Control and Prevention., Results: A total of 2 667 325 women in the US with delivery hospitalizations between 2010 and 2014 were identified; of those, 809 377 women (30.3%) had Medicaid insurance (30.3%; mean [SD] age, 25.6 [5.5] years; 51.1% White), and 1 857 948 women (69.7%; mean [SD] age, 30.6 [5.4] years; 36.4% from the southern region of the US) had commercial insurance. Among those with Medicaid insurance, 17 584 women (2.2%) experienced SMM during the delivery hospitalization, and 3265 women (0.4%) experienced de novo SMM after delivery discharge. Among those with commercial insurance, 32 079 women (1.7%) experienced SMM during the delivery hospitalization, and 5275 women (0.3%) experienced de novo SMM after hospital discharge. A total of 5275 SMM cases (14.1%) and 3265 SMM cases (15.7%) among women with commercial and Medicaid insurance, respectively, developed de novo within 6 weeks after hospital discharge; of those, 3993 cases (75.7%) in the commercial insurance cohort and 2399 cases (73.5%) in the Medicaid cohort were identified in the first 2 weeks after discharge. The most common factors associated with SMM varied based on the timing of diagnosis. In the Medicaid population, non-Hispanic Black women (adjusted odds ratio [aOR], 1.53; 95% CI, 1.48-1.58), Hispanic women (aOR, 1.46; 95% CI, 1.37-1.57), and women of other races or ethnicities (aOR, 1.40; 95% CI, 1.33-1.47) had higher rates of SMM during delivery hospitalization than non-Hispanic White women; however, only the disparity between Black and White women (aOR, 1.69; 95% CI, 1.57-1.81) persisted into the postdischarge period., Conclusions and Relevance: In this study, 15.7% of SMM cases in the Medicaid cohort and 14.1% of SMM cases in the commercial insurance cohort first occurred after the delivery hospitalization, with notable disparities in factors and maternal characteristics associated with the development of SMM. These findings suggest a need to expand the focus of SMM assessment to the postdelivery discharge period.

Objective: Evaluation of perinatal results in a set of pregnancies complicated by eclampsia., Methods: Analysis of 67,304 births performed at the Department of Gynecology and Obstetrics, Masaryk University, Faculty of Medicine and University Hospital, Brno from 2008-2018. During the given period, eclampsia was dia-gnosed in 16 mothers (0.2). The during the time of eclampsia (week of gestation, prepartum, intrapartum, postpartum) fetal and neonatal status (signs of intrauterine distress, pH of the umbilical artery, Apgar score, intrauterine fetal death, death in the early neonatal period) were evaluated. Symptoms and course of the eclamptic attack, maternal comorbidities, associated obstetric complications (placental abruption, surgical complications, blood loss, hysterectomy) and non-obstetric complications (coagulopathy, renal and hepatic impairment, neurological complications) were monitored., Results: Out of a total of 16 cases of eclampsia, 13 cases (81.3%) were confirmed during pregnancy, one case (6.2%) during childbirth, and two cases (12.5%) within 24 hours after childbirth. The mean gestational week of eclampsia was 33 weeks and 3 days. The typical course of an eclamptic attack characterized by headache and visual disturbances followed by a rapid onset of convulsions was noted in five cases (31%). Fetal hypoxia with a pH of the umbilical artery less than 7.10 occurred in four cases (25%). The dependence of the decrease in pH value on the time interval from the dia-gnosis of eclampsia to the termination of pregnancy was demonstrated. The pH of the umbilical artery decreased on average by 0.054 every 30 minutes from the onset of the eclamptic attack until the end of pregnancy. There were 3 perinatal deaths in the group (19%). Intrauterine fetal death occurred in one case due to partial abruption of the placenta during an eclamptic attack; two newborns died in the early neonatal period. The cause of death was sepsis in one case and perforation of the intestine in necrotizing enterocolitis in the other. The death of the mother was not recorded in the file. The incidence of preeclampsia in subsequent pregnancies reached 18.8%. Non-obstetric and neurological complications (amaurosis, subarachnoid hemorrhage, amnesia) occurred in the group in three cases (18.8%), and renal failure occurred in two cases (12.5%)., Conclusion: The incidence of eclampsia at the Department of Gynecology and Obstetrics, Masaryk University, Faculty of Medicine and University Hospital, Brno reached 0.2 and was stable for a long time. Associated serious maternal complications occurred in 37.5% of cases and neonatal complications in 31.3% of cases. Early dia-gnosis of eclampsia and minimization of the time delay until the end of pregnancy is a prerequisite for reducing the risk of associated complications. An interdisciplinary approach is needed.

Background: Studies have shown the impact of female genital mutilation (FGM), especially infibulation (WHO type III), on reproductive health, and adverse obstetric outcomes like postpartum haemorrhage and obstructed labour. However, whether an association exists with maternal hypertensive complication is not known. The present study sought to investigate the role of the different types of FGM on the occurrence of eclampsia., Methods: The study used data from the 2006 Demographic and health survey of Mali. The proportion of eclampsia in women with each type of FGM and the unadjusted and adjusted odds ratios (OR) were calculated, using women without FGM as reference group. Unadjusted and adjusted OR were also calculated for women who underwent infibulation compared to the rest of the population under study (women without FGM and women with FGM type I, II, and IV)., Results: In the 3997 women included, the prevalence of infibulation was 10.2% (n = 407) while 331 women did not report FGM (8.3%). The proportion of women reporting signs and symptoms suggestive of eclampsia was 5.9% (n = 234). Compared with the absence of female genital mutilation and adjusted for covariates, infibulation was associated with eclampsia (aOR 2.5; 95% CI:1.4-4.6), while the association was not significant in women with other categories of FGM. A similar aOR was found when comparing women with infibulation with the pooled sample of women without FGM and women with the other forms of FGM., Conclusion: The present study suggests a possible association between infibulation and eclampsia. Future studies could investigate this association in other settings. If these findings are confirmed, the possible biological mechanisms and preventive strategies should be investigated.

Objective: The aim of this study was to analyze the association of ATPase plasma membrane Ca2+ transporting 1 (ATP2B1) gene polymorphism with the incidence of eclampsia, and to investigate the possible underlying mechanism., Patients and Methods: ATP2B1 genotype and allele distributions in umbilical venous blood cells were analyzed in 50 control subjects and 117 eclampsia patients via Reverse Transcription-Polymerase Chain Reaction (RT-PCR) and TaqMan genotyping technique. Meanwhile, the differences in the single nucleotide polymorphisms at rs2681472 and rs17249754 in the case group and control group were analyzed using the χ2-test. The risk factors for eclampsia were analyzed via univariate, multivariate, and Logistic regression analyses. Furthermore, the associations of rs2681472 gene polymorphism with risk factors for eclampsia (hypertension and lower extremity edema) were verified via χ2-test., Results: The statistically significant differences were observed in the gestational week, body mass index, blood pressure, and incidence rates of proteinuria and lower extremity edema of pregnant women between the case group and the control group (p<0.05). Meanwhile, the genotype and allele distributions at rs2681472 in the case group were remarkably different from those of the control group (p<0.05). However, no evident differences were observed at rs17249754 between the two groups (p>0.05). According to univariate, multivariate, and logistic regression analyses, hypertension, and lower extremity edema were significantly associated with the incidence of eclampsia (p<0.05). In addition, the gene polymorphism at rs2681472 showed significant differences among subjects with and without hypertension and lower extremity edema (p<0.05)., Conclusions: ATP2B1 gene polymorphism at rs2681472 shows significant differences between eclampsia patients and normal controls. Moreover, its gene polymorphism is closely related to the occurrence of hypertension and lower extremity edema.

Objective : Hypertensive disorders in pregnancy particularly severe preeclampsia and eclampsia result in significant maternal and neonatal morbidity and mortality. Many of these misfunctions can aggravate some of the neuropathological complications of hypertensive disorders during pregnancy. Method : In this review article, we described some of the neuropathological complications associated with hypertensive disorders of pregnancy. Results and conclusion : It is explained how the possible mechanism of neuropathological events triggers some of the complications associated with hypertensive disorders of pregnancy. Conclusion : A strong plea is made for the early detection of high blood pressure, its immediate control with rapid acting anti-hypertensive agents if necessary and timeous delivery of fetus as the exact pathogenesis of preeclampsia remains unknown.

Objective: We analyzed the maternal and perinatal outcomes in early onset preeclampsia (EOPE) and late onset preeclampsia (LOPE) pregnant women who had scheduled caesarean deliveries. We sub-analyzed the two categories into HIV positive and HIV negative., Patients and Methods: This prospective study was conducted at a regional hospital in Durban, South Africa during 14 months. A total of 14304 deliveries were registered. Out of the 1759 preeclampsia, 351 (19.9%) were EOPE and 1408 (80.1%) were LOPE. Hundred and twenty preeclamptics (n = 120) scheduled for caesarean delivery were selected and divided into two categories namely EOPE (n = 60) and LOPE (n = 60). Each preeclampsia category was then further stratified into HIV positive (n = 30) and HIV negative (n = 30) groups. Maternal demographic, clinical details for preeclampsia, blood laboratory tests, maternal, and perinatal outcomes were recorded., Results: Women with EOPE were older compared to those with LOPE (P = 0.0001). Also the HIV positive women were older compared to the HIV negative groups in both EOPE and LOPE categories (P = 0.03). However, multiparous and primiparous were predominant in EOPE and LOPE categories, respectively (P = 0.00 and P = 0.00). The severity of hypertension and the HIV status did not differentiate the 2 groups. Overall, maternal complications (eclampsia, persistent postpartum hypertension, HELLP syndrome, maternal death) and poor fetal outcomes occurred predominately in EOPE., Conclusion: This study confirms the heterogeneity of preeclampsia and shows that the timing of onset of this pregnancy disorder is important to disease severity. Further HIV status influences maternal and neonatal outcome., Competing Interests: None

Background: Hypertensive disorders of pregnancy (HDP) and gestational diabetes mellitus (GDM) are common maternal complications during pregnancy, with short- and long-term sequelae for both mothers and children., Objective: Two systematic review questions were used to examine the relation between 1) dietary patterns before and during pregnancy, 2) HDP, and 3) GDM., Methods: A search was conducted from January 1980 to January 2017 in 9 databases including PubMed, Embase, and Cochrane. Two analysts independently screened articles using a priori inclusion and exclusion criteria; data were extracted from included articles, and risk of bias was assessed. After qualitative synthesis, a conclusion statement was drafted for each question and the evidence supporting the conclusion was graded., Results: Of the 9103 studies identified, 8 [representing 4 cohorts and 1 randomized controlled trial (RCT)] were included for HDP and 11 (representing 6 cohorts and 1 RCT) for GDM. Limited evidence in healthy Caucasian women with access to health care suggests dietary patterns before and during pregnancy that are higher in vegetables, fruits, whole grains, nuts, legumes, fish, and vegetable oils and lower in meat and refined grains are associated with reduced risk of HDP, including preeclampsia and gestational hypertension. Limited but consistent evidence suggests certain dietary patterns before pregnancy are associated with reduced risk of GDM. These protective dietary patterns are higher in vegetables, fruits, whole grains, nuts, legumes, and fish and lower in red and processed meats. Most of the research was conducted in healthy, Caucasian women with access to health care. Insufficient evidence exists on the associations between dietary patterns before and during pregnancy and risk of HDP in minority women and those of lower socioeconomic status, and dietary patterns during pregnancy and risk of GDM., Conclusions: Although some conclusions were drawn from these systematic reviews, more research is needed to address gaps and limitations in the evidence., (© American Society for Nutrition 2019.)

Objective: To examine the association between maternal BMI>50kg/m2 during pregnancy and maternal and perinatal outcomes., Materials and Methods: An international cohort study was conducted using data from separate national studies in the UK and Australia. Outcomes of pregnant women with BMI>50 were compared to those of pregnant women with BMI<50. Multivariable logistic regression estimated the association between BMI>50 and perinatal and maternal outcomes., Results: 932 pregnant women with BMI>50 were compared with 1232 pregnant women with BMI<50. Pregnant women with BMI>50 were slightly older, more likely to be multiparous, and have pre-existing comorbidities. There were no maternal deaths, however, extremely obese women had a nine-fold increase in the odds of thrombotic events compared to those with a BMI<50 (uOR: 9.39 (95%CI:1.15-76.43)). After adjustment, a BMI>50 during pregnancy had significantly raised odds of preeclampsia/eclampsia (aOR:4.88(95%CI: 3.11-7.65)), caesarean delivery (aOR: 2.77 (95%CI: 2.31-3.32)), induction of labour (aOR: 2.45(95% CI:2.00-2.99)) post caesarean wound infection (aOR:7.25(95%CI: 3.28-16.07)), macrosomia (aOR: 8.05(95%CI: 4.70-13.78)) compared a BMI<50. Twelve of the infants born to women in the extremely obese cohort died in the early neonatal period or were stillborn., Conclusions: Pregnant women with BMI>50 have a high risk of inferior maternal and perinatal outcomes., Competing Interests: The authors have declared that no competing interests exist.

Objectives: Eclampsia results in high morbidity and mortality, so it is important to identify clinical and laboratorial aspects that may be useful as potential markers to differentiate women at higher risk. Thus, we aim to identify, among women with preeclampsia, aspects that may increase the risk to develop eclampsia., Study Design: Retrospective cohort study. The records of patients delivered at Hospital São Lucas/PUCRS were reviewed retrospectively; 733 pregnant women with hypertension were analyzed; 329 had preeclampsia, and 45 eclampsia., Main Outcome Measures: Serum uric acid levels and protein excretion in women that develop eclampsia., Results: Patients with eclampsia had higher serum uric acid levels and protein excretion, systolic and diastolic blood pressure; were more likely to have cesarean section and had worst perinatal outcomes. The combination of uric acid above 5.9 mg/dL and protein/creatinine ratio over 4.9 had a striking association with eclampsia (p ≤ 0.001). The occurrence of HELLP syndrome was significantly different between groups, with a higher incidence among women who developed eclampsia (OR 6.5; 95%CI, 3.2-13.2; p < 0.001)., Conclusion: Our data suggest that the combination of high levels of maternal serum uric acid and proteinuria are strongly associated with the development of eclamptic crises., (Copyright © 2018 International Society for the Study of Hypertension in Pregnancy. Published by Elsevier B.V. All rights reserved.)

Purpose: To evaluate peripapillary retinal nerve fiber layer (RNFL) thickness during and after pregnancy in pregnant women with preeclampsia or eclampsia and compare it with normotensive pregnant women as controls., Methods: In a prospective comparative case-control study 35 women (70 eyes) with mild to moderate preeclampsia, 70 women (140 eyes) with severe preeclampsia and eclampsia, and 44 (88 eyes) healthy pregnant women were enrolled in three groups. Peripapillary RNFL thickness in three groups was measured after 28 weeks of pregnancy and 2 months postpartum by using optical coherence tomography. Mean and quadratic RNFL thickness changes were compared within and among the groups., Results: Mean peripapillary RNFL thickness decreased significantly from 104 ± 10, 104 ± 23, and 106 ± 9 µm during pregnancy to 101 ± 10, 96 ± 10, and 103 ± 9 µm 2 months after pregnancy in the mild to moderate preeclampsia, severe preeclampsia and eclampsia, and healthy pregnant women groups, respectively (P < 0.001 for all). While the difference among the groups was insignificant during pregnancy, it reached to a significant level after delivery (P = 0.006). The highest reduction in mean RNFL thickness (6 ± 10 µm) occurred in the severe preeclampsia and eclampsia groups., Conclusions: In relation to the time of pregnancy, peripapillary RNFL reduced in preeclamptic and eclamptic cases as well as in normotensive pregnant women at 2 months postpartum. This reduction was more in the severe forms of pregnancy-induced hypertension.

Objective: To examine the association between availability of obstetric institutions and risk of eclampsia, HELLP-syndrome, or delivery before 35 gestational weeks in preeclamptic pregnancies., Study Design: National population-based retrospective cohort study of deliveries in Norway, 1999-2009 (n = 636738) using data from The Medical Birth Registry of Norway and Statistics Norway. Main exposures were institution availability, measured by travel time to the nearest obstetric institution, and place of delivery. We computed relative risks (RR) with 95% confidence intervals (CI) using travel time ≤1 h as reference. We stratified analyses by parity and preeclampsia, and adjusted for socio-demographic and medical risk factors. Successive deliveries were linked using the national identification number., Results: We identified 1387 eclampsia/HELLP cases (0.2%) and 3004 (0.5%) deliveries before 35 weeks in preeclamptic pregnancies. Nulliparous women living >1 h from any obstetric institution had 50% increased risk of eclampsia/HELLP (0.50 versus 0.35%, adjusted RR 1.5; 95 %CI 1.1-1.9). Parous women living >1 h from emergency institutions had a doubled risk of eclampsia (0.6‰ versus 0.3‰, adjusted RR 2.0; 1.2-3.3). Women without preeclampsia in the present pregnancy or history of preeclampsia constituted all eclampsia/HELLP cases in midwife-led institutions, 39-50% of cases in emergency institutions, and 78% of cases (135/173) in subsequent deliveries. Women with risk factors delivered in the emergency institutions, indicating well-implemented selective referral., Conclusion: The study shows the importance of available obstetric institutions. Policymakers and clinicians should consider the distribution of potential benefits and burdens when planning and evaluating the obstetric health service structure., (Copyright © 2018 International Society for the Study of Hypertension in Pregnancy. Published by Elsevier B.V. All rights reserved.)

Hypertensive disorders of pregnancy are a heterogeneous group of conditions that include chronic hypertension, gestational hypertension, preeclampsia, and preeclampsia superimposed on chronic hypertension. These disorders account for a significant proportion of perinatal morbidity and mortality nearly 10% of all maternal deaths in the United States. Given the substantial health burden of hypertensive disorders in pregnancy, there is increasing interest in optimizing management of these conditions. This article summarizes the diagnosis and management of each of the disorders in the spectrum of hypertension in pregnancy and highlights recent updates in the field., (Copyright © 2018 Elsevier Inc. All rights reserved.)

In this study, the association of high homocysteine concentrations (>10 μmol/L) of pregnant women with hypertensive disorders during pregnancy was studied, as well as other complications of pregnancy, such as loss of pregnancy in the first half, premature birth, intrauterine growth retardation, congenital malformations development of the fetus. A single-center prospective cohort study was conducted. Depending on the concentration of homocysteine detected by the immunoenzyme assay with monoclonal antibodies Homocysteine EIA ELISA (Axis-Shield Diagnostics Ltd, Scotland), for a period of up to 14 weeks, the subjects were divided into 2 groups: with high concentrations (>10 μmol/L) and normal levels (<10 μmol/L). We controlled complications of pregnancy: loss of pregnancy in the first half, premature birth, delayed fetal growth, congenital malformations of the fetus, gestational hypertension, mild and severe preeclampsia, eclampsia and HELLP syndrome. The results of the study showed that at a level of homocysteine I trimester >10 μmol/l spontaneous abortion, premature birth, gestational hypertension, mild preeclampsia develop more often. There were no differences in the groups for delaying intrauterine growth of the fetus, congenital malformations, severe preeclampsia.

Objective: To explore the predictive factors of oedema types in reversible posterior leukoencephalopathy syndrome (RPLS) with preeclampsia (PE) and eclampsia, which is closely related to reversible lesions and clinical recovery., Method: We collected data from 44 consecutive patients diagnosed with RPLS in PE or eclampsia between 2013 and 2017. All patients were classified into vasogenic oedema (n = 31) or cytotoxic oedema (n = 13) groups according to magnetic resonance imaging (MRI) results. General information, clinical data, biochemical indicators and imaging features were collected retrospectively to explore the differences between the groups. Furthermore, we analysed potential predictive factors by logistic regression., Results: The occurrence rates of immune disease and stillbirth, hospitalization time and the levels of serum albumin (ALB), lactate dehydrogenase (LDH), aspartate transaminase (AST) and alanine aminotransferase (ALT) were higher, while the values of systolic blood pressure (SBP), mean arterial pressure (MAP) and 24-h urine protein were lower in the cytotoxic oedema patients than those in the vasogenic oedema patients (p < .05). The ALB concentration was closely correlated with vasogenic oedema, while AST and ALT were closely correlated with cytotoxic oedema by logistic regression (p < .05)., Conclusion: The levels of ALB, AST and ALT are potential predictors for the development of oedema in RPLS. ALB is related to vasogenic oedema by a possible mechanism of decreased colloid osmotic pressure, while AST and ALT are related to cytotoxic oedema by a possible mechanism of endothelial dysfunction., (Copyright © 2018 International Society for the Study of Hypertension in Pregnancy. Published by Elsevier B.V. All rights reserved.)

Background: Eclampsia is a major cause of maternal and neonatal morbidity and mortality in low and middle income countries. The aim of this study was to assess the risk factors and maternal and perinatal outcome in patients with eclampsia in order to get reliable data that helps in reducing the incidence and improving the outcome in an area with high incidence of eclampsia., Methods: Retrospective study including 250 patients diagnosed with eclampsia at Minia Maternity University Hopsital, Minia, Egypt in the period between January 2013 and December 2014.We analyzed the data obtained from medical records of these patients including patient characteristics, medical, obstetric, current pregnancy history, data on hospital admission, treatment given at hospital and maternal and perinatal outcome. Statistical analysis was done using SPSS version 21., Results: During the study period, 21690 women gave birth in the hospital; of which 250 cases of eclampsia were diagnosed (1.2%).Four women died (case fatality rate 1.6%). The main risk factors identified were young age, nulliparity, low level of education, poor ante-natal attendance and pre-existing medical problems. The most common complication was HELLP syndrome (15.6%). Magnesium sulphate therapy was given to all patients but there was lack of parenteral anti-hypertensive therapy. Forty six cases delivered vaginally (18.4%). Assisted delivery was performed in 22 (8.8%) cases and caesarean section in 177 (70.8%) cases; 151(60.4%) primary caesarean sections and 26 (10.4%) intra-partum. Perinatal deaths occurred in 11.9% on cases. Prematurity and poor neonatal services were the main cause., Conclusion: Morbidity and mortality from eclampsia are high in our setting. Improving ante-natal and emergency obstetric and neonatal care is mandatory to improve the outcome.

Objective: To determine the prevalence of eclampsia symptoms and to explore associations between eclampsia and early neonatal mortality., Methods: The present secondary analysis included Demographic and Health Surveys data from 2005 to 2012; details of signs related to severe obstetric adverse events of singleton deliveries during interviewees' most recent delivery in the preceding 5 years were included. Data and delivery history were merged for pooled analyses. Convulsions-used as an indicator for having experienced eclampsia-and early neonatal mortality rates were compared, and a generalized random effect model, adjusted for heterogeneity between and within countries, was used to investigate the impact of presumed eclampsia on early neonatal mortality., Results: The merged dataset included data from six surveys and 55 384 live deliveries that occurred in Colombia, Bangladesh, Indonesia, Mali, Niger, and Peru. Indications of eclampsia were recorded for 1.2% (95% confidence interval [CI] 1.0-1.3), 1.7% (95% CI 1.5-2.1), and 1.7% (95% CI 1.5-2.1) of deliveries reported from the American, South East Asian, and African regions, respectively. Pooled analyses demonstrated that eclampsia was associated with increased risk of early neonatal mortality (adjusted risk ratio 2.1 95% CI 1.4-3.2)., Conclusion: Increased risk of early neonatal mortality indicates a need for strategies targeting the early detection of eclampsia and early interventions., (© 2017 International Federation of Gynecology and Obstetrics.)

Introduction: Eclampsia is one of the most dreaded causes of adverse outcomes of pregnancy worldwide. It is one of the greatest causes of maternal and perinatal morbidity and mortality world over. We do not know the prevalence, management outcome, and the devastation caused by this dreaded disease in our center hence the need for this work., Materials and Methods: This is a 7-year retrospective review of all cases of eclampsia managed in Mater Misericordiae Hospital Afikpo, a rural secondary cum referral Catholic Mission Hospital in Afikpo, Ebonyi State in Southeastern Nigeria., Results: The prevalence of eclampsia in our center is 1.12% or one case of eclampsia for every 89 women that delivered in our facility. The majority of the women that had eclampsia in our center 56 (71.8%) were primigravidae. Seventeen women (21.8%) had various antenatal complications with 4 or 23.6% presenting with intrauterine fetal deaths and two (11.8%) each with intrauterine growth restriction, and domestic violence, respectively. Thirty-five or 44.9% of the women were delivered by emergency lower segment cesarean section. Fifteen or 17.9% babies were dead giving a perinatal mortality rate of 174 per 1,000After delivery, and 3 (3.8%) of the women had postpartum hemorrhage. Two women (2.6%) died giving a maternal mortality ratio of 2564 per 100,000 deliveries., Conclusion: Eclampsia is a dreaded obstetric disease with adverse fetal and maternal consequences that are not mitigating, and no effort should be spared in managing it effectively including public enlightenment.

Background: Women with a history of pre-eclampsia have a higher risk of developing pre-eclampsia in subsequent pregnancies. However, the role of the inter-pregnancy interval on this association is unclear., Objective: To explore the effect of inter-pregnancy interval on the risk of recurrent pre-eclampsia or eclampia., Search Strategy: MEDLINE, EMBASE and LILACS were searched (inception to July 2015)., Selection Criteria: Cohort studies assessing the risk of recurrent pre-eclampsia in the immediate subsequent pregnancy according to different birth intervals., Data Collection and Analysis: Two reviewers independently performed screening, data extraction, methodological and quality assessment. Meta-analysis of adjusted odds ratios (aOR) with 95 % confidence intervals (CI) was used to measure the association between various interval lengths and recurrent pre-eclampsia or eclampsia., Main Results: We identified 1769 articles and finally included four studies with a total of 77,561 women. The meta-analysis of two studies showed that compared to inter-pregnancy intervals of 2-4 years, the aOR for recurrent pre-eclampsia was 1.01 [95 % CI 0.95 to 1.07, I(2) 0 %] with intervals of less than 2 years and 1.10 [95 % CI 1.02 to 1.19, I(2) 0 %] with intervals longer than 4 years., Conclusion: Compared to inter-pregnancy intervals of 2 to 4 years, shorter intervals are not associated with an increased risk of recurrent pre-eclampsia but longer intervals appear to increase the risk. The results of this review should be interpreted with caution as included studies are observational and thus subject to possible confounding factors.

Introduction: Eclampsia is a rare but serious threat to maternal and fetal well-being. Magnesium sulfate was introduced in Finland as management of eclampsia in the late 1990s. The aim of this study was to assess the incidence of eclampsia in Finland after the increased use of magnesium sulfate., Material and Methods: Eclampsia diagnoses in Finland during 2006 to 2010 were retrieved from the national Medical Birth Register and the Care Register for Health Care. Medical records were reviewed., Results: In 2006-10, 295 447 deliveries were registered in Finland and 46 women with eclampsia were identified. Hence, the incidence of eclampsia was 1.5 per 10 000 deliveries. The median gestational age at the time of eclampsia was 38 gestational weeks. There were no maternal deaths due to eclampsia, but 46% of the women had severe complications. Eighty-seven per cent received magnesium sulfate for treatment and 7% for prevention of eclampsia. The perinatal mortality rate was 8%. Thirty-four per cent of the newborns were preterm and 15% were small-for-gestational-age., Conclusions: The incidence of eclampsia in Finland was very low. Increased use of magnesium sulfate probably contributed to the low incidence, as well as to the low number of recurrent seizures and prolonged complications. However, some women at risk of eclampsia still remain undetected and untreated. Seven percent had magnesium sulfate for prevention of eclampsia. Increased use of prophylactic magnesium sulfate might further reduce the incidence of eclampsia., (© 2016 Nordic Federation of Societies of Obstetrics and Gynecology.)

Objective: To study maternal and fetal outcomes in Ghanaian women with systemic lupus erythematosus (SLE)., Methods: Retrospective study of pregnancies in women with SLE in a single centre in Ghana., Results: The mean age was 30.1 years and all were nulliparous. Two out of the seven pregnancies were in disease remission at the time of booking. Nephritis without renal impairment was present in 7 pregnancies (6 women). One woman developed intrapartum eclampsia. Two women had secondary antiphospholipid syndrome (APS). Two suffered early fetal losses and one late fetal loss at 32 weeks. All three who lost their fetus had uncontrolled hypertension. Six had mild flares mainly joint pains during pregnancy. There was no maternal mortality. The median gestational age at delivery was 38 weeks (range, 16 to 40 weeks) and the mean birth weight was 3017 g; the median Apgar scores were 8 and 9 at 1 and 5 minutes of life, respectively. There were no cases of intrauterine growth restriction (IUGR). There were no cases of congenital heart block or neonatal lupus., Conclusion: Good pregnancy outcomes are possible in women with SLE even in resource poor settings. . All pregnancies should still be considered high risk and be managed jointly between the obstetricians, the perinatologists and the rheumatologists, in particular, those with renal involvement and hypertension. Long term follow up of a larger cohort is needed., Funding: None declared., Competing Interests: Conflicts of Interest: None declared

MicroRNAs represent nonprotein coding small RNA molecules that are very stable to degradation and responsible for gene silencing in most eukaryotic cells. Increased evidence has been accumulating over the years about their potential value as biomarkers for several diseases. MicroRNAs were predicted to be involved in nearly all biological processes from development to oncogenesis. In this review, we address the importance of circulating microRNAs in different conditions associated with pregnancy starting with the implantation period to preeclampsia and we shortly describe the correlation between placental circulating miRNAs and pregnancy status. We also discuss the importance of microRNAs in recurrent abortion and ectopic pregnancy.

Background: Denial of pregnancy, an inappropriate reaction where the woman does not consciously recognise her pregnancy, has been widely associated with poor outcomes for the woman's mental health, the events of labour and the newborn's health. However, reports of maternal physical complications are rare., Aims: To evaluate the physical morbidity associated with denial of pregnancy., Materials and Methods: Birth records from 2007 to 2013 were searched for women who did not receive any antenatal care. The medical records of women with denial of pregnancy were then examined in detail. The primary outcome measure was physical morbidity in women with denial of pregnancy until labour, using the hospital's general obstetric population as a comparator., Results: Six cases of denial of pregnancy (involving five women) were identified, a rate of 1:1420 births. All characteristics and complications were in keeping with previous studies, except regarding maternal physical morbidity. Three of the five women experienced physical complications, namely pre-eclampsia and its sequelae. Concerningly, two of these women required admission to the intensive care unit, one after an eclamptic seizure. These complications were significantly higher than in the hospital's wider obstetric population (all P < 0.05)., Conclusions: Previous reports of low maternal physical morbidity associated with denial of pregnancy are likely a reflection of low rates of diagnosis and underreporting. Given this study's increased rate of maternal physical morbidity and the implications this has for the women's future pregnancies, this underlines the importance of actively considering physical complications in women presenting with denial of pregnancy., (© 2015 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.)

Background: Pre-eclampsia progressing to eclampsia is one of the major causes of maternal death in Nigeria. Since there is long term association of pre-eclampsia with cardiovascular disease, cerebrovascular disease, renal disease, short life expectancy and mortality, it is essential to obtain obstetric history for better counseling and long term monitoring. The study assessed the knowledge of health workers about the association of pre-eclampsia with future cardiovascular disease and offering any risk-reduction counseling to women with pre-eclampsia., Methods: During a training workshop, a validated questionnaire on the association between pre-eclampsia and cardiovascular risk was distributed among health care workers working at the infant welfare and family planning clinics in Osun State. Data were analysed using descriptive and inferential statistics., Results: One hundred and forty-six out of 150 health workers approached participated in the study (response rate 97.3%). Mean age of respondents was 35.6 ± 9.1 years. Median age of practice was 7 years, ranging from 1-40 years. They were medical doctors (60.3%), community health workers (26.7%) and nurses/midwives (13.0%). Most participants had good knowledge on future cardiovascular risk of pre-eclampsia. The medical doctors had better knowledge compared to nurses/midwives and community health workers (78.4 vs. 57.9 vs. 53.8%; p < 0.05). Below half (45.9%) offered risk-reduction counseling., Conclusion: Knowledge of the cardiovascular risk factors was lower among the nurses/midwives and community health workers. Risk reduction counseling was quite low across all the health workers. There is need for continuous medical education and possible review of the training curriculum of the lower cadres of health workers.

Background: Eclampsia and pre-eclampsia are well-recognized causes of maternal and neonatal mortality in low income countries, but are never studied in a district hospital. In order to get reliable data to facilitate the hospital's obstetric audit a retrospective medical record study was performed in Ndala Hospital, Tanzania., Methods: All patients diagnosed with severe pre-eclampsia or eclampsia between July 2011 and December 2012 were included. Medical records were searched immediately following discharge or death. General patient characteristics, medical history, obstetrical history, possible risk factors, information about the current pregnancy, antenatal clinic attendance and prescribed therapy before admission were recorded. Symptoms and complications were noted. Statistical analysis was done with Epi Info®., Results: Of the 3398 women who gave birth in the hospital 26 cases of severe pre-eclampsia and 55 cases of eclampsia were diagnosed (0.8 and 1.6%). Six women with eclampsia died (case fatality rate 11%). Convulsions in patients with eclampsia were classified as antepartum (44%), intrapartum (42%) and postpartum (15%). Magnesium was given in 100% of patients with eclampsia and was effective in controlling convulsions. Intravenous antihypertensive treatment was only started in 5% of patients. Induction of labour was done in 29 patients (78% of women who were not yet in labour). Delivery was spontaneous in 67%, assisted vaginal (ventouse) in 14% and by Caesarean section in 19% of women. Perinatal deaths occurred in 30% of women with eclampsia and 27% of women with severe pre-eclampsia and were associated with low birth weight and prolonged time between admission and birth., Conclusions: 2.4% of women were diagnosed with severe pre-eclampsia or eclampsia. The case fatality rate and overall perinatal mortality were comparable to other reports. Better outcomes could be achieved by better treatment of hypertension and starting induction of labour as soon as possible.

Objective: To examine whether and to what extent pre/early-pregnancy blood pressure (BP) in the prehypertensive range contributes to the development of hypertensive disorders in pregnancy and gestational diabetes mellitus (GDM)., Methods: The cohort consisted of women who had their prenatal care and delivered a live singleton neonate at the Kaiser Permanente Bellflower Medical Center during 2005-2010. Women with prepregnancy hypertension (HTN) were excluded from the analysis. Among the remaining women, pre/early-pregnancy prehypertension (preHTN) was defined as two consecutive elevated BPs (SBP ≥ 120 or DBP ≥ 80) at separate ambulatory visits in the period from 1 year prior to pregnancy through the first trimester. Hypertensive disorders of pregnancy, including pre-eclampsia/eclampsia (PE/E), were identified by ICD-9 diagnoses. Mid-pregnancy 75-g oral glucose tolerance tests were used to identify GDM. Multivariable logistic and robust Poisson regression was used to test the association between preHTN and each outcome, adjusted for potential confounders., Results: Among 7802 women with at least two BP measures prior to or early in pregnancy, 2156 (27.6%) had preHTN. Overall, 653 (8.4%) developed a hypertensive disorder of pregnancy, 373 (4.8%) had PE/E, and 1877 (24.1%) developed GDM. After covariate adjustment, women with preHTN were 2.65 [95% confidence interval (CI) 2.22-3.16], 2.17 (95% CI 1.72-2.73), and 1.20 (95% CI 1.09-1.33) times as likely to develop any hypertensive disorder, PE/E, and GDM, respectively, compared to normotensive women., Conclusion: Prospective studies aimed at evaluating whether women with preHTN detected prior to or early in pregnancy may benefit from more intensive screening and/or interventions to prevent hypertensive disorders in pregnancy and GDM are needed.

A 27-year-old woman with mental retardation was admitted to a nearby hospital for an abrupt onset of seizure. Physical examination revealed remarkable hypertension and pregnancy with estimated gestational age of 28th week. Severe pulmonary edema and hypoxia led to a diagnosis of pregnancy-induced hypertension (PIH) accompanied by eclampsia. She was orotracheally intubated because of refractory seizure and hypoxemia, and transferred to our hospital for further treatment. Besides severe hypoxia and hypercapnea, an enhanced lesion was detected in the left posterior cerebrum by brain MRI. No abnormal findings were detected in the fetus, with heart rate of 150 beats x min. She was diagnosed with posterior reversible encephalopathy syndrome (PRES) caused by PIH and emergency cesarean section under general anesthesia was scheduled. A male newborn was delivered with Apgar score of 1/4 (1/5 min), followed by starting continuous infusion of nicardipine for controlling hypertension. Chest X-P on completion of surgery revealed remarkably alleviated pulmonary edema. She received intensive treatment and continued positive pressure ventilation for four days after delivery. She recovered with no neurological deficits and her child was well without any complications.

Hypertensive disorders of pregnancy remain among the leading causes of maternal morbidity and mortality. The onset of headaches in patients with hypertensive disorders of pregnancy has been considered as a premonitory symptom for eclampsia and other adverse maternal outcomes. Headaches are very common symptoms during pregnancy and the postpartum period with a reported incidence of 39%; however, headache is absent in 30-50% of women before the onset of eclampsia and is a poor predictor of eclampsia and adverse maternal outcomes. If included in the definition of cerebral or visual disturbances, headache may be considered a symptom of preeclampsia, a diagnostic feature of preeclampsia with severe features, a premonitory symptom of eclampsia, and an indication for delivery. Inclusion of this nonspecific symptom in the diagnosis and management of hypertensive disorders of pregnancy in the absence of an evidence basis may lead to unintended consequences including excessive testing, visits to outpatient offices or emergency departments, additional hospitalization, and iatrogenic preterm delivery without proven benefit. If a cerebral disturbance such as severe or persistent headache presents for the first time during pregnancy or postpartum, an evaluation should be performed that considers a broad differential diagnosis, including but not limited to hypertensive disorders of pregnancy, and the diagnostic evaluation is similar to that in nonpregnant adults. This commentary draws attention to the implications of considering the cerebral disturbance of headache as a symptom that portends adverse pregnancy outcome in the current recommendations for diagnosing and managing hypertensive disorders of pregnancy.

Objective: To compare the risks of selected adverse pregnancy outcomes among untreated women who met The International Association of the Diabetes and Pregnancy Study Groups (IADPSG)-defined glucose criteria at two different thresholds., Methods: A retrospective cohort study of women tested for gestational diabetes mellitus (GDM) with the 75-g 2-hour glucose tolerance test (GTT) who delivered a live singleton neonate. Data of women who were treated because they met institutional criteria defining GDM (at least two GTT results greater than or equal to fasting 100 mg/dL, 1-hour 195 mg/dL, and 2-hour 160 mg/dL) were excluded. The data of the remaining women were analyzed in three groups. The prevalence of selected adverse pregnancy outcomes was compared for those with no GDM ("no GDM," n=7,943); those at least one of whose results were fasting 92-94 mg/dL, 1-hour 180-190 mg/dL, or 2-hour 153-161 mg/dL ("GDM-1," n=771); and those at least one of whose results were greater than or equal to fasting 95 mg/dL, 1-hour 191 mg/dL, or 2-hour 162 mg/dL ("GDM-2," n=1,121)., Results: Of the 9,835 women, 1,892 (19.2%) met criteria for GDM, of whom 771 (40.8%) were categorized as GDM-1 and 1,121 (59.2%) GDM-2. After adjustment for confounders, women with GDM-2 were at significantly greater risk for preeclampsia or eclampsia, preterm delivery, primary cesarean delivery, shoulder dystocia, higher birth weight, ponderal index, large for gestational age, transient tachypnea, and neonatal hypoglycemia than women without GDM. Only birth weight and large for gestational age were significantly greater in the GDM-1 compared with the no GDM group., Conclusion: Fewer adverse outcomes are found at lower levels of the IADPSG-defined glucose intolerance spectrum. Determining whether these patients will benefit from treatment will require a randomized controlled trial., Level of Evidence: II.

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 majorities 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.

Aim: Magnesium sulfate is an evidence-based anticonvulsant drug used to prevent and control eclampsia. Controversy persists on routine administration of magnesium sulfate in cases of pre-eclampsia without severe features. Our objective was to assess the pattern of blood pressure and maternal symptoms preceding eclamptic seizure based on the current published work., Material and Methods: A comprehensive computer-based publication search was conducted in the African Journals Online, Google scholar, HINARI, PubMed, and MEDLINE databases and the Cochrane library to identify descriptive study reports for blood pressure, severity symptoms or stage of pregnancy during convulsion in women with eclampsia., Results: A total of 59 publications were eligible for this review. Overall, 21,149 eclamptic women from 26 countries were included for the interest of one or more of the selected variables. Out of 18,488 eclamptic women, the proportion of antepartum, intrapartum and post-partum eclampsia was 59%, 20% and 21%, respectively. Out of 3443 eclamptic women, 25% were normotensive; 20% had mild-to-moderate hypertension; 32% had severe hypertension; and 21% were hypertensive but unclassified. Out of 2163 eclamptic women, 66% and 27% had a headache and visual disturbance, respectively, preceding the occurrence of convulsion. Out of 2053 eclamptic women, 25% had epigastric area pain, and out of 1092 women with eclampsia, 25% were asymptomatic., Conclusion: Although eclampsia is known to result from severe pre-eclampsia with or without organ function derangement, this review has revealed that a significant number of eclamptic women had either normal blood pressure or mild-to-moderate hypertension immediately before seizure. The findings are apparently in support of initiating magnesium sulfate prophylaxis to all women with mild pre-eclampsia., (© 2015 The Authors. Journal of Obstetrics and Gynaecology Research © 2015 Japan Society of Obstetrics and Gynecology.)

Available evidence concerning the association between indoor air pollution (IAP) from biomass and solid fuel combustion and preeclampsia/eclampsia is not available in developing countries. We investigated the association between exposure to IAP from biomass and solid fuel combustion and symptoms of preeclampsia/eclampsia in Indian women by analyzing cross-sectional data from India's third National Family Health Survey (NFHS-3, 2005-2006). Self-reported symptoms of preeclampsia/eclampsia during pregnancy such as convulsions (not from fever), swelling of legs, body or face, excessive fatigue or vision difficulty during daylight, were obtained from 39,657 women aged 15-49 years who had a live birth in the previous 5 years. Effects of exposure to cooking smoke, ascertained by type of fuel used for cooking on preeclampsia/eclampsia risk, were estimated using logistic regression after adjusting for various confounders. Results indicate that women living in households using biomass and solid fuels have two times higher likelihood of reporting preeclampsia/eclampsia symptoms than do those living in households using cleaner fuels (OR = 2.21; 95%: 1.26-3.87; P = 0.006), even after controlling for the effects of a number of potentially confounding factors. This study is the first to empirically estimate the associations of IAP from biomass and solid fuel combustion and reported symptoms suggestive of preeclampsia/eclampsia in a large nationally representative sample of Indian women and we observed increased risk. These findings have important program and policy implications for countries such as India, where large proportions of the population rely on polluting biomass fuels for cooking and space heating. More epidemiological research with detailed exposure assessments and clinical measures of preeclampsia/eclampsia is needed in a developing country setting to validate these findings., (© 2014 The Authors. Indoor Air published by John Wiley & Sons Ltd.)

HELLP syndrome (hemolysis, elevated liver enzymes, low platelet count) is a relatively rare complication of pregnancy. It usually develops in the IIId trimester or after delivery. HELLP syndrome is associated with increased maternal (placental abruption, disseminated intravascular coagulation, hepatic hematomas and rupture, and acute kidney injury) and neonatal (prematurity, low birth weight) risk complications. In this article the diagnosis, clinical picture and treatment of this disease have been shortly reviewed.

Aim: To investigate the maternal mortality ratio (MMR) and causes of maternal death in order to decrease these deaths., Materials and Methods: The number of live births, maternal deaths, and the causes of deaths in Yuzuncu Yil University were recorded between 2004 and 2013., Results: The MMR was 268 per 100,000. Forty-nine maternal deaths were examined in terms of cause. The most frequent cause of death is eclampsia (33%) and associated intracerebral complications. The antenatal follow-up rate was 23.3%. The majority of patients had low income (92.3%), 72.2% were from rural areas, and 95.5% were illiterate., Conclusion: The high MMR may arise from the high incidence of pregnancy complications in eastern Turkey, the rareness of antenatal follow-ups, and the present hospital being a referral hospital. The most frequent cause of maternal mortality is eclampsia and associated complications, followed by bleeding.

Aims and Objectives: This is a case of posterior reversible encephalopathy syndrome (PRES) associated with postpartum eclampsia in a primiparous Nigerian., Case Presentation: A 20-year-old primiparous woman presented to the emergency unit of the department of obstetrics and gynaecology of our hospital with symptoms and signs consistent with postpartum eclampsia. While being managed for this, she developed weakness of the left limbs with associated altered sensorium. Significant findings on physical examination were hypertension, left-sided hemiparesis and cortical blindness. She had a computed tomographic (CT) scan of the brain which showed features consistent with posterior reversible encephalopathy syndrome. She was given full supportive care with control of her blood pressure and she made a significant improvement. She was discharged home about 3 weeks after admission with improvement in clinical condition and is currently being followed up in our neurology clinic., Conclusion: PRES complicating eclampsia is a clinicoradiological diagnosis. In most cases neurological symptoms improve with good supportive care and adequate treatment of the underlying condition as was the case in this patient. However permanent neurological sequelae can result from delayed diagnosis and treatment; therefore a high index of suspicion, early diagnosis and treatment are essential.

Purpose: To determine whether the use of uterotonics, including oxytocin and prostaglandins, increases the risk of abruptio placentae and eclampsia., Materials and Methods: A retrospective analysis was conducted among 260,174 Japanese women at term. Demographic characteristics were studied as possible candidates for risk factors of abruptio placentae and eclampsia using multivariate logistic regression analyses., Results: A total of 1,058 (0.41 %) and 147 (0.06 %) women developed abruptio placentae and eclampsia, respectively. Abruptio placentae and eclampsia occurred in 177 (0.29 %) and 42 (0.07 %) of the 61,857 women treated with uterotonics, respectively. Multivariate regression analyses indicated that uterotonics did not increase risk of developing either abruptio placentae or eclampsia. Primiparity [odds ratio (95 % confidence interval) 1.41 (1.24-1.60)], age ≥35 years [1.17 (1.03-1.33)], and presence of hypertension [2.42 (1.93-3.03)] were significant independent risk factors for abruptio placentae, while advancing gestation [0.67 (0.63-0.71)] decreased risk of abruptio placentae. Primiparity [odds ratio (95 % confidence interval) 4.06 (2.49-6.63)], age <20 years [2.44 (1.07-5.58)], presence of hypertension [28.7 (20.5-40.1)], and advancing gestation [1.28 (1.11-1.47)] were significant independent risk factors for eclampsia., Conclusion: The use of uterotonics did not increase the risk of abruptio placentae and eclampsia.

Posterior reversible encephalopathy syndrome (PRES) is a serious clinico-neuroradiological maternal complication in pregnancy. Although it has various etiologies such as hypertensive encephalopathy, renal failure, autoimmune disorders, sepsis, multiple organ failure, and treatment with immunosuppressant or cytotoxic agents, pregnancy and postpartum complicated by hypertensive disorders more frequently lead to this condition. PRES is clinically characterized by headache, confusion, seizures, vomiting, and visual disturbances with radiographic vasogenic edema especially affecting symmetrical parietal and occipital lobes. The underlying pathophysiology is still a matter of debate. Prompt recognition and early intervention greatly improve the prognosis, so that obstetricians should be well aware of this rare entity. Timely imaging is of crucial importance especially in patients with an uncertain diagnosis for determining the appropriate treatment and preventing the possible development of neurologic deficits. In the present report, three cases of PRES are presented with clinical and radiological findings in pregnancies complicated by severe pre-eclampsia and eclampsia. The latest literature in the field is also carefully reviewed.

Purpose of Review: Stroke is a life-threatening condition whose frequency is increased during pregnancy, in particular in the two first weeks of the puerperium. Pre-eclampsia/eclampsia is a disorder that enhances this risk. The purpose of this review is to summarize existing data regarding the association, diagnosis as well as management for stroke in pre-eclampsia or eclampsia., Recent Findings: In about one third of stroke cases during pregnancy or puerperium, pre-eclampsia or eclampsia is concomitantly diagnosed. In these women, hemorrhagic stroke is more common than ischemic stroke, probably as a result of severe hypertension. Clinical presentation may vary but severe headache is the most common symptom. Neuroimaging techniques are warranted to identify affected cases. Prevention is based on blood pressure adjustment and thromboprophylaxis., Summary: The risk of stroke should be taken into consideration in women with a diagnosis of pre-eclampsia or eclampsia. In particular, women with neurologic symptoms should be promptly evaluated, blood pressure should be adjusted and thromboprophylaxis should be started.

Objective: Catastrophic antiphospholipid syndrome (CAPS) is a life-threatening disease caused by the onset of rapidly progressive and widespread small-vessel thromboses in the presence of aPLs. The aim of this study was to examine pregnancy-related CAPS., Methods: Retrospective series of 13 patients with pregnancy-related CAPS with special focus on the follow-up. RESULTS; Eleven patients had known APS and had been treated with low-molecular-weight heparin (n = 10), aspirin (n = 8), oral anticoagulants (n = 1), HCQ (n = 3) and/or steroids (n = 1) during pregnancy. The most frequent manifestations of CAPS were cutaneous (n = 11), hepatic (n = 11), renal (n = 10), cardiac (n = 8) and neurological (n = 5). CAPS usually followed haemolysis, elevated liver enzymes and low platelet count (HELLP) syndrome (n = 12), which was associated with pre-eclampsia (n = 6) or with eclampsia (n = 3). No maternal death was observed. The perinatal mortality of 54% was related to prematurity with a mean gestational age of 26.6 weeks at onset of CAPS or HELLP syndrome. During a mean follow-up of 4.8 years (range 2-8 years), seven new pregnancies occurred in five patients and led to one miscarriage, four successful pregnancies and two HELLP syndrome with pre-eclampsia or eclampsia that occurred at 28 weeks gestation in both cases despite optimal treatment. No relapse of CAPS was observed. Two mothers suddenly died 2.5 and 6 years after CAPS., Conclusion: The occurrence of HELLP syndrome in a patient with APS should raise the suspicion of CAPS in the following days, and anticoagulation should be maintained post-partum or post-abortum. Subsequent pregnancies are at very high risk.

Preeclampsia and eclampsia are fatal medical complications of pregnancy accounting for 20-80 % of increased maternal death in developing countries. Their aetiologies are still under investigation. Serum trace elements have been suggested to be involved in the pathogenesis of preeclampsia. Aim of this study was to address the correlation of serum trace elements with preeclampsia and eclampsia. It was a comparative cross-sectional study conducted on conveniently recruited 44 preeclampsia, 33 eclampsia and 27 normotensive pregnant patients. Atomic absorption spectrometry was employed to analyse serum concentrations of Ca, Mg, Cu, Zn and Fe. Data were analysed by Student's t test, one-way analysis of variance and multinomial logistic and binary regression analyses. p < 0.05 was considered as a level of significance. In preeclampsia, the serum Ca and Mg were significantly lower than those in eclampsia, while Cu and Zn values were higher. Significant changes of Ca, Mg and Cu were noted among preeclampsia, eclampsia and pregnant control. Serum Ca and Mg indicated a positive association, and Cu gave a negative association in preeclampsia. Cu/Fe ratio was high in eclampsia. Significant correlations of Mg with Zn in eclampsia and Mg with Fe in preeclampsia and eclampsia were predicted. Significant changes in serum trace element levels were present in preeclampsia and eclampsia that may have a link with the pathogenesis of pregnancy disorder.

It is known that hemorrhagic stroke at the perinatal period are caused by specifics conditions like eclampsia as well as by the existing abnormal vessels. We treated a case of HELLP syndrome resulting in eclampsia with non-aneurysmal, convexity subarachnoid hemorrhage. A 34-year-old female, who had been pointed out to have a high level of urinal protein at the 37th week, was seen in the emergency department because of severe headache, vomiting and respiratory discomfort. Her systolic blood pressure was over 190mmHg, and caesarean section was selected. On the way to the operating room, she had a generalized convulsion with loss of consciousness. The delivery was carried out. The CT immediately after the caesarean section revealed faint and localized subarachnoid hemorrhage in the bilateral convexity areas. Additionally, the FLAIR image of MRI demonstrated increased intensity in the bilateral cerebellar hemispheres, basal ganglion and subcortical area, suggesting vasogenic edema. The patient had a good clinical course and the abnormal signal of MRI also recovered by treatment with oral iron and zinc. Here, we report a speculation for the mechanism of this case and precautions against stroke in the perinatal period.

To establish the etiologies and therapeutic strategies for the treatment of eclampsia and stroke during pregnancy, we performed a questionnaire-based study of stroke during pregnancy in Aichi prefecture (2005-2009). This study revealed the following findings: 66% of deliveries were managed in primary medical institutions, 40% of eclampsia episodes and 31% of strokes occurred at primary medical institutions, and 19% of strokes occurred at home. Home-onset strokes displayed a mortality rate of 40%. Using the results of this questionnaire, we investigated cases of eclampsia and/or stroke during pregnancy and revealed important issues regarding their management. In pregnant women with eclampsia or stroke, accurate antihypertensive and anticonvulsive treatment are necessary. Discriminating between eclampsia and stroke during labor is difficult. However, when facial or arm muscle weakness or a facial deficit is detected, stroke should be strongly suspected. Brain computed tomography can usually detect most cases of hemorrhagic stroke. When a stroke is detected, collaborative treatment with a neurosurgeon should be started as soon as possible. If stroke is suspected at a primary medical institution, rapid maternal transport to an intensive medical institution is necessary. In patients whose blood pressure is greater than 180/120 mmHg, the use of MgSO4 to decrease the risk of convulsions and reduce blood pressure is recommended. These findings might aid the development of therapeutic strategies for pregnant women with eclampsia or stroke.

Background: Adults who were born with low birth weights are at increased risk of cardiovascular and metabolic conditions, including pregnancy complications. Low birth weight can result from intrauterine growth restriction, preterm birth or both. We examined the relation between preterm birth and pregnancy complications later in life., Methods: We conducted a population-based cohort study in the province of Quebec involving 7405 women born preterm (554 < 32 weeks, 6851 at 32-36 weeks) and a matched cohort of 16 714 born at term between 1976 and 1995 who had a live birth or stillbirth between 1987 and 2008. The primary outcome measures were pregnancy complications (gestational diabetes, gestational hypertension, and preeclampsia or eclampsia)., Results: Overall, 19.9% of women born at less than 32 weeks, 13.2% born at 32-36 weeks and 11.7% born at term had at least 1 pregnancy complication at least once during the study period (p < 0.001). Women born small for gestational age (both term and preterm) had increased odds of having at least 1 pregnancy complication compared with women born at term and at appropriate weight for gestational age. After adjustment for various factors, including birth weight for gestational age, the odds of pregnancy complications associated with preterm birth was elevated by 1.95-fold (95% confidence interval [CI] 1.54-2.47) among women born before 32 weeks' gestation and 1.14-fold (95% CI 1.03-1.25) among those born at 32-36 weeks' gestation relative to women born at term., Interpretation: Being born preterm, in addition to, and independent of, being small for gestational age, was associated with a significantly increased risk of later having pregnancy complications.

The morbidity and mortality from acute kidney injury (AKI) have remained relatively high over the last six decades. The triad of infections, nephrotoxins and obstetric complications are still major causes of acute kidney injury in the tropics. This retrospective study is a five-year audit of acute renal failure (ARF) (or stage 3 AKI) in patients requiring hemodialysis at the renal unit of the Department of Medicine of the Ladoke Akintola University of Technology (LAUTECH) Teaching Hospital, Osogbo, Nigeria. A total of 80 patients with AKI were treated over a five-year period at our center, of which 45 (56.2%) were in ARF, i.e. stage 3 AKI requiring hemodialysis. There were 24 males and 21 females. The most common cause of ARF among the patients was sepsis syndrome 16 (35.5%), while pregnancy-related cases accounted for 15 (33.3%) and nephrotoxins for 6 (13.3%). Five (33%) of the 15 pregnancy-related patients survived, and all were cases of septic abortion. Of the other 10 patients that did not survive, three (30%) had post-partum hemorrhage and seven (70%) post-partum eclampsia. In all, the mortality rate among our AKI presenting for hemodialysis at our center over a given year period was 28.8%. Majority of these were eclampsia related. The causes of ARF still remain the same in the tropics, eclampsia portends poor prognosis. Concerted efforts should be made at limiting this trend by active preventive services and early recognition of high-risk obstetrics cases.