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A questionnaire about the management of hypertension in pregnancy was sent to the 150 members of the Royal New Zealand College of Obstetricians and Gynaecologists. Sixty five out of a total of 77 replies were suitable for analysis. There was a wide variation in the criteria for diagnosis and the outpatient and inpatient investigation and treatment. The commonest drugs prescribed in imminent eclampsia were hydralazine as an anti-hypertensive, and diazepam or phenytoin as anticonvulsants. All clinicians practised aggressive management with induction of delivery if significant proteinuria complicated hypertension in pregnancy. Glucocorticoid therapy for the premature induction of fetal lung maturity in mothers and severe hypertension was considered beneficial by some, yet contraindicated by others.
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PMID:New Zealand obstetricians' management of hypertension in pregnancy. A questionnaire survey. 275 77

Eclampsia is a syndrome of hypertension, proteinuria, edema, and neurologic manifestations such as seizures, focal deficits, or blindness occurring during pregnancy, mainly in primigravidas. Although it is not seen often in the pediatric population, it occurs with greater frequency among pregnant patients under the age of 15 than in the general population. Serious sequelae can be prevented with prompt and adequate treatment, including termination of pregnancy.
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PMID:Eclampsia: a pediatric neurologic problem. 291 12

Prospectively gathered data from eight geographically defined areas in south-east Asia included serial measures of blood pressure, proteinuria and oedema during pregnancy. A total of 15,476 pregnancies were included. Both antenatal oedema and proteinuria were markers of increased risk of antenatal diastolic hypertension, proteinuric pre-eclampsia and eclampsia. However they identified fetuses at high risk of low birthweight and perinatal mortality only in areas where the incidence of hypertension was low. As a screening strategy to identify women who are at increased risk of antenatal diastolic hypertension, of proteinuric pre-eclampsia and of eclampsia, the most efficient strategy is probably to use the presence of oedema and/or proteinuria. The sensitivity of using this method for identifying women with proteinuric pre-eclampsia is high, but for identifying eclampsia it is still relatively low. Where resources are available there is probably no substitute for using a sphygmomanometer and measuring blood pressure.
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PMID:Could oedema and proteinuria in pregnancy be used to screen for high risk? The WHO International Collaborative Study of Hypertensive Disorders of Pregnancy. 323 84

The incidence of preeclampsia in a consecutive series of 642 twin pregnancies was 25.9% compared with 9.7% in singleton pregnancies (p less than 0.001); in primiparas it was 35.2% and in multiparas 20.4% (p less than 0.001). Preeclampsia in twin pregnancies was more commonly of early onset (p less than 0.001) and the maternal disease more severe as assessed by the incidences of severe hypertension (p less than 0.001), proteinuria (p less than 0.004), and eclampsia (p less than 0.01). There were 1 maternal and 12 perinatal deaths. Oestriol excretion before the emergence of preeclampsia was lower in patients with severe compared with milder preeclampsia (p less than 0.05) as was plasma glucose concentration (p less than 0.05). Mean birth and placental weights according to gestation, tended to be lower in the severe group compared with uncomplicated cases and those with milder preeclampsia, as were also the placental-fetal weight ratios. The similarity of results with those already reported for singleton pregnancy suggested a similar pathogenesis for preeclampsia in twin and singleton pregnancies.
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PMID:Preeclampsia in twin pregnancy--severity and pathogenesis. 347 80

Six women without hypertension or proteinuria, admitted for severe upper abdominal pain in the third trimester of pregnancy had elevated serum liver enzymes (SGOT, SGPT), markedly increased serum LDH levels, thrombocytopenia and abnormal blood coagulation tests, in particular low antithrombin III levels, indicating disseminated intravascular coagulation (DIC). Liver biopsies showed periportal and/or focal parenchymal lesions with large fibrin deposits, comparable to the liver lesions in eclampsia. Immunofluorescence (IF) showed microthrombi and large fibrin deposits. Three of the six women recovered spontaneously before delivery; in the remaining three all signs and symptoms rapidly disappeared after delivery. Perinatal outcome was poor. Seven women with pregnancy-induced hypertension and elevated serum liver enzymes constituted a reference series. Histopathological examination of liver biopsies in the reference group revealed periportal and/or focal parenchymal lesions in three whereas IF showed fibrin deposition in all seven, but less extensive than in the study group. The present findings indicate that upper abdominal pain in the last trimester of pregnancy can be caused by a syndrome of (pre)-eclamptic liver damage and DIC, even when hypertension and proteinuria are lacking.
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PMID:A syndrome of liver damage and intravascular coagulation in the last trimester of normotensive pregnancy. A clinical and histopathological study. 351 56

A diagnosis of eclampsia has been considered inappropriate when the onset of a convulsion is greater than 24 hours after delivery. The observations presented here provide strong support for waiving the 24-hour rule, at least when convulsions from no other apparent cause and accompanied by hypertension and proteinuria occur in a primipara as late as 10 days postpartum. Late postpartum eclampsia seems an appropriate term for this very uncommon condition.
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PMID:Convulsions in hypertensive, proteinuric primiparas more than 24 hours after delivery. Eclampsia or some other cause? 362 13

This study reviews liver disease in toxemia of pregnancy based on 102 cases submitted to the Armed Forces Institute of Pathology. The common clinical features were right upper quadrant and epigastric pain, nausea, vomiting, and elevation of the serum transaminases. Jaundice occasionally developed. These occurred in severe preeclampsia or eclampsia and their cause was usually recognized. However, hepatic symptoms and signs did result in inappropriate diagnoses and misdirected therapy. Such confusion occurred when these were the initial problems confronting the clinician in women presenting with advanced toxemia due to poor prenatal care. They were also likely to be misleading when other more classic parameters, such as blood pressure and proteinuria, were only midly abnormal. Central nervous system complications were the common cause of death but liver disease could be partially or wholly responsible. Extensive periportal lesions, hepatic hematomas, spontaneous rupture, and infarction all contributed to hepatic injury and to morbidity. Fibrin deposition, hemorrhage, or both in the periportal areas was characteristic of the histopathology. Scanning electron microscopy validated this spectrum of change. A toxemic vasculopathy related to severe vasospasm in the hepatic arterial circulation may be responsible.
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PMID:Liver disease in toxemia of pregnancy. 378 23

From January 1978 to July 1983 22 patients have recovered from eclampsia in the Obstetrics and Gynecology Department - Vitt. Emanuele II Hospital - Catania University. 64% of the patients had hypertension in pregnancy combined with edema in 92.85% of the cases (13 cases) and with proteinuria in 18% of the cases (4 cases). Eclampsia manifested itself before labour in 28.57% (6 cases), during labour in 19.05% (4 cases), in postpartum in 19.05% (4 cases) and in the successive three days after delivery in 33.33% (7 cases). Perinatal death rate was 11.28% and in all the cases it was due to intrauterine fetal death. In 22 patients treated there was a case of acute pulmonary edema and a case of maternal death.
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PMID:A clinical and epidemiological study on eclampsia in the obstetrics and gynecology department of Catania in the years 1978-1983. 384 Jul 26

For the purpose of clinical management, any woman with an acute rise in blood pressure in the latter half of pregnancy must be regarded as having preeclampsia with the possibility of progression to eclampsia. Unfortunately, such diagnoses have been accepted uncritically in the selection of cases for clinical and laboratory studies of preeclampsia, with inevitably erroneous and contradictory conclusions about the disorder. The diagnosis of mild preeclampsia may be correct in roughly one-half of cases, but others may be latent or frank essential hypertension or any of a variety of renal diseases. In selecting cases for research, the diagnostic errors can be greatly reduced by the exclusion of all multiparas and all primigravidas without abundant proteinuria. The primigravidas should have a reliable history of normality or follow-up studies proving it, be aged 25 or less, and have hyperuricemia. The selection of cases for the study of preeclampsia demands far more rigid criteria for diagnosis than does the diagnosis for clinical management.
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PMID:Diagnosis of preeclampsia. 388 67

Scanning electron microscopy was used to study the morphologic characteristics of erythrocytes in women with preeclampsia and eclampsia. In nine nulliparous women with eclampsia, the proportion of abnormal red cells (schistocytes, echinocytes, and spherocytes) was significantly greater than in 12 normally pregnant control women (p less than 0.001). Likewise, the proportion of these abnormal erythrocyte forms was significantly greater in 12 nulliparous women with preeclampsia than in 25 normally pregnant control women (p = 0.009). Six women with mild pregnancy-induced hypertension without proteinuria were studied before and after magnesium sulfate therapy had been given, and no differences in the proportion of abnormal erythrocyte forms were found. Evidence for microangiopathic hemolysis, manifest by reticulocytosis and thrombocytopenia, was apparent with eclampsia, although only reticulocytosis was identified in women with preeclampsia. There was evidence for hepatic dysfunction in more than half of the women with eclampsia, and in nearly one third of those with preeclampsia. We speculate that compositional changes in the membrane, induced by plasma/erythrocyte lipid interchanges, which are predisposed by normal pregnancy and amplified by severe preeclampsia, especially in the presence of liver dysfunction, may have participated in the genesis of the red cell abnormalities observed. Furthermore, these abnormalities in the cell membrane may increase erythrocyte susceptibility to microangiopathic hemolysis.
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PMID:Erythrocyte morphology in women with severe preeclampsia and eclampsia. Preliminary observations with scanning electron microscopy. 405 Sep 10


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