Atypical eclampsia and postpartum status epilepticus
Zeynep Ozcan Dag1,&, Yuksel Isik1, Yakup Turkel2,
Murat Alpua2, Yavuz Simsek1
1Department of Obstetrics and Gynecology, Kirikkale University, Faculty of Medicine, Kirikkale, Turkey, 2Department of Neurology, Kirikkale University, Faculty of Medicine, Kirikkale, Turkey
Zeynep Ozcan Dag, Department of Obstetrics and Gynecology, Kirikkale University, Faculty of Medicine, Kirikkale, Turkey
Preeclampsia is an entity that may present from 20th week of gestation up to 48 hours postpartum and is associated with hypertension and proteinuria. Eclampsia is emergence of convulsions pre-eclampsia in pregnant women with signs and symptoms. Recent studies showed that in some women, preeclampsia and even eclampsia may occur without hypertension or proteinuria. Here, we present a case of 26 years old women who had an uneventful pregnancy until 30 weeks' of gestation. She had only proteinuria in laboratory tests and was diagnosed as status epilepticus in early postpartum period. Preeclampsia and eclampsia is related with serious fetal and maternal morbidity and mortality and may present with atypical course. The awareness of atypical cases of preeclampsia enhances early diagnosis and management which are critical to avoid feto-maternal complications.
Preeclampsia is characterized with hypertension and proteinuria during pregnancy, and can have serious consequences about maternal and fetal health. The incidence of preeclampsia in developing countries is 12% and it also constitutes a significant proportion of maternal mortality in developed countries. Complications such as acute pulmonary edema, intracranial hemorrhage and eclampsia can also be negative fetomaternal consequences [1,2]. Fetal outcomes of preeclampsia also include prematurity, intrauterine growth retardation, increased neonatal mortality, cardiovascular and metabolic disorders later in life and neurological disability . Eclampsia is emergence of convulsions pre-eclampsia in pregnant women with signs and symptoms. In recent years, atypical cases showing atypical course have been reported . The characteristics of these cases was reported as eclampsia in the absence of hypertension and proteinuria, a partial seizure following eclampsia with antecedent proteinuria without hypertension, a case presenting with fetal distress, without hypertension and a case with unusually rapid progression and massive proteinuria that was unresponsive to therapy. Here, we aimed to present a case that had no signs of pre-eclampsia during pregnancy follow-up, except for proteinuria and developed status epilepticus in the postpartum period.
A 26 years-old nulligravida was presented with regular contractions at
30 weeks gestation. On admission, systemic blood pressure was normal.
There was no symptoms at that time such as headaches or visual disturbances
all her prenatal visits had been normal, including blood pressure (BP),
which was recorded as 120/80 to 110/70 mmHg. There was no prodrome
of hypertensive disease and no laboratory abnormality, including platelet
LDH, electrolytes, and glucose, although proteinuria (3+) on dipstick
was noticed on admission. There was no preeclampsia or other hypertensive
in previous pregnancy. There were no co-morbid conditions in the patient
such as history of preexisting hypertension, diabetes or kidney disease.
In the delivery room, she developed generalized tonic-clonic convulsions
lasting 3 min, despite being normotensive. MgSO4 was given (loading
dose of 46 g over 1520 min, followed by a maintenance dose of 2 g/h
as a continuous
intravenous infusion). As intrapartum fetal heart rate recordings revealed
poor variability, an emergency cesarean delivery was performed. In
the postoperative period within two hours of admission, second generalized
was observed. Due to ongoing seizure, 0.1 mg/kg intravenous bolus diazepam
was administered slowly. In the post-ictal period, her BP raised abruptly
to 150/100 to 140/100 mmHg. Her BP continued high for two days, ranging
between 160/100 and 140/90 mmHg and normalized on postpartum day 2,
with 870 mg/dL
proteinuria in the 24 h urine collected postpartum. The patient was
consulted to the Neurology department. She had no focal neurological
deficits. In order
to rule out intracranial hemorrhage, brain tomography (CT)
was obtained. It revealed no pathological findings. Due to recurrent
seizures and unconsciousness, the patient was accepted as status epilepticus
infusion of 20 mg/kg loading dose was initiated. Maintenance dose of
8 mg/kg phenytoin was infused. During the observation after 10 hours
of admission, speech arrest and contralateral dystonic posturing and
partial seizure, has been detected and 0.1 mg/kg intravenous bolus
diazepam was administered slowly. After 16 hours of admission focal
was shorter than previous ones ended without any medications. Electroencephalography
(EEG) revealed 4 Hz frequency high amplitude waveforms in bilateral
frontal regions at 15th hours of postpartum period (Figure
1). On the
3rd day of
admission, control EEG was reported as normal. Phenytoin 300
mg/day was continued.
She was discharged on the 7th postoperative day.
New onset of hypertension and proteinuria during pregnancy is called
preeclampsia. The diagnosis is easy in the presence of the classical
findings, therefore fetal and maternal morbidity and mortality are significantly
If preeclamptic patients present with atypical course, the treatment
may be delayed and more serious statements such as eclampsia develops. In
patient, routine biochemical tests, coagulation studies and doppler
uterine artery studies in early pregnancy were all normal. Proteinuria was
in the urine analysis during control visits but blood pressure
was in normal limits. In this respect, our patient showed an atypical course
as in previous
reports [4-7]. Our patient did not have any complaints
such as headache, blurred vision, and epigastric pain which are
seen in preeclampsia cases. In the literature, 80% of eclampsia cases arise
prenatal period and childbirth. Eclampsia has emerged in the postpartum
period in a few cases [8,9]. In
our case, the first seizure occurred before delivery. Status epilepticus
is defined as one continuous, unremitting seizure lasting longer
than five minutes, or recurrent seizures without regaining consciousness
for more than five minutes . Our patient who did
not have epilepsy had her first seizure during the follow-up in
hospital. Despite magnesium sulfate and antiepileptic treatment she was
as status epilepticus. Partial epilepsy such as frontal lobe epilepsy
may not lead to loss of consciousness. Sometimes partial onset seizures
progress to generalized seizures. The clinical and EEG features
of our patient were considered as eclampsia with partial onset seizure.
may be overlooked because they are not obvious generally and than
eclampsia diagnosis may be delayed.
Preeclampsia and eclampsia which are important causes of maternal and fetal mortality may have atypical features in terms of clinical and laboratory findings. As in cases of proteinuria in the form of seemingly innocent isolated cases, atypical cases must be kept in mind in the differential diagnosis of preeclampsia so that this may have an important role in reducing maternal and infant mortality.
The authors declare no competing interests.
The work presented here was carried out in collaboration between all authors. ZOD, YI and YT analyzed the data and wrote the manuscript. MA, YS have been involved in the acquisition of clinical data. ZOD, YI, YT, MA and YS participated in reviewing the scientific literature and contributed to the final version of the manuscript. All authors read and approved the final manuscript.
Figure 1: high amplitude teta slow wave activity in bilateral frontal regions
- Khan KS, Wojdyla D, Say L, Gülmezoglu AM, Van Look PF. WHO analysis of causes of maternal death: a systematic review. Lancet. 2006;367(9516):1066-74. PubMed | Google Scholar
- Thornton C, Dahlen H, Korda A, Hennessy A. The incidence of preeclampsia and eclampsia and associated maternal mortality in Australia from population-linked datasets: 2000–2008. Am J Obstet Gynecol. 2013;208(6):476. e1-e5. PubMed | Google Scholar
- Kane SC, Dennis A, da Silva Costa F, Kornman L, Brennecke S. Contemporary Clinical Management of the Cerebral Complications of Preeclampsia. Obstet Gynecol Int. 2013;2013:985606. PubMed | Google Scholar
- Albayrak M, Özdemir I, Demiraran Y, Dikici S. Atypical preeclampsia and eclampsia: report of four cases and review of the literature. J Turkish-German Gynecol Assoc. 2010;11(2):115-117. PubMed | Google Scholar
- Al-Jameil N, Aziz Khan F, Fareed Khan M, Tabassum H. A Brief Overview of Preeclampsia. J Clin Med Res. 2014;6(1):1-7. PubMed | Google Scholar
- Agwu FE, Nduka EC, Nwachukwu KC. Atypical Eclampsia: Case Report. Pioneer Medical Journal. 2013; 3:5. PubMed | Google Scholar
- Shirin Niroomanesh a, Fatemeh Mirzaie. Atypical postpartum eclampsia: Status epilepticus without preeclamptic prodromi. Women and Birth. 2008;21(4):171-173. PubMed | Google Scholar
- Santos VM, Correa FG, Modesto FR, Moutella PR. Late-onset
postpartum eclampsia: still a diagnostic dilemma?Hong Kong Med J.2008;14(1):60-63. PubMed | Google Scholar
- Mathew R, Raj RS, Sudha P. Late postpartum eclampsia without prodroma. Neurol India. 2003;51(4):539-540. PubMed | Google Scholar
- Nandhagopal R. Generalised convulsive status epilepticus: an overview. Postgrad Med J. 2006;82(973):723-732. PubMed | Google Scholar