Late postpartum eclampsia as an obstetric complication seen in the ED

Brendon Graeber BA^a, Tamara Vanderwal BSc^a, Robert J. Stiller MD^b,*, Michael J. Werdmann MD^c

^aYale University School of Medicine, New Haven, CT 06510, USA

^bDepartment of Obstetrics and Gynecology, Bridgeport Hospital, Bridgeport, CT 06610, USA

^cDepartment of Emergency Medicine, Bridgeport Hospital, Bridgeport, CT 06610, USA

Received 21 April 2004; accepted 22 April 2004

Abstract Preeclampsia is a complication of pregnancy associated with hypertension and proteinuria. Preeclampsia may be associated with grand mal seizures and is termed eclampsia. Historically, eclampsia occurring more than 48 hours after delivery, known as late postpartum eclampsia, was thought to be uncommon; however, recent evidence suggests that its incidence is increasing. In addition, the presentation of late postpartum preeclampsia-eclampsia may differ from that occurring during the pregnancy. This contributes to difficulty in diagnosing late postpartum preeclampsia-eclampsia in an emergency department setting. We report 2 cases of late postpartum eclampsia presenting 8 days after delivery, which highlight the unique features of this disorder and discuss some of the difficulties in managing these patients. Greater awareness and knowledge of this disorder by ED physicians should improve outcomes in these potentially life-threatening cases.

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Introduction

Hypertensive disorders of pregnancy occur in 5% to 10% pregnancies [1]. Preeclampsia is defined as blood pressure higher than 140/90 mm Hg and proteinuria of more than 300 mg per 24 hours occurring after 20 weeks of gestation [2]. Edema may also accompany this disorder along with abnormalities in coagulation or liver function testing. In its most Severe form, preeclampsia may be accompanied by new-onset grand mal seizures and is termed eclampsia. Preeclampsia-eclampsia generally occurs close to term and typically resolves within 48 hours of delivery. Because this

* Corresponding author. Tel.: +1 203 384 3544; fax: +1 203 384 3574.

E-mail address: [email protected] (R.J. Stiller).

disorder is most commonly seen in either pregnant or immediately delivered women, obstetricians are most famil- iar with its presentation and treatment. However, preeclamp- sia-eclampsia may develop after 48 hours and patients may initially present to the emergency department (ED) with the findings of hypertension and headaches, with later develop- ment of seizures. We present 2 cases of late postpartum eclampsia seen initially in the ED and review the pertinent features of this disorder.

Case 1

A 27-year-old woman, gravida 2, para 1, presented to the ED with complaints of headache and visual changes with a

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Late postpartum eclampsia as an obstetric complication seen in the ED 169

duration of 1 day. Eight days earlier, she had delivered a full-term baby boy by cesarean section, which was indicated because of failure to progress in labor after an uncompli- cated pregnancy. Her headache was localized to the left side, and the patient reported the pain at 7/10. Her initial blood pressure was 177/92 mm Hg, which decreased to 140/68 mm Hg over the next few hours in the ED. On evaluation by the ED physician, the pain was not relieved by acetamin- ophen or ibuprofen. She reported a history of migraines in the distant past. Her Neurological examination was reported as normal. A cranial computerized tomogram without contrast was unremarkable. The urinalysis for protein was negative. The patient was given 2 doses of meperidine and the pain resolved. She was discharged approximately 4 hours later.

At home, she experienced vomiting and the return of her headache. Approximately 90 minutes after discharge, her mother reported a loss of consciousness, followed by convulsions lasting about 5 minutes, with postictal confu- sion. She experienced a second seizure at home approxi- mately 5 minutes later. She arrived in the ED by ambulance at approximately 2 hours after her initial discharge. Diazepam and labetolol were administered, a lumbar puncture was performed, and neurology and obstetric consultations were requested. Laboratory results included the following values: creatinine, 0.8 mg/dL; aspartate aminotransferase, 30 IU/L; hemoglobin, 11.1 mg/dL; hematocrit, 33.9; and platelets, 427,000. The urine protein/ creatinine ratio was 0.18 (normal b0.3).

The patient was evaluated by the obstetrics consultant who recommended that magnesium sulfate therapy be instituted, with an initial 6-g Intravenous bolus. She experienced a third generalized convulsion lasting about 60 seconds shortly after beginning the intravenous magnesium sulfate infusion. After this episode, the patient was continued on magnesium sulfate and experienced no further seizures.

The patient was admitted to the medical intensive care unit. Blood cultures, electroencephalogram, and magnetic resonance imaging studies were ordered and the results were normal. Cerebrospinal fluid cultures were also negative. The patient had no further complications and was discharged on hospital day 2.

Case 2

A 26-year-old woman, gravida 1, para 1, who had delivered a healthy full-term baby by spontaneous vaginal delivery, presented to the ED in the evening of the eighth postpartum day complaining of worsening, persistent head- ache with a duration of 2 days, accompanied by nausea and vomiting with some blurring of her vision. Initially, the headache had responded to acetaminophen, but on the day of admission, nothing had succeeded in relieving it. Examina- tion of the patient revealed only a significantly Elevated blood pressure of 166/94 mm Hg. The patient denied other

complaints or pain beyond her headache. Given her postpartum status, an obstetrics consultation was requested. The obstetrics consultant suspected postpartum pre- eclampsia, and magnesium sulfate was requested from the pharmacy. Approximately 3 hours later, while awaiting the institution of magnesium sulfate therapy, the patient experienced a generalized tonic-clonic seizure, accompanied by urinary incontinence. She received diazepam (10 mg IV). After the resolution of her first seizure, a blood chemistry panel and a cranial Computerized tomography study were ordered by the ED physician. Half hour after her first seizure, the patient experienced another tonic-clonic seizure in the ED. Magnesium sulfate therapy was then initiated with a 6-g intravenous bolus followed by a 2-g/h intravenous infusion, and she underwent a CT scan. CT findings were negative for any obvious abnormalities. The patient was admitted to the medical intensive care unit receiving intravenous magnesium sulfate with a diagnosis of late

postpartum eclampsia.

The patient’s blood chemistry results were normal including the following values: Na⁺, 147 mEq/L; Cl^—, 109 mEq/L; HCO^—, 14 mEq/L; K⁺, 4.0 mEq/L; blood, urea, and nitrogen, 11 mg/dL; creatinine, 0.7 mg/dL; Ca²⁺, 9.5 mg/dL; and glucose, 70 mg/dL. However, a complete blood count revealed a hemoglobin level of 14.0 g/dL, a Hematocrit level of 43.2, a platelet count of 89,000, and a white blood cell count of 19,100. Spot urinalysis showed 1+ protein.

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The patient’s remaining hospital course was unremark- able. Cranial magnetic resonance imaging was negative. Blood cultures were negative as well. A urine culture was positive for Klebsiella pneumoniae, which was treated with antibiotic therapy. Intravenous magnesium sulfate infusion at 2 g/h was continued for 48 hours. The remainder of her hospital admission was uncomplicated and she was dis- charged on the third day.

Discussion

Preeclampsia is a complication of pregnancy consisting of hypertension and proteinuria. In its most severe form, preeclampsia may be accompanied by seizures and is termed eclampsia. Generally, eclampsia occurs either before or within 48 hours of delivery. Eclampsia occurring more than 48 hours but less than 4 weeks after delivery is known as late postpartum eclampsia. Late postpartum eclampsia was initially thought to be very uncommon [3]. However, recent data suggest that the timing of eclampsia in this country is changing and that the incidence of documented late postpartum eclampsia is increasing [3,4].

Lubarsky et al [3] reported on 334 cases of eclampsia from 1977 to 1992. Ninety-seven cases (29%) occurred in postpartum period. Of 97 cases of postpartum eclampsia, 54 (56%) occurred after 48 hours of delivery. Convulsions occurred 3 to 23 days postpartum, with mean of 6 days postpartum. Of 54 patients, 37 (69%) developed convulsions

170 B. Graeber et al.

after hospital discharge and 45 (83%) complained of either Severe headache (n = 38) or Visual disturbances (n = 17) before seizures occurred. In 56% of cases, preeclampsia was diagnosed before the onset of convulsions.

Chames et al [4] studied patients with eclampsia at 3 centers during the period of 1996-2001. There were 89 patients diagnosed with eclampsia. Twenty-nine (33%) cases occurred in the postpartum period. Of 29 patients with postpartum eclampsia, 23 (79%) occurred after 48 hours. The presenting symptoms were headache (87%), visual changes (44%), nausea or vomiting (22%), and Epigastric pain (22%). Only 5 patients of these 23 patients (22%) were previously diagnosed with preeclampsia during labor.

The differential diagnosis of seizures in a postpartum patient includes cerebral venous thrombosis, intracerebral hemorrhage, hypertensive encephalopathy, space-occupying lesions of the brain, Metabolic disorders such as hypogly- cemia, hyponatremia, and epilepsy. Imaging studies of the brain are recommended when focal or persistent neurolog- ical findings are present.

The recommended treatment of preeclampsia for preven- tion of seizures is magnesium sulfate [1,2]. This is administered as a 4- to 6-g intravenous infusion over 15 to 30 minutes, followed by a maintenance dose of 2 g/h [1]. The maintenance infusion should be titrated to the patient’s patellar reflexes, urine output, respiratory rate, and serum magnesium levels [1,2]. Magnesium toxicity should, thus, be avoidable, but can be treated with parenteral Calcium gluconate (10 mL of a 10% solution), if necessary. Blood pressure higher than 160/110 mm Hg is generally treated with antihypertensive agents such as labetolol, hydralazine, or nifedipine. Treatment with magnesium sulfate is gener- ally discontinued after 24 hours.

In contrast with the nonpregnant patient, magnesium sulfate is the preferred agent for prevention and treatment of seizures due to eclampsia. Lucas et al [5] compared magnesium sulfate and phenytoin for the prevention of eclamptic seizures. In this study, 10 of the 1089 women randomized to phenytoin had eclamptic seizures whereas none of the 1049 women randomized to magnesium sulfate experienced convulsions. This provided clear evidence of the superiority of magnesium sulfate over phenytoin for this disorder.

Late postpartum preeclampsia may not present with all the classical symptoms of intrapartum preeclampsia such as hypertension (z140/90), proteinuria, and associated symp- toms such as headache, visual changes, abdominal pain, or edema. Laboratory abnormalities, such as hemolysis, elevated liver transaminases, and low platelet count, known as the HELLP syndrome, are seen in a minority of cases of

late postpartum eclampsia [4]. This makes the diagnosis of late postpartum preeclampsia-eclampsia more difficult to make.

Our 2 cases demonstrate the subtlety with which late postpartum preeclampsia may present. In both cases, the presentation was marked by hypertension associated with worsening headache and visual changes with nausea and vomiting. However, there were no signs of preeclampsia during labor or during the immediate postpartum period and symptoms did not develop until after discharge. Significant proteinuria, a hallmark of preeclampsia, was not present in the first case. The second case did show laboratory abnormalities including hemoconcentration, thrombocyto- penia, and proteinuria.

In conclusion, patients may present after hospital discharge and be seen by either primary care and emergency physicians, and it is important for other specialties to recognize women at risk for late postpartum preeclampsia- eclampsia. prompt treatment of preeclampsia may prevent the progression to seizures. Magnesium sulfate, the pre- ferred therapy, may not be stocked in the ED, leading to a potential delay in instituting therapy once ordered. Obste- tricians should inform new mothers about the symptoms of postpartum preeclampsia, such as the development of severe headache, visual changes, or abdominal pain. In addition, emergency physicians should always be prepared to consider late postpartum preeclampsia in postpartum hyper- tensive patient.

Acknowledgment

The authors thank Steven A. Laifer, MD, for his careful reading and review of the manuscript.

References

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2. American College of Obstetricians and Gynecologists. Diagnosis and management of preeclampsia and eclampsia. ACOG Practice Bulletin

33. Washington (DC)7 ACOG; 2002.

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