Late Postpartum Eclampsia: Report of Two Cases Managed by Uterine Curettage and Review of the Literature

ABSTRACT

The purpose of this study was describe two patients with rapid recovery of refractory late postpartum eclampsia (LPPE) following uterine curettage, and to evaluate the literature about supportive evidence for such a management in LPPE. A detailed literature search was performed focusing on studies reporting the clinical presentation, laboratory workup, imaging, and management of LPPE. Mean reported onset of LPPE was on postpartum day 7.0 ± 2.9. Only 35.3% had a history of preeclampsia: these had earlier onset of seizures compared with the subjects without history of preeclampsia (4.3 ± 1.4 versus 7.6 ± 2.9 days; p < 0.005). Onset of seizure was correlated with systolic blood pressure (Pearson's r = 0.34; p < 0.05). Major associated symptoms were headaches (71.4%), visual changes (46.0%), and nausea/vomiting (22.2%); 67.5% of patients were proteinuric. The remaining laboratory tests were usually normal. Among the patients with a normal head computed tomography, magnetic resonance imaging identified additional abnormalities in 53.8% (seven of 13). A total of 69.7% of patients developed multiple seizure episodes, some of these occurred while the patient was receiving magnesium sulfate treatment; 82.5% of patients underwent magnesium therapy and approximately half of those patients required multiple antiseizure drugs. The number of seizures was only correlated with the diastolic blood pressure (Pearson's r = 0.52; p < 0.01). Even remote from delivery, headaches, visual change, and nausea/vomiting are important symptoms of LPPE. Hypertension and/or proteinuria are important diagnostic findings. LPPE is often characterized by refractory seizures and controlling the diastolic blood pressure is important. Patients presented in our case report showed no seizures after uterine curettage. This potential useful management for LPPE requires additional investigation.

KEYWORDS

Late postpartum eclampsia - uterine curettage - review

REFERENCES

• 1 Hirshfeld-Cytron J, Lam C, Karumanchi S A, Lindheimer M. Late postpartum eclampsia: examples and review.  Obstet Gynecol Surv. 2006;  61 471-480
• 2 Mattar F, Sibai B M. Eclampsia. VIII. Risk factors for maternal morbidity.  Am J Obstet Gynecol. 2000;  182 307-312
• 3 Leitch C R, Cameron A D, Walker J J. The changing pattern of eclampsia over a 60-year period.  Br J Obstet Gynaecol. 1997;  104 917-922
• 4 Chames M C, Livingston J C, Ivester T S, Barton J R, Sibai B M. Late postpartum eclampsia: a preventable disease?.  Am J Obstet Gynecol. 2002;  186 1174-1177
• 5 Lubarsky S L, Barton J R, Friedman S A, Nasreddine S, Ramadan M K, Sibai B M. Late postpartum eclampsia revisited.  Obstet Gynecol. 1994;  83 502-505
• 6 Munjuluri N, Lipman M, Valentine A, Hardiman P, Maclean A B. Postpartum eclampsia of late onset.  BMJ. 2005;  331 1070-1071
• 7 Miles Jr J F, Martin Jr J N, Blake P G, Perry Jr K G, Martin R W, Meeks G R. Postpartum eclampsia: a recurring perinatal dilemma.  Obstet Gynecol. 1990;  76 328-331
• 8 Matthys L A, Coppage K H, Lambers D S, Barton J R, Sibai B M. Delayed postpartum preeclampsia: an experience of 151 cases.  Am J Obstet Gynecol. 2004;  190 1464-1466
• 9 Harer Jr W B, McIndoe D W. Postpartum eclampsia treated by curettage.  Am J Obstet Gynecol. 1962;  84 1349-1350
• 10 Magann E F, Martin Jr J N, Isaacs J D, Perry Jr K G, Martin R W, Meydrech E F. Immediate postpartum curettage: accelerated recovery from severe preeclampsia.  Obstet Gynecol. 1993;  81 502-506
• 11 Magann E F, Bass J D, Chauhan S P, Perry Jr K G, Morrison J C, Martin Jr J N. Accelerated recovery from severe preeclampsia: uterine curettage versus nifedipine.  J Soc Gynecol Investig. 1994;  1 210-214
• 12 Veltkamp R, Kupsch A, Polasek J, Yousry T A, Pfister H W. Late onset postpartum eclampsia without pre-eclamptic prodromi: clinical and neuroradiological presentation in two patients.  J Neurol Neurosurg Psychiatry. 2000;  69 824-827
• 13 Martin J, Sidman R. Late postpartum eclampsia: a common presentation of an uncommon diagnosis.  J Emerg Med. 2003;  25 387-390
• 14 Dziewas R, Stogbauer F, Freund M et al.. Late onset postpartum eclampsia: a rare and difficult diagnosis.  J Neurol. 2002;  249 1287-1291
• 15 Hara N, Fujii T, Tsutsumi O. Postpartum eclampsia associated with cortical blindness.  Int J Gynaecol Obstet. 1994;  47 287-288
• 16 Hauswald M. Cortical blindness and late postpartum eclampsia.  Am J Emerg Med. 1987;  5 130-132
• 17 Hinchey J, Chaves C, Appignani B et al.. A reversible posterior leukoencephalopathy syndrome.  N Engl J Med. 1996;  334 494-500
• 18 Parisaei M, Derwig I, Yoon J, Erskine K J, Jarman P R. Posterior reversible leukoencephalopathy in a case of postpartum eclampsia.  Am J Obstet Gynecol. 2005;  193 885-886
• 19 Dziewas R, Stogbauer F, Freund M et al.. Late onset postpartum eclampsia a rare and difficult diagnosis.  J Neurol. 2002;  249 1287-1291
• 20 Arkwright P D, Rademacher T W, Dwek R A, Redman C W. Pre-eclampsia is associated with an increase in trophoblast glycogen content and glycogen synthase activity, similar to that found in hydatidiform moles.  J Clin Invest. 1993;  91 2744-2753
• 21 Nugent C E, Punch M R, Barr Jr M, LeBlanc L, Johnson M P, Evans M I. Persistence of partial molar placenta and severe preeclampsia after selective termination in a twin pregnancy.  Obstet Gynecol. 1996;  87 829-831
• 22 Felz M W, Barnes D B, Figueroa R E. Late postpartum eclampsia 16 days after delivery: case report with clinical, radiologic, and pathophysiologic correlations.  J Am Board Fam Pract. 2000;  13 39-46
• 23 Brady W J, DeBehnke D J, Carter C T. Postpartum toxemia: hypertension, edema, proteinuria and unresponsiveness in an unknown female.  J Emerg Med. 1995;  13 643-648
• 24 Alkan A, Tugrul S, Oral O, Uslu H, Kose D, Catakli F T. Effects of postpartum uterine curettage on maternal well-being in severe preeclamptic patients.  Clin Exp Obstet Gynecol. 2006;  33 55-58
• 25 The Eclampsia Trial Collaborative Group . Which anticonvulsant for women with eclampsia? Evidence from the Collaborative Eclampsia Trial.  Lancet. 1995;  245 1455-1463
• 26 Belfort M A, Anthony J, Saade G R, Allen Jr J C. Nimodipine Study Group . A comparison of magnesium sulfate and nimodipine for the prevention of eclampsia.  N Engl J Med. 2003;  348 304-311
• 27 Ludmir J, Stubblefield P G. Surgical procedures in pregnancy. Gabbe SG, Niebyl JR, Simpson JL, et al Obstetrics: Normal and Problem Pregnancies. 4th ed. New York; Churchill Livingstone 2002: 607-650
• 28 Belogolovkin V, Levine S R, Fields M C, Stone J L. Postpartum eclampsia complicated by reversible cerebral herniation.  Obstet Gynecol. 2006;  107 442-445
• 29 Gold K J, Barnes C, Lalley J, Schwenk T L. Case report: late-onset eclampsia presents as bilateral cortical blindness.  Am Fam Physician. 2005;  71 856 , 858, 861
• 30 Asaeda G, Ferreira R, Pierre-Louis A. Uncommon seizures: eclampsia in the postpartum patient.  JEMS. 2005;  30 36-38
• 31 Azonobi I, McBride-Richter H, Patrick L. Late-onset postpartum eclampsia.  J Midwifery Womens Health. 2006;  51 51-53
• 32 Graeber B, Vanderwal T, Stiller R J, Werdmann M J. Late postpartum eclampsia as an obstetric complication seen in the ED.  Am J Emerg Med. 2005;  23 168-170
• 33 Chambers K A, Cain T W. Postpartum blindness: two cases.  Ann Emerg Med. 2004;  43 243-246
• 34 Mathew R, Raj R S, Sudha P. Late postpartum eclampsia without prodroma.  Neurol India. 2003;  51 539-540
• 35 Martin J, Sidman R. Late postpartum eclampsia: a common presentation of an uncommon diagnosis.  J Emerg Med. 2003;  25 387-390
• 36 Winston A W, Norman D. Late postpartum eclampsia coincident with postdural puncture headache: a case report.  AANA J. 2003;  71 371-372
• 37 Graves J C, Vandergriff J V. Atypical eclampsia: a case report and review.  Tenn Med. 2001;  94 173-175
• 38 Newbould S. Postpartum eclampsia.  Am Fam Physician. 2002;  66 378
• 39 Veltkamp R, Kupsch A, Polasek J, Yousry T A, Pfister H W. Late onset postpartum eclampsia without pre-eclamptic prodromi: clinical and neuroradiological presentation in two patients.  J Neurol Neurosurg Psychiatry. 2000;  69 824-827
• 40 Iffy L. Late postpartum eclampsia at 20 weeks' gestation.  Am J Perinatol. 1993;  10 95
• 41 Mandelkern D, Burger A. Cortical blindness in postpartum preeclampsia progressing to eclampsia: case report.  Mt Sinai J Med. 1992;  59 72-74
• 42 Michaeli J. Late appearance of postpartum eclampsia.  JAMA. 1985;  254 909
• 43 Sibai B M, Schneider J M, Morrison J C et al.. The late postpartum eclampsia controversy.  Obstet Gynecol. 1980;  55 74-78
• 44 Steiner G J, Plasha M K. Late postpartum eclampsia: report of a case.  Obstet Gynecol. 1964;  24 594-596