Postpartum Eclampsia Research Articles

Frequency, Management and Outcome of Postpartum Hemorrhage at a tertiary care Hospital.

Introduction: According to WHO, world estimates of 2017, 295 000 maternal deaths were reported all over the world and maternal mortality rate ranged from UI 99 to 243 per 100 000 live births. There has been 35% reduction since year 2000. Similarly, there has been 51% reduction in maternal mortality rate in Pakistan. 94% of all maternal deaths occur in low and lower middle-income countries. The major complications that account for nearly 75% of all maternal deaths are: severe bleeding mostly Post-Partum Hemorrhage (PPH), Postpartum sepsis, pre-eclampsia and eclampsia and other.
 Objective: To find out the frequency of patients presenting with PPH among all patients delivered during the study period, their management and subsequent morbidity and mortality.
 Methodology: This retrospective study was conducted between January 2018 to December 2019 at the department of Obstetrics and Gynecology PUMHS Hospital Nawabshah, Benazirabad. The demography, parity, gestational age, mode of delivery and type of PPH developed as well as treatment for PPH and subsequent morbidity and mortality were all documented. Data analyzed using SPSS version 20.
 Results: During study period frequency of PPH was 32.73 per 1000 deliveries, prevalence of primary PPH was 90.51%. Among the causes of PPH, Uterine atony was the leading cause 42/137 (30.65%). 56 (40.87%) patients were managed in the ICU for ventilatory &, inotropic support and septic shock, management. Mortality was 7(5%).
 Conclusion: Majority of patients are of primary PPH and uterine atony remains the most common cause of PPH which requires prompt and timely management as per guidelines.

Eclampsia and posterior reversible encephalopathy syndrome (PRES): A retrospective review of risk factors and outcomes.

Posterior reversible encephalopathy syndrome (PRES) is a clinical and radiological entity initially described in 1996. PRES frequently develops in patients with preeclampsia and eclampsia. There is not much literature on risk factors causing PRES in pregnant patients with eclampsia. This study aimed to determine the incidence of PRES in eclampsia, its association with pregnancy, risk factors, and maternal and perinatal outcomes.Patients and methods: All patients who were admitted with eclampsia and developed PRES in an intensive care unit of a tertiary medical facility between 1997 and 2017 were included in the study. Patients’ demographics, pregnancy and gestational data, treatment mode, and outcomes were retrospectively obtained from their medical charts/files. Data were entered using SPSS program version 23. Chi-square test was used to compare the variables, and a p value of < 0.05 was considered statistically significant.Results: A total of 151 patients were admitted during the study period, and 25 developed PRES. The diagnosis was common in patients older than 25 years. Eclampsia patients who developed PRES were without any pregnancy-associated comorbidities (p < 0.08). At the time of diagnosis, their gestational age was more than 36 weeks, which was significant (p < 0.04). Incidence was significantly higher in patients presenting with eclampsia and had recurrent seizures (p < 0.01 and 0.002, respectively). Its incidence was significantly higher in postpartum eclampsia patients (p < 0.01). It was also significantly higher in patients who had cesarean section and hypertension treated with labetalol (p < 0.001 and 0.02, respectively). Overall, the maternal mortality rate of eclampsia patients complicated with PRES was 4% in our population.Conclusion: Of eclampsia patients, 16% developed PRES, which is on the lower side than the reviewed literature (10%–90%). Eclampsia on presentation, recurrent seizures, postpartum eclampsia, cesarean delivery, and labetalol use were associated with increased risk of PRES development.

Risk factors for postpartum readmission for preeclampsia or hypertension before delivery discharge among low-risk women: a case-control study

Postpartum hypertension or preeclampsia is one of the most frequent reasons for readmission after delivery discharge, and risk factors for readmission remain poorly characterized. This study aimed to determine risk factors of postpartum readmission for hypertension or preeclampsia among low-risk women before delivery discharge. We conducted a nested case-control study from 2012 to 2015 at a tertiary care medical center. Cases were identified using diagnostic codes for postpartum transient hypertension, mild preeclampsia, severe preeclampsia, eclampsia, superimposed preeclampsia, and unspecified hypertension and readmission within 6 weeks of delivery. Controls not readmitted for hypertension or preeclampsia were time matched within 4 weeks of the delivery date to each case. We fit multivariable logistic regression models to identify independent risk factors for postpartum readmission for hypertension or preeclampsia and then calculated a receiver operating characteristic curve of the final model to assess model discrimination. Within the source cohort resulting in 58 cases and 232 matched controls, the rate of postpartum readmission for preeclampsia or hypertension was 0.4% (n=58 of 14,503). The median time to readmission was 6 days (range, 2-15 days), and 40% of cases had an outpatient postpartum visit before readmission. In multivariable analysis, non-Hispanic black race (adjusted odds ratio, 2.14; 95% confidence interval, 0.99-4.59), gestational hypertension (adjusted odds ratio, 2.70; 95% confidence interval, 1.12-6.54), preeclampsia during delivery admission (adjusted odds ratio, 3.12; 95% confidence interval, 1.29-7.50), and maximum postpartum systolic blood pressure during delivery admission (adjusted odds ratio, 1.05; 95% confidence interval, 1.03-1.08) were risk factors for readmission. This model had a good discriminative ability to predict women who would require readmission for preeclampsia or hypertension (area under the curve, 0.83; 95% confidence interval, 0.74-0.89). Using these 4 factors to illustrate this model, the predicted risk of readmission ranged from <1% in the lowest risk scenario (eg, postpartum systolic blood pressure of 120 mm Hg + no hypertensive disorders of pregnancy + white race) to 26% in the highest risk scenario (eg, postpartum systolic blood pressure of 160 mm Hg + preeclampsia + black race). Risk factors of postpartum readmission for hypertension or preeclampsia can be identified at the time of delivery discharge among low-risk women, regardless of an antenatal hypertensive disorder. A next step could be using these risk factors to develop a predictive model to guide postpartum care.

An unusual presentation of posterior reversible encephalopathy syndrome\u2014a case report

BackgroundAcute neurological emergencies in pregnant and postpartum women presenting as headache, visual disturbances, seizures, and elevated blood pressure are usually attributed to preeclampsia and eclampsia. However cerebral venous sinus thrombosis (CVST) and posterior reversible encephalopathy syndrome (PRES) are two important, rare conditions which should be considered. PRES is a rare neuroradiological syndrome characterised by vasogenic oedema of subcortical white matter, commonly involving posterior cerebral hemispheres. Preeclampsia and eclampsia are the common causes of PRES. However, late postpartum eclampsia concurrent to PRES is rare. Here, we report a rare case of PRES secondary to late postpartum eclampsia with atypical radiological findings.Case presentationA 25-year-old married woman with prior history of two spontaneous abortions presented to us on day 5 postpartum, post lower segment caesarean section (LSCS) with complaints of headache followed by one episode of new onset generalised tonic-clonic seizures. There was no history of seizures prior to the pregnancy and no history of hypertension or diabetes during any of her pregnancies. On examination, BP was 140/90 mm Hg and PR 98 bpm. Systemic examination revealed GCS 15/15, no focal neurological deficits, and bilateral flexor plantar response. Fundus examination was normal with no evidence of hypertensive retinopathy. Preliminary haematological and biochemical tests including antiphospholipid antibody (APLA) profile were done in view of prior abortions and were within normal limits. Lumbar puncture was done—normal study. EEG was normal. MRI with MRV was suggestive of atypical posterior encephalopathy. In view of late onset postpartum seizure, the patient was started on injection of magnesium sulphate, anti-hypertensives, and antiepileptics; following which, she improved and was discharged.ConclusionThough preeclampsia and eclampsia are usually screened entities, we should also follow women in puerperium for late postpartum eclampsia which is defined as seizures beyond 48 h of delivery up to 4 weeks postpartum. So it is important to follow-up postpartum women for complications like PRES because early detection and treatment can lessen the morbidity and mortality as they are completely reversible. Thus, health care professionals should be educated about the same. Apart from antenatal and intrapartum care, postpartum care should also be given equal importance.

Reversible Posterior Leukoencephalopathy Syndrome (RPLS) in Late Onset Postpartum Eclampsia- A Retrospective Study

Background: Reversible posterior leukoencephalopathy syndrome (RPLS) or Posterior reversible encephalopathy syndrome (PRES) is a unique clinicoradiologic entity characterized by acute onset headache, seizures, blindness and altered mental state associated with reversible vasogenic edema of the brain. It is a major complication of eclampsia, but data on clinicoradiological features of PRES in late-onset postpartum eclampsia are scarce. The objective is to analyze the clinicoradiologic features and outcome in a cohort of late postpartum eclampsia patients with PRES. Subjects and Methods: Eighteen patients of late postpartum eclampsia with clinical as well as neuroimaging features consistent with PRES were included in this retrospective study. All had undergone magnetic resonance imaging (MRI) with diffusion-weighted imaging (DWI) and apparent diffusion coefficient(ADC) mapping. Data on age, antepartum history, peak systolic and diastolic blood pressures, clinical features, time to neuroimaging, location of lesions on brain imaging and presence of associated ischemia or hemorrhage in MRI were collected and analyzed. Results: The mean age was 25.72 3.23 years. The average duration between labor and clinical symptoms was 8.5 days. 13/18 patients (72.2%) had elevated blood pressure at admission. Mean systolic and diastolic blood pressures were 143.88 (120-180) and 93.88 (80-100) mm Hg respectively. Headache was the presenting feature in 16 patients. The parieto-occipital regions were the most frequently involved followed by the cerebellum (7/18) and frontal lobe (4/18). Atypical regions were not involved. Clinical recovery had been noted in all. Conclusion: PRES associated with late postpartum eclampsia, an entity of limited awareness can present without antecedent preeclampsia. Radiological changes are the key to early diagnosis.

Guillainbarré Syndrome not responding to Remdesivir, Enoxaparin and High dose methylprednisolone in Patient with Covid 19 and eclampsia in Pregnancy: A case report.

COVID-19 pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has protean manifestations. Nervous system involvement though uncommon in COVID-19 can present with debilitating manifestations like necrotising encephalopathy, myopathy, seizure, peripheral neuropathy and Guillain Barré syndrome. In this case report, we report a case of 27 years old woman who presented to us with post partum eclampsia and developed acute flaccid quadriparesis 5 days after COVID-19 infection which was manifested as cough, anosmia and ageusia without fever. Patient developed dyspnoea followed by type 2 respiratory failure 8 days after hospitalization for which she was put into mechanical ventilation. She was treated with high dose Methylprednisolone and standard medical therapy. IVIG or plasmapheresis could not be given due to non-availability. Patient expired in ICU after 18 days of hospital admission. SARS-COV-2 mainly infects the respiratory system of the body but it may have the neurotropic capacity and its ability to produce immune dysregulation can produce a cascade of inflammatory reactions in the nervous system. Guillain Barré syndrome is a heterogeneous disorder triggered by many viral infections and its development following COVID-19 infection can be attributed to the virus or immune response of the host against it. Possibility of COVID-19 infection triggering Guillain Barré syndrome cannot be ruled out. More studies regarding association of COVID-19 with the neurological disease may help in unraveling the neuro-invasion ability of the virus and to develop measures to prevent it.

Medico-Social Characteristics of Patients with eclampsia in a metropolitan hospital in North western Nigeria: Is there a changing pattern?

Background: Eclampsia is a recognized cause of maternal and neonatal morbidity and mortality in North western Nigeria. It’s a preventable obstetrics calamity were adequate antenatal care services are provided.Objective: To review medico-social characteristics of patients with eclampsia at a metropolitan Specialist Hospital in North-western Nigeria,Methodology: Eighty consecutive patients that presented with eclampsia at Murtala Mohammed Specialist Hospital were recruited for the study from 1st December, 2016 to 28th February, 2017. Data were collected using structured questionnaire, administered by research assistants. Information obtained included sociodemographic data, duration of fits before presentation and maternal-fetal outcome.Results: A total of 1931 patients delivered within the study period, among them 80 had eclampsia. This gives an incidence of 4.0%. Teenage pregnancy accounted for 35%. Forty-nine patients (61.2%) were primigravidae and up to 95% were booked. Majority of the patients 40(50%) had antepartum eclampsia while only 10(12.5%) had postpartum eclampsia. Most of the patients (73.8%) presented within 12 hours of convulsions and (87%) had vaginal delivery. There were 3 maternal deaths with case fatality rate of 3.8%. Live birth was achieved in 65%. Fresh still birth and Macerated still births were recorded in 20% and 12.5% respectively.Conclusion: The incidence of eclampsia is still high despite introduction of free maternity care services. Socio medical factors and poor quality of Antenatal Care services may be the contributing factors to development of eclampsia. There is need to review and improve the quality of antenatal care services offered at the primary health care centers.

Late-onset postpartum eclampsia: Do not ignore the headache!

Pre-eclampsia and eclampsia continue to be a poorly understood neurological entity of pregnancy that substantially contributes to maternal morbidity and mortality. The onset of postpartum eclampsia occurring more than 48 h after the onset of the postpartum period is defined as late-onset postpartum eclampsia (LPE). We report the case of a 27-year-old woman who had eclampsia on the 6th postpartum day after cesarean section with a throbbing headache as the only prodromal symptom and normal blood pressure (BP) recordings at the time of convulsion. She was managed successfully with magnesium sulfate therapy. This case emphasizes that headache and/or visual changes developing during the postpartum period can be the only warning symptom of impending eclampsia and that LPE can occur even when the BP has normalized post-delivery. Early diagnosis and subsequent initiation of appropriate therapy prevent severe complications.

A RETROSPECTIVE STUDY OF FETOMATERNAL OUTCOME IN ECLAMPSIA

In India the perinatal and maternal outcome in eclampsia cases is still poor due to inadequate antenatal care in rural areas, financial restraints and non-availability of transportation facilities, and social taboos causing delay in management resulting in poor maternal and neonatal outcome. Aim of the study was to evaluate fetomaternal outcome in patients with eclampsia. This retrospective study was conducted over a period of 2 years from May 2018 to April 2020 at department of obstetrics and gynaecology of Government medical college and Sir T General hospital, Bhavnagar , Gujarat , India. During the review period total 50 cases of eclampsia reported.Incidence in our study is 0.43%.Results showed 86 % of eclampsia patients were of age less than 25 years. 82% of patients had antepartum eclampsia , 14 % had postpartum eclampsia and 4% had intrapartum eclampsia . 90% patients had 1 episodes of convulsion. 8% patients had 2 episodes of convulsions.2% pateint had 5 episode of convulsion. Out of 50 patients 36 patients were delivered by C-section and 14 patients by vaginal delivery.1 patient had twin pregnancy.Out of 51 newborn, 5 were stillbirth and 1 early neonatal death.Maternal mortility was 2 % .Eclampsia is still one of the important and common obstetric emergencies, which has a significant role in maternal and perinatal outcome. Regular Antenatal Care (ANC), proper health education, improvements of socioeconomic conditions and spreading of awareness in the community has major roles in prevention of eclampsia. Timely and appropriate intervention including primary management, early referral and judicious termination of pregnancy help in reducing morbidity and mortality of both mother and fetus.&#x0D; Keywords: Eclampsia, Fetomaternal outcome.

Late postpartum eclampsia

In view of the rarity of late postpartum eclampsia, the author considers it not uninteresting to report a case where he had to observe seizures of eclampsia on the eighth day after childbirth.

Postpartum complications increased in women with polycystic ovary syndrome

Women with polycystic ovary syndrome are at a higher risk of cardiometabolic and psychiatric comorbidities and preconception and antepartum complications, but the impact of polycystic ovary syndrome during the postpartum period is unknown. This study aimed to investigate the risk of postpartum cardiovascular disease complications and perinatal and postpartum depression. This was a retrospective cohort study conducted using a United States insurance claims database. Women with and without polycystic ovary syndrome aged 18 to 50 years enrolled continuously in a single health plan during the preconception, antepartum, and postpartum periods between 2000 and 2016 were included. The primary outcome was postpartum cardiovascular disease and depression (perinatal and postpartum). Multivariable logistic regression was used to adjust for covariates including age, geographic location, preterm delivery, assisted reproductive technology use, multiple births, prepregnancy depression, prepregnancy diabetes, prepregnancy hypertension, gestational diabetes, gestational hypertension, obesity, history of hyperlipidemia, smoking, and race. We identified 42,391 unique women with polycystic ovary syndrome and 795,480 women without polycystic ovary syndrome. In multivariable models, women with polycystic ovary syndrome had significantly higher odds of cardiovascular disease complications, including postpartum preeclampsia (adjusted odds ratio, 1.30; 95% confidence interval, 1.17-1.45), eclampsia (adjusted odds ratio, 1.45; 95% confidence interval, 1.14-1.86) cardiomyopathy (adjusted odds ratio, 1.26; 95% confidence interval, 1.03-1.54), hypertensive heart disease (adjusted odds ratio, 1.32: 95% confidence interval, 1.07-1.64), thrombotic disease (adjusted odds ratio, 1.50; 95% confidence interval, 1.20-1.87), congestive heart failure (adjusted odds ratio, 1.35; 95% confidence interval, 1.13-1.61), and cerebrovascular accidents (adjusted odds ratio, 1.21; 95% confidence interval, 1.14-1.29), than those without polycystic ovary syndrome, as well as both perinatal (adjusted odds ratio, 1.27; 95% confidence interval, 1.22-1.33) and postpartum depression (adjusted odds ratio, 1.46; 95% confidence interval, 1.36-1.57). Nonobese women with polycystic ovary syndrome had higher odds of postpartum eclampsia (adjusted odds ratio 1.72; 95% confidence interval, 1.31-2.26), peripartum cardiomyopathy (adjusted odds ratio, 1.43; 95% confidence interval, 1.14-1.79), and cerebrovascular accidents (adjusted odds ratio, 1.28; 95% confidence interval, 1.19-1.38) than nonobese women without polycystic ovary syndrome. In the group of women without prepregnancy depression, the odds of perinatal depression (adjusted odds ratio, 1.32; 95% confidence interval, 1.26-1.39) and postpartum depression (adjusted odds ratio, 1.50; 95% confidence interval, 1.39-1.62) were higher in women with polycystic ovary syndrome than those without polycystic ovary syndrome. In a large United States cohort, our study found that women with polycystic ovary syndrome are at increased risk of both cardiovascular and psychiatric complications during the postpartum period. Polycystic ovary syndrome should be recognized as an at-risk condition; our findings underscore the need for routine screening and early interventions for these major comorbidities.

Maternal health training priorities for nursing and allied professions in Haiti.

ABSTRACTObjectives.This study summarizes the findings of a training needs and priority assessment completed in Haiti. Its objective is to describe the characteristics of nursing and allied professions providing first level maternal health care and identify training needs and priorities to inform planning of Human Resources for Health interventions.Methods.A cross-sectional survey was completed between October 2016 and March 2017 by the Pan American Health Organization/World Health Organization Haiti office in collaboration with national health authorities. Participants reached consensus to submit one finalized version of the survey. Data were collected on composition, capacities, and training needs and priorities of traditional birth attendants, community health workers, registered nurses, professional midwives, and auxiliary nurses.Results.Haiti relies heavily on community level workers including community health workers, auxiliary nurses, and traditional birth attendants. Traditional birth attendants attend the majority of Haiti’s births, despite having low education levels and not being regulated by the Ministry of Public Health and Population. All professional categories prioritize preventive capacities such as timely identification of complications, while none are trained to manage postpartum hemorrhage, preeclampsia, or eclampsia. Management of obstetric emergencies is a training priority for Haiti but is not part of the scope of work of the nursing and allied health professions included in this study.Conclusions.Community level health workers are key in providing preventive care and referral of complicated pregnancies, but lack of access to providers qualified to treat obstetric complications remains a challenge to reducing maternal mortality.

Maternal deaths due to eclampsia in teenagers: Lessons from assessment of maternal deaths in South Africa.

BackgroundEclampsia remains a major cause of maternal mortality, particularly in teenage pregnancies. Healthcare professionals providing antenatal must regard teenagers as a high risk group for the pre-eclampsia-eclampsia syndrome.SettingData extracted from the South African Saving Mothers Report: 2014–2016.AimTo establish the clinical details in teenage maternal deaths owing to eclampsia.MethodRetrospective review of the case records and maternal death assessment forms of teenagers that died due to eclampsia during 2014–2016.ResultsThere were 47 teenagers (aged 14 to 19 years) who died from eclampsia. Of these 18 out of 47 (38%) deaths occurred in the post-partum period. Forty (85.1%) of the patients had antenatal care. Three (6.4%) had post-partum eclampsia, and of the remaining 44 of the 47 (93.6%), the gestational age at first occurrence of a seizure ranged from 25 to 39 weeks. The blood pressures at the time of seizure ranged from systolic of 131 to 210 mmHg and diastolic of 89 to 130 mmHg. The commonest final causes of death were intracerebral haemorrhage associated with severe hypertension and multi-organ failure. Avoidable factors included transport delays, referral to the wrong levels of health care and poor care by health professionals.ConclusionTeenage pregnancy is a risk factor for eclampsia-related death; awareness of borderline elevations of blood pressure levels from baseline values (prehypertension levels) and taking following national guidelines on the management of hypertensive disorders of pregnancy will decrease deaths from eclampsia.

Eclampsia.

Emergency medicine residents and medical students on emergency medicine rotations. Eclampsia is an uncommon but important life-threatening obstetrical emergency, complicating 1.5-10 deliveries per 10,000 pregnancies in resource-rich countries.1 If not recognized and treated promptly, there is risk of significant morbidity or death to both mother and baby. Clinically, eclampsia is defined by new-onset seizures or coma in women with preeclampsia.2 Preeclampsia is defined by maternal hypertension after 20 weeks gestation with or without signs of end organ dysfunction, and, like eclampsia, can develop in the postpartum period.1 Eclampsia manifests as new onset generalized tonicclonic seizures. Eclamptic seizures are usually preceded by neurologic symptoms such as severe or atypical headache, visual disturbances, and non-neurologic symptoms such as severe abdominal pain or proteinuria.1 Emergent treatment involves prompt administration of (intravenous) IV magnesium sulfate.2,3,4 Adjuncts include securing the airway if necessary and administration of IV antihypertensive medications. Like preeclampsia, definitive management is by prompt delivery of the fetus if the mother is still pregnant.1 If untreated, maternal mortality is as high as 14%.1 Women who develop eclampsia are at increased risk of obstetric complications in subsequent pregnancies and at higher risk for cardiovascular disease and metabolic disease later in life. At the end of this oral boards session, examinees will: 1) Demonstrate ability to obtain a complete medical history including a detailed obstetric history. 2) Demonstrate the ability to perform a detailed physical examination in a postpartum female patient who presents with a seizure. 3) Investigate the broad differential diagnoses which include electrolyte imbalances, brain tumor, meningitis or encephalitis, hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome and eclampsia. 4) List the appropriate laboratory and imaging studies to differentiate eclampsia from other diagnoses (complete blood count, comprehensive metabolic panel, magnesium level, pregnancy testing, urinalysis, and computed tomography [CT] scan of the head). 5) Identify a postpartum eclampsia patient and manage appropriately (administer IV magnesium therapy, administer IV antihypertensive therapy, emergent consultation with an obstetrician). 6) Provide appropriate disposition to the intensive care unit after consulting with an obstetrician. This was envisioned as an oral board testing case due to the multiple aspects which require emergency care. Residents are expected to assess the seriousness of the patient's condition, elicit critical details from her recent medical history, and synthesize that data in order to treat a medically complex patient. Oral board testing is able to incorporate each of these aspects together and provide the resident with a dynamic learning environment.Oral board testing is a way to assess the resident's ability to rapidly obtain and interpret multiple sources of information simultaneously. By utilizing a case that requires pharmaceutical therapy, the clinical competency committee is able to obtain additional milestones which are sometimes difficult to test in the emergency department itself.Learners were assessed using online evaluation tools available, ie, Google forms. Critical actions were subsequently tied to Emergency Medicine Milestones and the results were compiled and used for resident evaluations and clinical competency. Residents were given verbal feedback immediately after the examination, and they were provided with the scores of their online evaluation after all results were compiled. Learners and instructors provided written feedback after the case was administered to assess for strengths and weaknesses of the case, and modifications were then made to better address concerns. Learners answered written multiple-choice questions on high-level concepts, ie, critical actions, at least one month after this exam was completed. Learners found this a challenging, but enjoyable, way to refresh their knowledge and skills regarding preeclampsia, and this was a highly rated part of their mock oral board examination. Overall, residents rated the session 4.3 (1-5 Likert scale, 5 being Excellent) after the oral board review session was completed. Comments from residents included "haven't seen post-partum preeclampsia in residency" and "challenging to remember magnesium dosing." Residents and medical students were evaluated using this method and both enjoyed the activity as a novel way to study as well as exercise their medical knowledge. The content was both highly relevant to the practice of emergency medicine and the format was an effective way to deliver the information to the learners. The case is a good model to evaluate for the high stakes testing of both the written and oral board examinations, but also a way to assess residents' abilities to treat preeclamptic and eclamptic patients in the emergency department. Eclampsia, preeclampsia, seizures, end-organ damage, hypertensive emergency, altered mental status, neurologic emergency, obstetric emergency.

Late onset postpartum eclampsia complicated with posterior reversible encephalopathy syndrome

Posterior reversible encephalopathy syndrome (PRES) is a rare entity characterized by headache, vomiting, visual disturbances, seizure and unconsciousness with characteristic magnetic resonance imaging. Late onset postpartum eclampsia complicated by PRES has been reported in the literature, &#x0D; We report a unique case of 23-year-old patient who developed late onset postpartum eclampsia complicated by PRES and acute kidney injury requiring renal replacement therapy. The case report emphasizes the need to continue antihypertensive medication in hypertensive parturients during postpartum period for at least 6 weeks as frequency of late postpartum eclampsia is high. The medication should be tapered off slowly to avoid reactive hypertensive episode which might trigger PRES and acute kidney injury.

Pregnancy Outcome Among Primigravidae Aged 35 Years and Above: A Comparative Study

Introduction: Maternal age is an important determinant of pregnancy outcome. Women aged 35 years ormore at their first pregnancy are considered high risk as they are associated with increased adverse maternaland perinatal outcomes. Methods: A retrospective, comparative study was carried out over a period of two years in a tertiary center. Each elderly primigravida was matched with two primigravidwomen aged 20-34 years who delivered during the same period. Secondary data on obstetric outcomes (diabetes, oligohydramnios, polyhydramnios, hypothyroidism), postpartum complications (post-partum hemorrhage, postpartum eclampsia) and perinatal outcome (intra-uterine growth restriction, prematurity, congenital anomalies, and neonatal death)of 82 elderly primigravidae (study group) was compared to 164 younger primigravida (control group) delivered during the period of study. The Chi Square test and Fisher’s Exact test were used for statistical analysis and p value of <0.05 was taken as level of significance. Results: During the study period, there were 15,012 deliveries and 82 of these were elderly primigravidae giving an incidence of 0.55%. The mean age of the elderly primigravidae was 36.8±2.16 years. The study group had more antepartum complications with preterm labor, diabetes in pregnancy, hypertensive disorders in pregnancy, multiple pregnancy and polyhydramnios (p<0.05). Seventy-one elderly primigravidae were delivered by caesarean section, the commonest indication being maternal request. The study group had higher incidence of post-partum hemorrhage but no perinatal mortality of significant proportion. Conclusion: Maternal age at the first pregnancy influences pregnancy and neonatal outcomes. Hence, elderly primigravidae should be considered as high risk and followed up accordingly.

Maternal mortality risk indicators: Case-control study at a referral hospital in Guinea

ObjectiveThis study aimed to describe intrapartum and postpartum exposures possibly associated with the risk of in-hospital maternal mortality in Guinea. Study DesignData were collected in the Western Sub-Saharan Africa setting at the university hospital in Conakry, Guinea, during 2016−2017. Case-control study design was applied. The cases comprised all intrapartum and postpartum maternal deaths recorded during the study period. The controls were selected by random sampling from patients discharged alive following hospitalization due to vaginal delivery or cesarean section. Maternal mortality ratio (MMR) was defined as a quotient of the number of maternal deaths per 100,000 live births. Multivariable logistic regression was applied to generate odds ratios (OR) and 95 % confidence intervals (95 %CI). ResultsA total of 10,208 live births and 144 maternal deaths were recorded. The MMR was at 1411 per 100,000 live births. The main causes of maternal death included postpartum hemorrhage (56 %), retroplacental hematoma (10 %), and eclampsia (9%). The ORs of maternal death were significantly elevated in case of transfer from another hospital (OR 24.60, 95 %CI 11.32–53.46), misoprostol-induced labor (OR 4.26, 95 %CI 2.51–7.91), non-use of partogram (OR 3.70, 95 %CI 1.31–5.20), duration of labor ≥24 h (OR 2.87, 95 %CI 1.35–5.29), and positive history of cesarean section (OR 2.54, 95 %CI 1.12–6.19). ConclusionTo stop preventable maternal mortality in Sub-Saharan Africa, continued efforts are needed to provide perinatal monitoring, to reorganize the obstetric reference system, and to decrease the number of avoidable cesarean sections. Furthermore, the internal supervision of misoprostol doses used for labor induction should be a priority.

Delays in emergency obstetric referrals in Addis Ababa hospitals in Ethiopia: a facility-based, cross-sectional study.

ObjectiveTo assess where the delays occur in the referral chain of most maternal health outcomes in Addis Ababa, Ethiopia, based on the three-delay model.DesignThe study was a facility-based, cross-sectional study.SettingTwo public and tertiary hospitals in Addis Ababa.ParticipantsAll pregnant women who were referred only for labour and delivery services after 28 weeks of gestation between December 2018 and February 2019 in Zewditu and Gandhi Memorial Hospitals.Primary and secondary outcome measuresThe primary outcome was the type of delays, from the three-delay model, which met operationally defined time. The secondary outcome was maternal health outcomes based on the three-delay model.ResultsA total of 403 pregnant women referred for delivery to the study hospitals were included in the study. Three-fourths (301, 74.7%) of the referred pregnant women experienced the third delay (delay in receiving appropriate care); 211 (52.4%) experienced the first delay (delay in making a decision to seek care). Overall 366 (90.8%) pregnant women had experienced at least one of the three delays and 71 (17.6%) experienced all three delays. Twenty-nine (7.2%) referred women had severe maternal outcomes. The leading causes/diagnoses of severe maternal outcomes were blood transfusion (17, 58.6%), followed by postpartum haemorrhage (15, 52%) and eclampsia (9, 31%). In addition, women who experienced severe maternal outcomes were 2.9 times more likely to have experienced at least one of the three delays.Conclusion and recommendationThis study highlights the persistence of delays at all levels, and especially the third delay and its contribution to severe maternal outcomes. We recommend strengthening the health referral systems and addressing specific health system bottlenecks during labour and birth in order to ensure no mother is endangered. We also recommend conducting a qualitative method of study (focus group discussion and indepth interview) and observing tertiary hospitals’ set-up and readiness to manage obstetric emergencies.

Effects of Selective Early Magnesium Cessation Protocol on Preeclampsia With Severe Features [12L

INTRODUCTION: We evaluate the effect of a selective early postpartum magnesium cessation protocol in patients diagnosed with preeclampsia with severe features. METHODS: A standardized protocol was implemented in March 2017 identifying patients at lower risk of postpartum eclampsia, and thus eligible for early discontinuation of magnesium sulfate at 12 hours postpartum. An IRB approved, retrospective cohort study was performed of all patients with preeclampsia with severe features 25 months before and after protocol implementation. The primary outcome assessed was the incidence of postpartum readministration of magnesium sulfate after completion of the initial course. RESULTS: Preeclampsia with severe features was identified in 737 patients with exclusion of 58 patients due to postpartum preeclampsia diagnosis or eclampsia prior to initial magnesium cessation. While the rate of preeclampsia with severe features increased (3.9% vs 7.0%, p&lt;.001) in the pre and post-implementation groups, there was no difference in the rate of eclampsia (0.03% vs 0.05%, P=.59). Analysis included 272 patients pre and 407 patients post protocol implementation. Rates of early magnesium cessation, less than 23 hours of postpartum magnesium, were 11.1% vs 55.5% pre and post protocol implementation. In patients who underwent early magnesium cessation (n=226), there was no significant difference in postpartum readministration of magnesium (1.5% vs 3%, P=.25). There was no difference in readmission for hypertensive disorders of pregnancy (1.1% vs 2.5%, P=.20). CONCLUSION: In patients with preeclampsia with severe features who underwent selective early magnesium cessation there was no difference in postpartum readministration of magnesium sulfate or readmission for hypertensive disorders of pregnancy.

Fetomaternal Outcome of Eclamptic Patient in Secondary Health Care Level-3 years study

Background: Eclampsia is defined as the development of seizures that cannot be attributed to other causes and /or unexplained coma during pregnancy or puerperium in a woman with pre-eclampsia. The purpose of this hospital based observational study is to evaluate the extent of the problem and to estimate the associate of foetal and maternal complications&#x0D; Methodology: The observational study was carried out Department of Obstetrics and Gynaecology in 250 bedded general Hospital Tangail from January 2015 to November 2017. All on the diagnosed patients of eclampsia were included in this study.&#x0D; Results: Regarding types of eclampsia 187(62.3%) patients had antepartum eclampsia, 78(26.0%) had postpartum eclampsia and 35(11.7%) had intrapartum eclampsia. Majority (57.0%) patients had 5-9 times of convulsion, 65(21.7%) had &gt;10 times and 64(21.3%) had &lt;5 times of convulsion. Most (95.0%) patients had cesarean section and 15(5.0%) had normal vaginal delivery (NVD). Maternal alive was found 293(97.7%) and death was 7(2.3%). Male baby was found 203(67.7%) and female baby was 97(32.3%). More than three fourth (75.7%) babies had weight 2.5-4.0 kg. Alive babies were found 282(94.0%), neonatal death was 8(2.7%) and intrauterine death was 10(3.3%).&#x0D; Conclusion: Improving ante-natal and emergency obstetric and neonatal care is mandatory to improve the outcome.&#x0D; Anwer Khan Modern Medical College Journal Vol. 11, No. 1: Jan 2020, P 11-15