Late Postpartum Eclampsia 16 Days After Delivery: Case Report With Clinical, Radiologic, and Pathophysiologic Correlations

, Department of Family Medicine, , Department of Family Medicine, and , Department of Neuroradiology, Medical College of Georgia, Augusta.

J Am Board Fam Med. 2000;13(1) 

In This Article

Abstract and Introduction

Abstract

Background: Postpartum eclampsia is a rare, frightening, and potentially tragic complication of hypertensive pregnancies, usually developing within 48 hours of delivery. Seizures occurring days to weeks after parturition are exceedingly uncommon and require rapid, precise clinical evaluation by multiple specialists.
Methods: A case presentation of delayed postpartum eclampsia illustrates unique features of the syndrome. Extensive review of the literature highlights pathogenesis, controversies, and dilemmas surrounding this enigmatic hypertensive disorder.
Results and Conclusions: A 39-year-old hypertensive patient had an uneventful full-term delivery by her family physician only to develop headache, double vision, and recurrent tonic-clonic seizures 16 days later. Initial evaluation showed severe hypertension, diplopia, hyperreflexia, proteinuria, and hyperuricemia. She was given a magnesium sulfate infusion. Magnetic resonance imaging (MRI) documented asymmetric ischemic foci within gray matter in the distribution of the posterior cerebral arteries. All symptoms, signs, and abnormal laboratory values resolved within 4 days. A follow-up MRI showed complete resolution of all cytotoxic cortical lesions. Based on human autopsy data, radiologic investigations, and animal studies, eclampsia is believed to result from explosive vasospasm, endothelial dysfunction, and cytotoxic edema of cerebral cortex. This central nervous system vasculopathy is most prominent in the posterior cerebral vasculature and is often rapidly reversible. Difficulties in differential diagnosis, typical findings on neuroimaging, and urgent management strategies are discussed. The time limit for postpartum eclampsia probably should be lengthened to 4 weeks, as indicated by our case and other clinical series.

Introduction

Eclampsia, a dramatic and often unpredictable complication of pregnancy-induced hypertensive disorders, is characterized by sudden hypertension, proteinuria, edema, and seizures.[1,2,3] A relatively rare syndrome, eclampsia complicates approximately 3 in 1000 pregnancies, with higher incidence rates in preeclamptic or twin pregnancies, women of low socioeconomic status or in developing countries, and nulliparous patients younger than 20 years or multiparous patients older than 35 years of age.[4,5] Whether preceded during prenatal visits by prodromal evidence of preeclampsia, or occurring without antecedent warning symptoms, the great majority of eclamptic seizures occur in the antepartum setting between 20 and 40 weeks of gestation or within a few hours to 2 days postpartum. Most authorities report that 50%, 25%, and 25% of seizures occur in the antepartum, intrapartum, and postpartum periods, respectively.[5] Controversy surrounds the occurrence of eclampsia developing longer than 48 hours after delivery. Some authors are skeptical that a relation exists between pregnancy and any seizure occurring more than 2 days postpartum.[1,6] Others, however, acknowledge the development of postpartum eclampsia as late as 3 to 4 weeks after delivery.[5,7,8,9,10,11,12,13,14,15,16] We describe a case of eclampsia occurring 16 days after parturition and compare the clinical, radiologic, and electroen-cephalographic findings with other published reports. Theoretical and proved pathophysiologic derangements of this serious pregnancy-related disorder are also reviewed.

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