Postpartum eclampsia of late onset
BMJ 2005; 331 doi: https://doi.org/10.1136/bmj.331.7524.1070 (Published 03 November 2005) Cite this as: BMJ 2005;331:1070All rapid responses
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Sir/madam
I certainly do agree that postdural headache is one of the
possibilities in this. It crossed my mind too when I read this article.
Having seen at least 4 patients with convulsions after a spinal anesthesia
in the last few months/years, this is very likely diagnosis
Almost invariably the blood pressure is elevated after an episode like
this and what rather favors/confuses the issue is proteinuria. I think it
is worth being cautious in labelling such cases as eclampsia and postdural headache and the consequences must also be a differential diagnosis.
Competing interests:
None declared
Competing interests: No competing interests
This case report highlights the possibility of post partum eclampsia
of late onset.The list of differential diagnosis is extensively covered
but may we raise the possibility of postdural puncture headache (PDPH)
presenting with convulsion.
The regional anaesthetic will be a spinal or an epidural (with
inadvertant dural puncture) which can cause the PDPH.
A history of regional anaesthesia, headache, visual
disturbances(photophobia and diploplia)(1), and convulsions(2,3) are
associted with PDPH.
PDPH as a differntial diagnosis is usually easy to exclude from the
postural nature of the headache and associated symptoms such as
photophobia,diplopia, autophonia, tinnitus etc.
1.Lybecker H, Djernes M, Schmidt F. Postdural puncture headache
(PDPH): onset, duration, severity and associated symptoms. Acta
Anaesthesiol Scan 1995;39:605-612
2.Shearer VE, Jhaveri HS, Cunningham FG. Puerperal seizures after
postdural puncture headache. Am J Obstet Gynecol 1995;82:255-260
3.Oliver CD, White SA. Unexplained fitting in three parturients
suffering from postdural puncture headache. Br J Anaesth 2002;89:782-85
Competing interests:
None declared
Competing interests: No competing interests
Sir,
Re:Postpartum eclampsia of late onset
That was a rare variant of eclampsia and it highlighted important
learning points for Obstetrics trainees like us.We all are aware of 48%of
eclampsia can occur postnatally.(RCOG Guideline)But in the present case
this has happened 9 days after delivery.This stresses the importance of
community care (Community midwives and General Practioners) on the early
detection of warning signs of eclampsia.
In all UK Hospitals women with preeclampsia are discharged from the
hospitals once the blood pressure is stable on medication.Then it is the
responsibility of the community midwife for daily B.P checks and prompt
referral to the GP or to the hospital if any concerns.If all goes as
normal the mother will see her GP at her 6 weeks postnatal check.
The lesson learnt from this case is that such women should be seen by
GP who can perform a complete assessment on the lady including checks for
BP, deep tendon reflexes and vision.By this way we can't miss any rare
complications.
The recommendations from CEMACH Report 2002 suggest similar point.It
has pointed out that substandard care was seen in both hospital and
community care.
This case report should be read by all who provide care to the
pregnant women and newly delivered mothers both in community and secondary
care Hospitals.
We do very well in managing postnatal women.But rare events like this
should not be missed. Adequate and timely care as quoted in the case
report will improve maternal and child health care.
Competing interests:
None declared
Competing interests: No competing interests
Since late post partum eclampsia can present even more than a week
after the delivery, it is mandatory to educate the mothers regarding the
possible risk of an eclamptic attack and the prodromal symptoms when they
go home. Since most of the women go home within 48 hours after a normal
vaginal delivery,the risk of development of eclampsia occurs when they
are at home.
Most hospitals can not accomodate women after a normal vaginal
delivery for more than two days. So it is the responsibility of the medical
officer who discharges the patient and local midwife to educate the
family regarding this rare but grave possibility and its prodromal
symptoms.
Competing interests:
None declared
Competing interests: No competing interests
While the take home message from this case is undoubtedly very
important this case does not illustrate an uncomplicated pregnancy as
"clinically significant proteinuria" exsisted from 30 weeks onwards in a
woman that was already at a significantly increased risk of pre-eclampsia
because of her past obstetric history.1 Proteinuria can precede
hypertension in the development of pre-eclampsia and had her proteinuria
been quantified, it may have alerted her obstetricians to the possibility
of post partum pre-eclampsia.
Hypertension often doesn't become evident until the 4th or 5th
postpartum day and women with antenatal pre-eclampsia or at increased risk
should continue to have their blood presuure measured past the usual
rather short postpartum stays increasingly seen in hospitals both in the
UK and Canada.
1.Kirsten Duckitt and Deborah Harrington
Risk factors for pre-eclampsia at antenatal booking: systematic review of
controlled studies
BMJ, Mar 2005; 330: 565
Competing interests:
Author of systematic review on risk factors for pre-eclampsia
Competing interests: No competing interests
Late onset eclampsia and bromocriptine treatment
To the Editors,
Munjuluri et al reported a case of late onset postpartum eclampsia1. This
case included several features of Reversible Posterior Leukoencephalopathy
Syndrome (PRES)2. Several drugs are thought to be responsible of PRES2.
The following case suggests that PRES can occur after a normal pregnancy
during bromocriptine treatment given for suppression of lactation.
A 26-year-old woman was admitted for severe headaches eight days
after an unenventful second pregnancy (blood pressure was 120/70 mmHg and
no protein was found in her urine). She had been treated with
bromocriptine ( Bromokin® 2.5mg b.i.d.) for suppression of lactation. On
admission, blood pressure was found at 220/100 mmHg ; the patient was
treated with intravenous nicardipin (4mg/h) and furosemide. Twenty minutes
later, blood pressure was 170/90 mmHg when generalised tonic clonic
convulsions occurred. Bromocriptine was interrupted ; clonazepam and
sodium valproate were givenas. Two days later, blood pressure was 150/90
mmHg when a second crisis of generalised seizures happened. A magnetic
resonance scan of the brain showed high T2 signal abnormality involving
bilateral occipital and frontal areas. Search for antiphospholipid and
antinuclear antibodies was negative. Fifteen days after delivery, blood
pressure was 120/70 mmHg with nicardipin (100mg/d) and the patient was
discharged home.
Several cases of headaches, seizures and hypertension have been
reported during bromocriptine treatment given for suppression of
lactation after a normal pregnancy3-5, as in our case. It would be
interesting to know if the patient reported by Munjuluri et al1 had been
treated with bromocriptine, a drug which must be added to the list of
drugs associated with PRES2. As a matter of fact, it must be emphazised
that, although actually rare, side-effects of bromocriptin treatment for
suppression of lactation are often very severe and even sometimes life-
threatening4 : when this drug is prescribed, strong advice should be
given to the parturient so as to interrupt immediately this treatment in
case of headache or defect of vision.
Olivier Pourrat, Michel Pinsard and Fabrice Pierre
Intensive Care and Internal Medicine Unit, Gynaecology and Obstetrics
Unit, Academic Hospital, Poitiers, F
References
1 Munjulury N, Lipman M, Valentine A, Hardiman P, Maclean AB. Postpartum
eclampsia of late onset. BMJ 2005;331:1070-1.
2 Hinchey J, Chaves C, Appignani B, Breen J, Pao L, Wang et al. A
reversible posterior leukoencephalopathy syndrome. N Engl J Med
1996;334:494-500.
3 Katz M, Kroll D, Pak I, Osimoni A, Hirsch M. Puerpueral hypertension,
stroke and seizures after suppression of lactation with bromocriptine.
Obstet Gynecol 1985;66:822-4.
4 Kirsch C, Iffy L, Zito GE, Mc Ardle JJ. The role of hypertension in
bromocriptine-related puerpueral intracranial hemorrhage. Neuroradiology
2001;43:302-4.
5 Janssens E, Hommel M, Mounnier-Vehier F, Leclerc X, Guerin du Masgenet
B, Leyls D. Postpartum cerebral angiopathy possibly due to bromocriptine
therapy. Stroke 1995;26:128-30.
Competing interests:
None declared
Editorial note
The patient whose case is described has given her signed informed consent to publication.
Competing interests: No competing interests