Eclampsia: a neurological perspective.

Eclampsia is a poorly understood disorder characterized by seizures or unexplained coma in setting of gestational hypertension. Its neurological manifestations are varied and are an important cause of the morbidity and mortality associated. We present a comprehensive prospective study of forty women recruited over four years describing neurological symptoms and signs, neuroimaging and laboratory studies as well as prognosis including 3-6 months follow-up. The seizures occurred in the postpartum period in majority of women (55%), while 45% had seizures before labor, and the rest (5%) during labor. Interestingly, one third of the women suffered their first seizures more than 48 h postpartum (late postpartum eclampsia). A sizable minority suffered more than one seizure and some had documented partial seizures. Headache preceded seizures by more than a day and was described as throbbing or pounding pain by most. The visual symptoms in decreasing frequency were blurring, blindness, scotoma and visual processing deficits. The most common finding during the neurological exam was memory deficits, followed by increased deep tendon reflexes (asymmetric in some), visual perception deficits, visual information processing deficits, altered mental status and cranial nerve deficits. Intracranial or intraspinal pressure when examined was elevated. Among neuroimaging studies, MRI was more sensitive compared to CT scan. The MRI abnormalities included both white as well as gray matter and the most common location of abnormalities was high frontal/parietal lobe. The laboratory studies revealed proteinuria in majority, but not in all. The liver function tests were abnormal in many, while few patients had HELLP syndrome. The neurological deficits resolved by the time of discharge in all. At follow-up, some patients developed new neurological problems such as recurrent headaches or seizures.

The effect of intrapartum magnesium sulfate therapy on fetal cardiac troponin I levels at delivery.

OBJECTIVE: To determine whether intrapartum magnesium sulfate (MgSO4) therapy for seizure prophylaxis in pre-eclampsia-eclampsia is associated with biochemical evidence of subacute fetal myocardial damage at delivery. STUDY DESIGN: Troponin I, a cardiac-specific protein used to detect myocardial injury, was measured from the umbilical vein at delivery in term pregnancies complicated by pre-eclampsia and uncomplicated control pregnancies. Women with pre-eclampsia received intravenous MgSO4 as a 6-g load followed by 2 g/hour until delivery. Clinical characteristics and fetal troponin levels were compared between groups. RESULTS: There was no difference in troponin I concentrations between term patients with intrapartum MgSO4 therapy and controls who did not receive MgSO4 (median 0.86 ng/ml, range 0.72-1.10 vs. 0.89 ng/ml, range 0.68-1.50; p = 1.0). There was also no statistically significant difference in the number of patients with a troponin I level of > or = 1.0 ng/ml between groups (30.8% (4/13) vs. 15.4% (4/26); p = 0.4). CONCLUSIONS: Our findings suggest that, in term fetuses that are not growth impaired, exposure to intrapartum MgSO4 is not associated with subacute myocardial injury.

Effects of gestational alcohol exposure on the fatty acid composition of umbilical cord serum in humans.

This study examined the effects of maternal periconceptional alcohol intake on polyunsaturated fatty acid (PUFA) concentrations in human neonates. The area percentage of each fatty acid in cord blood serum from 12 infants born to control women (who consumed <2 mL absolute ethanol/d) was compared with that of 9 infants born to women whose periconceptional alcohol intake averaged > or = 30mL absolute ethanol/d. Periconceptional alcohol use was associated with a 30% increase in the proportion of docosahexaenoic acid (22:6n-3) in cord blood (3.0% of total lipid in control infants compared with 3.9% in alcohol-exposed infants; P < 0.01). The rise in the proportion of 22:6n-3 was responsible for increases in the ratio of n-3 to n-6 fatty acids and the ratio of long-chain n-3 to n-6 fatty acids (P < 0.055). Examination of the lipid-class fatty acid profile indicated that serum lipid alterations were localized to the cholesterol esters; 22:6n-3 in the cholesterol esters of alcohol-exposed infants increased 54% (P < 0.011) and arachidonic acid increased 55% (P < 0. 005). The relative fatty acyl composition of maternal serum showed a significant increase in 18:0 fatty acids in the alcohol-exposed group (25%, P < 0.005) but there were no changes in the other fatty acids. The increase in the proportion of 22:6n-3 was unexpected but is consistent with the hypothesis that this essential lipid may be conserved selectively. These results imply that the lifelong neurobehavioral and sensory dysfunction in fetal alcohol syndrome and other alcohol-related neurodevelopmental disorders may be due in part to PUFA dysregulation.

Brain MRI in peripartum seizures: usefulness of combined T2 and diffusion weighted MR imaging.

Peripartum seizure is a serious disease with significant morbidity and mortality for women and their unborn children. The underlying etiologies are varied, with eclampsia and venous stroke being the most common causes. T2 weighted MR images of the brain show hyperintense lesions in either condition. Diffusion weighted MR images (DWI) of the brain is abnormal in strokes. We report three cases of eclampsia with abnormal T2 weighted images, but normal DWI. Diffusion weighted MR images in association with T2 weighted MR images can be extremely helpful in evaluation of women with new onset peripartum seizures.

Does delivery improve maternal condition in the respiratory-compromised gravida?

OBJECTIVE: To describe the effect of delivery on respiratory status and outcome in the respiratory-compromised pregnant woman. METHODS: During 1990-1994, 10 patients requiring intubation for respiratory compromise who delivered during ventilatory support were identified by International Classification of Diseases, Ninth Revision codes. Charts were reviewed retrospectively for cardiorespiratory variables and outcome. RESULTS: Pneumonia led to intubation in all but one case. The onset of labor was spontaneous in eight. Three were delivered by cesarean. Mechanical ventilation was used for a median (range) of 7 (2-22) days in surviving patients. Fraction of inspired oxygen requirements decreased an average of 28% by 24 hours after delivery. Positive end-expiratory pressure requirements remained unaltered. Surviving patients remained intubated for a median (range) of 2.6 (1-19) days postpartum. Three women died, all after vaginal delivery (days 4-14). CONCLUSION: Delivery of respiratory-compromised gravidas resulted in a 28% reduction in fraction of inspired oxygen requirement within 24 hours after delivery. Although most patients were then able to be maintained below critical fraction of inspired oxygen requirement levels (under 0.6), dramatic improvement in overall respiratory function was not observed uniformly. Given the limited benefit of delivery on maternal oxygenation, along with the inherent risks of labor induction in this critically ill population, caution should be exercised in initiating the induction process electively.

Cord blood carbohydrate-deficient transferrin levels are markedly higher than maternal.

Regular, heavy alcohol intake results in transferrin that is deficient in carbohydrate moieties. Carbohydrate-deficient transferrin (CDT) has been used as a biologic marker of heavy alcohol exposure in nonpregnant humans. There have been no reports of CDT levels in pregnancy. Our objective was to determine maternal and cord blood levels of CDT. Parturients were recruited at delivery based on graded representative alcohol consumption, from abstainers to heavy drinkers, as determined by screeners skilled at eliciting drug and alcohol histories. Maternal and cord blood serum samples were obtained at delivery. A double antibody radioimmunoassay was used to determine CDT in each sample. There were 83 paired specimens analyzed by paired t tests and stepwise regression analysis. Cord blood CDT units/liter (44.0 +/- 29.5) were significantly (P < 0.0001) higher than maternal (18.4 +/- 7.0). Maternal and cord CDT did not correlate with race, perinatal risk score, gestational age at delivery, birth weight, Apgar scores, or reported alcohol intake. Maternal CDT levels had a significant negative correlation with cigarette smoking. Cord blood CDT levels are significantly higher than maternal. While regular, heavy alcohol consumption by adults results in serum transferrin deficient in carbohydrate moieties, the reason for elevated fetal CDT is unknown.

Serum ionized magnesium levels in normal and preeclamptic gestation.

OBJECTIVE: To compare serum levels of ionized and total magnesium with those of ionized calcium, total calcium, sodium, and potassium over the course of pregnancy in normal women and in women who develop preeclampsia. METHODS: We collected venous serum samples from 31 pregnant women during their first, second, and third trimesters. Gestational ages ranged from 6 to 37 weeks. Samples were analyzed for ionized and total magnesium, ionized and total calcium, sodium, and potassium using a biomedical chemistry analyzer. Data were analyzed with repeated-measures analysis of variance and two-way repeated-measured analysis of variance. RESULTS: In 22 normal pregnant women, both serum ionized and total magnesium levels decreased significantly with increasing gestational age. No changes in sodium, potassium, or ionized or total calcium were observed. Nine of the 31 subjects developed preeclampsia by term; serum total magnesium levels decreased significantly by the second trimester in these women compared with those of normal pregnant women. CONCLUSION: Our results provide evidence of decreases in ionized and total magnesium levels with increasing gestational age during normal pregnancy, as well as evidence of a magnesium disturbance in women who later develop preeclampsia. Future studies of magnesium balance in women at risk for developing complications of pregnancy are indicated.

Clinical significance of increasing histologic severity of acute inflammation in the fetal membranes and umbilical cord.

The purpose of this study was to determine the importance of varying histologic stages of inflammation in the placental membranes and cord. Acute inflammation was histologically staged in fetal membranes and umbilical cord sections from 2899 placentas received from consecutive singleton deliveries. Then clinical data were collected for a subset of randomly selected placentas with stage 1 through stage 4 membrane inflammation (n = 212) and without significant inflammation (stage 0, n = 216). Statistical analyses revealed that increasing stage of membrane inflammation was associated with an increasing rate of funisitis, perinatal death, and preterm birth (P < .05). Inflammation permeating the entire trophoblastic layer of the chorion (stage 1) was associated with clinical symptoms of intrauterine infection and thus was an important pathologic finding. Acute necrotizing chorioamnionitis was very strongly associated with perinatal death and preterm birth. Acute funisitis was a more specific but less sensitive marker for perinatal complications than inflammation in the membranes. With increasing stage of funisitis, there was an increased incidence of clinical symptoms of intrauterine infection, preterm birth, and perinatal death. Almost three-fourths of the cases with histologic evidence of membrane inflammation were clinically silent. In conclusion, increasing histologic stages of inflammation of the membranes and cord are associated with an increased rate of perinatal morbidity and mortality. Stage I membrane inflammation provides a clinically acceptable minimum threshold for the reporting of pathologic changes.

Fetal ionized magnesium levels parallel maternal levels during magnesium sulfate therapy for preeclampsia.

OBJECTIVE: Little is known about ion regulation in fetuses. Our aim was to determine the effects of magnesium sulfate therapy on ionized (bioactive) magnesium in the cord blood of pregnancies complicated by preeclampsia. STUDY DESIGN: Seventy-four pregnant women were studied (37 preeclamptic and 37 controls matched for maternal age, gravidity, and gestational age). The preeclamptic women received intravenous magnesium sulfate 6 gm load followed by 2 gm/hour for > or = 4 hours; controls were not preeclamptic and received no magnesium. Maternal venous and fetal cord blood samples were obtained from study and control patients and were analyzed for sodium, potassium, total magnesium, ionized magnesium, total calcium, and ionized calcium. Comparisons between the groups were made and analyzed by the Mann-Whitney U test. RESULTS: There were no significant differences between the treatment and control group cord samples with respect to sodium or potassium. However, total magnesium and ionized magnesium were significantly elevated (p < 0.001) in cord samples of the treated group. At the same time ionized calcium and total calcium were reduced. Interestingly, ionized calcium levels were lower in preeclamptic women before magnesium sulfate therapy was begun, whereas total calcium levels were not different. Importantly, there was no difference between maternal and fetal ionized magnesium levels in either treatment or control groups. CONCLUSIONS: In preeclamptic women undergoing magnesium sulfate therapy, ionized magnesium levels in cord blood parallel maternal levels. Before magnesium therapy ionized calcium levels were lower in preeclamptic women than in matched controls. In the presence of elevated magnesium levels ionized calcium appears to be tightly regulated.

Oxytocin augmentation in arrest disorders in the presence of thick meconium: influence on neonatal outcome.

The objective of this report was to study the effect of oxytocin augmentation in arrest disorders in the presence of thick meconium on meconium aspiration and fetal acidosis. We evaluated 3,321 singleton, term deliveries with cephalic presentation at our institution. Eight percent (253/3,321) had thick meconium in labor, and these patients comprised the study sample. Of the 253 women with thick meconium, 84 had an arrest disorder in the active phase of labor with normal fetal heart rate tracing at the time of diagnosis. Seventy-four percent (62/84) of the women with arrest were treated with oxytocin (group 1) and 26% (22/84) delivered by cesarean section without augmentation (group 2). There was a significant (p < 0.05) increase in the incidence of meconium aspiration (14.5 vs. 4.5%) and low (< 7.20) cord arterial pH (27.8 vs. 4.5%) in patients who received oxytocin compared to those who did not. Of the women who received oxytocin, 36 delivered vaginally, and 2 neonates had meconium aspiration. The remaining 26 women had cesarean sections following oxytocin augmentation and had a significantly higher (p < 0.05) frequency of meconium aspiration (26.9 vs. 4.5%) and low cord arterial pH (38.5 vs. 4.5%) compared to women who had cesarean sections without oxytocin augmentation. The findings suggest that oxytocin augmentation in arrest disorders in the presence of thick meconium may be associated with a higher risk of meconium aspiration and low umbilical cord arterial pH.

Automated blood pressure measurements in laboring women: are they reliable?

OBJECTIVE: In laboring women a consistent difference has become evident between measurements obtained with an automated blood pressure device and those obtained with the auscultatory method. A prospective study was designed to assess the concordance of these two methods. STUDY DESIGN: Three sets of brachial blood pressure measurements were made by both oscillatory and auscultatory techniques in 30 women in labor, 20 term pregnant women not in labor, and 20 nonpregnant volunteers. RESULTS: In the nonlaboring women and the nonpregnant controls there was satisfactory agreement between the results of the two methods of measurement. In the parturients systolic pressures were consistently and significantly higher and diastolic pressures consistently and significantly lower with the oscillatory compared with the auscultatory method, but mean arterial pressures were not different. CONCLUSION: In laboring women there is a discrepancy between systolic and diastolic pressures obtained by the auscultatory versus the oscillatory method of measurement, although mean pressures are not significantly different. We suggest that during labor the diagnoses of hypertension and hypotension be based on the mean rather than the systolic or diastolic pressure.

Maternal perception of decreased fetal movement as an indication for antepartum testing in a low-risk population.

Maternal perception of decreased fetal movement has traditionally been used as an indication for fetal testing in high-risk patients. Two hundred ninety-two low-risk patients who presented with a complaint of decreased fetal movement were studied to determine the incidence of adverse outcome and need for further testing. Initial testing included a nonstress test and ultrasonographic examination. Five (1.7%) of the study group had fetal death on initial examination and 4.4% of patients required immediate delivery because of abnormal maternal or fetal evaluation. An additional 5.8% had abnormal fetal heart rate tracings that necessitated follow-up. Fifty-two percent of patients with normal initial evaluations underwent additional testing. There were no significant differences between patients undergoing additional testing, patients having no additional testing, and a low-risk nontested group with regard to adverse outcome. Fetal surveillance is indicated in low-risk patients with decreased fetal movement. Additional testing of patients with a normal initial evaluation and no further complaint of decreased fetal movement may not be necessary.