Contemporary Clinical Management of the Cerebral Complications of Preeclampsia

Abstract

The neurological complications of preeclampsia and eclampsia are responsible for a major proportion of the morbidity and mortality arising from these conditions, for women and their infants alike. This paper outlines the evidence base for contemporary management principles pertaining to the neurological sequelae of preeclampsia, primarily from the maternal perspective, but with consideration of fetal and neonatal aspects as well. It concludes with a discussion regarding future directions in the management of this potentially lethal condition.

Multisystem Effects of Hypertensive Disorders of Pregnancy

“…24 One of the advantages of magnesium sulfate, compared with other medications used for seizure prophylaxis, is its ability to protect the women from seizures but not depress the gag reflex, thereby reducing the risk for maternal aspiration, acute respiratory distress, brain injury, and death. 25 Magnesium sulfate is considered, for obstetric use, as a "high alert" drug by the Institute for Safe Medication Practice, meaning that it is one that may cause significant harm when used incorrectly.…”

“…39 Neuroimaging, preferably with magnetic resonance imaging, optimizes management by excluding cerebral hemorrhage and may aid in identifying the cause of the neurologic deficit. 24 Furthermore, inquiry about the nature of the patient's headache is key and includes evaluation of pain that is progressive and increasing in severity, pain unresponsive to analgesia or lowering of blood pressure, or headache accompanied by nausea or vomiting or other behavior disturbances. 38 The manifestation of more classic signs and symptoms of stroke may enhance the team's decision to proceed with neuroimaging along with early consultation with clinicians expert in the identification or management of stroke (ie, multidisciplinary stroke team).…”

“…24,40 Although first described in the setting of eclampsia in 1996, PRES is not unique to preeclampsia or pregnancy. Hypertension is the most common antecedent, but PRES also occurs with sepsis, renal disease, and less commonly autoimmune disease.…”

Posterior reversible encephalopathy syndrome in eclamptic patients: Neuroradiological manifestation, pathogenesis and management

“…It complicates one in 100 -1700 pregnancies in developing countries and one in 2000 -3450 pregnancies in the western world [4,5]. Preeclampsia/eclampsia is responsible for 10-18% direct obstetric deaths [6][7][8][9][10].…”

“…Diagnostic parameters of hypertensive disorders of pregnancy are well defined [1,6,7,12,[17][18][19][20], but clinicians should be aware of the existence of atypical forms of preeclampsia, with symptoms ranging from mild hypertension with or without proteinuria to severe hypertension with/without proteinuria and/or end organ damage [2,5,6,12,21]. Hypertension is considered to be the hallmark of the diagnosis of eclampsia; nevertheless, patients may be normotensive in even 16-30% of cases [3,15]; severe hypertension was found in 47% of eclamptic patients [10,15].…”