Eclampsia

Last updated
Eclampsia
Placenta held.jpg
A gross anatomy image of a placenta that has been cut after delivery
Specialty Obstetrics
Symptoms Seizures, high blood pressure [1]
Complications Aspiration pneumonia, cerebral hemorrhage, kidney failure, cardiac arrest [1]
Usual onsetAfter 20 weeks of pregnancy [1]
Risk factors Pre-eclampsia [1]
Prevention Aspirin, calcium supplementation, treatment of prior hypertension [2] [3]
Treatment Magnesium sulfate, hydralazine, emergency delivery [1] [4]
Prognosis 1% risk of death [1]
Frequency1.4% of deliveries [5]
Deaths46,900 hypertensive diseases of pregnancy (2015) [6]

Eclampsia is the onset of seizures (convulsions) in a woman with pre-eclampsia. [1] Pre-eclampsia is a hypertensive disorder of pregnancy that presents with three main features: new onset of high blood pressure, large amounts of protein in the urine or other organ dysfunction, and edema. [7] [8] [9] If left untreated, pre-eclampsia can result in long-term consequences for the mother, namely increased risk of cardiovascular diseases and associated complications. [10] In more severe cases, it may be fatal for both the mother and the fetus. [11]

Contents

The diagnostic criterion for pre-eclampsia is high blood pressure, occurring after 20 weeks gestation or during the second half of pregnancy. [1] Most often it occurs during the 3rd trimester of pregnancy and may occur before, during, or after delivery. [1] The seizures are of the tonic–clonic type and typically last about a minute. [1] Following the seizure, there is either a period of confusion or coma. [1] Other complications include aspiration pneumonia, cerebral hemorrhage, kidney failure, pulmonary edema, HELLP syndrome, coagulopathy, placental abruption and cardiac arrest. [1]

Low dose aspirin is recommended to prevent pre-eclampsia and eclampsia in those at high risk. [12] Other preventative recommendations include calcium supplementation in areas with low calcium intake and treatment of prior hypertension with anti-hypertensive medications. [2] [3] Exercise during pregnancy may also be useful. [1] The use of intravenous or intramuscular magnesium sulfate improves outcomes in those with severe pre-eclampsia and eclampsia and is generally safe. [4] [13] Treatment options include blood pressure medications such as hydralazine and emergency delivery of the baby either vaginally or by cesarean section. [1]

Pre-eclampsia is estimated to globally affect about 5% of deliveries while eclampsia affects about 1.4% of deliveries. [5] In the developed world eclampsia rates are about 1 in 2,000 deliveries due to improved medical care whereas in developing countries it can impact 10–30 times as many women. [1] [14] Hypertensive disorders of pregnancy are one of the most common causes of death in pregnancy. [14] They resulted in 46,900 deaths in 2015. [6] Maternal mortality due to eclampsia occurs at a rate of approximately 0–1.8% of cases in high-income countries and up to 15% of cases in low- to middle- income countries. [15] The word eclampsia is from the Greek term for lightning. [16] The first known description of the condition was by Hippocrates in the 5th century BC. [16]

Signs and symptoms

Diagram of the regions (or quadrants) of the abdomen, to assist in locating the right upper quadrant or the epigastric region, where eclampsia-associated pain may occur Abdominal Quadrant Regions.jpg
Diagram of the regions (or quadrants) of the abdomen, to assist in locating the right upper quadrant or the epigastric region, where eclampsia-associated pain may occur

Eclampsia is a disorder of pregnancy characterized by seizures in the setting of pre-eclampsia. [17] Most women have premonitory signs/symptoms in the hours before the initial seizure. Typically the woman develops hypertension before the onset of a convulsion (seizure). [18] Other signs and symptoms include: [19]

Any of these symptoms may be present before or after the seizure. [21] It is also possible for the woman to be asymptomatic prior to the onset of the seizure.

Other cerebral signs that may precede the convulsion include nausea, vomiting, headaches, and cortical blindness. If the complication of multi-organ failure ensues, signs and symptoms of those failing organs will appear, such as abdominal pain, jaundice, shortness of breath, and diminished urine output.

Onset

The seizures of eclampsia typically present during pregnancy and prior to delivery (the antepartum period), [22] but may also occur during labor and delivery (the intrapartum period) or after the baby has been delivered (the postpartum period). [17] [21] [23] If postpartum seizures develop, it is most likely to occur within the first 48 hours after delivery. However, late postpartum seizures of eclampsia may occur as late as 4 weeks after delivery. [17] [21]

Characteristics

Eclamptic seizure is typically described as a tonic–clonic seizure which may cause an abrupt loss of consciousness at onset. [24] This is often associated with a shriek or scream followed by stiffness of the muscles of the arms, legs, back and chest. During the tonic phase, the mother may begin to appear cyanotic. This presentation lasts for about a minute, after which the muscles begin in jerk and twitch for an additional one to two minutes. [25] Other signs include tongue biting, frothy and bloody sputum coming out of the mouth. [26]

Complications

There are risks to both the mother and the fetus when eclampsia occurs. The fetus may grow more slowly than normal within the womb (uterus) of a woman with eclampsia, which is termed intrauterine growth restriction and may result in the child appearing small for gestational age or being born with low birth weight. [27] Eclampsia may also cause problems with the placenta. The placenta may bleed (hemorrhage) or begin to separate early from the wall of the uterus. [28] It is normal for the placenta to separate from the uterine wall during delivery, but it is abnormal for it to separate prior to delivery; this condition is called placental abruption and can be dangerous for the fetus. [29] Placental insufficiency may also occur, a state in which the placenta fails to support appropriate fetal development because it cannot deliver the necessary amount of oxygen or nutrients to the fetus. [28] During an eclamptic seizure, the beating of the fetal heart may become slower than normal (bradycardia). [27] [30] If any of these complications occurs, fetal distress may develop. Treatment of the mother's seizures may also manage fetal bradycardia. [22] [31] If the risk to the health of the fetus or the mother is high, the definitive treatment for eclampsia is delivery of the baby. Delivery by cesarean section may be necessary, especially if the instance of fetal bradycardia does not resolve after 10 to 15 minutes of resuscitative interventions. [22] [32] It may be safer to deliver the infant preterm than to wait for the full 40 weeks of fetal development to finish, and as a result prematurity is also a potential complication of eclampsia. [28] [33]

In the mother, changes in vision may occur as a result of eclampsia, and these changes may include blurry vision, one-sided blindness (either temporary due to amaurosis fugax or potentially permanent due to retinal detachment), or cortical blindness, which affects the vision from both eyes. [34] [35] There are also potential complications in the lungs. The woman may have fluid slowly collecting in the lungs in a process known as pulmonary edema. [28] During an eclamptic seizure, it is possible for a person to vomit the contents of the stomach and to inhale some of this material in a process known as aspiration. [27] If aspiration occurs, the woman may experience difficulty breathing immediately or could develop an infection in the lungs later, called aspiration pneumonia. [21] [36] It is also possible that during a seizure breathing will stop temporarily or become inefficient, and the amount of oxygen reaching the woman's body and brain will be decreased (in a state known as hypoxia). [21] [37] If it becomes difficult for the woman to breathe, she may need to have her breathing temporarily supported by an assistive device in a process called mechanical ventilation. In some severe eclampsia cases, the mother may become weak and sluggish (lethargy) or even comatose. [35] These may be signs that the brain is swelling (cerebral edema) or bleeding (intracerebral hemorrhage). [28] [35]

Risk factors

Eclampsia, like pre-eclampsia, tends to occur more commonly in first pregnancies than subsequent pregnancies. [38] [39] [40] Women who have long term high blood pressure before becoming pregnant have a greater risk of pre-eclampsia. [38] [39] Patients who have gestational hypertension and pre-eclampsia have an increased risk of eclampsia. [41] Furthermore, women with other pre-existing vascular diseases (diabetes or nephropathy) or thrombophilia disease such as the antiphospholipid syndrome are at higher risk to develop pre-eclampsia and eclampsia. [38] [39] Having a placenta that is enlarged by multiple gestation or hydatidiform mole also increases risk of eclampsia. [38] [39] [42] In addition, there is a genetic component: a woman whose mother or sister had the condition is at higher risk than otherwise. [43] Patients who have experienced eclampsia are at increased risk for pre-eclampsia/eclampsia in a later pregnancy. [39] The occurrence of pre-eclampsia was 5% in white, 9% in Hispanic, and 11% in African American patients and this may reflect disproportionate risk of developing pre-eclampsia among ethnic groups. [44] Additionally, black patients were also shown to have a disproportionately higher risk of dying from eclampsia. [44]

Mechanism

Diagram of the placenta and its position in the uterus during pregnancy Placenta.svg
Diagram of the placenta and its position in the uterus during pregnancy

The mechanisms of eclampsia and preeclampsia are not definitively understood, but following provides some insight. The presence of a placenta is required, and eclampsia resolves if it is removed. [45] Reduced blood flow to the placenta (placental hypoperfusion) may be a key feature of the process. It is typically accompanied by increased sensitivity of the maternal vasculature to agents which cause constriction of the small arteries, leading to reduced blood flow to multiple organs. Vascular dysfunction-associated maternal conditions such as Lupus, hypertension, and renal disease, or obstetric conditions that increase placental volume without an increase in placental blood flow (such as multifetal gestation) may increase risk for pre-eclampsia. [46] Also, activation of the coagulation cascade can lead to microthrombi formation, which may further impair blood flow. Thirdly, increased vascular permeability results in the shift of extracellular fluid from the blood to the interstitial space which reduces blood flow and causes edema. These events can lead to hypertension, renal dysfunction, pulmonary dysfunction, hepatic dysfunction, and cerebral edema with cerebral dysfunction and convulsions. [45] In clinical context, increased platelet and endothelial activation may be detected before symptoms appear. [45]

Hypoperfusion of the placenta is associated with abnormal modelling of the fetal–maternal placental interface that may be immunologically mediated. [45] The pathogenesis of pre-eclampsia is poorly understood and may be attributed to factors related to the woman and placenta since pre-eclampsia is seen in molar pregnancies absent of a fetus or fetal tissue. [46] The placenta normally produces the potent vasodilator adrenomedullin but it is reduced in pre-eclampsia and eclampsia. [47] Other vasodilators, including prostacyclin, thromboxane A2, nitric oxide, and endothelins, are reduced in eclampsia and may lead to vasoconstriction. [30]

Eclampsia is associated with hypertensive encephalopathy in which cerebral vascular resistance is reduced, leading to increased blood flow to the brain, cerebral edema and resultant convulsions. [48] An eclamptic convulsion usually does not cause chronic brain damage unless intracranial haemorrhage occurs. [49]

Diagnosis

If a pregnant woman has already been diagnosed with pre-eclampsia during the current pregnancy and then develops a seizure, she may be assigned a 'clinical diagnosis' of eclampsia without further workup. While seizures are most common in the third trimester, they may occur any time from 20 weeks of pregnancy until 6 weeks after birth. [50] Because pre-eclampsia and eclampsia are common conditions in women, eclampsia can be assumed to be the correct diagnosis until proven otherwise in pregnant or postpartum women who experience seizures. [51] However, if a woman has a seizure and it is unknown whether or not they have pre-eclampsia, testing can help make the diagnosis clear.

Pre-eclampsia is diagnosed when repeated blood pressure measurements are greater or equal to 140/90mmHg, in addition to any signs of organ dysfunction, including: proteinuria, thrombocytopenia, renal insufficiency, impaired liver function, pulmonary edema, cerebral symptoms, or abdominal pain. [52]

Vital signs

One of the core features of pre-eclampsia is the new onset of high blood pressure. Blood pressure is a measurement of two numbers: systolic blood pressure and diastolic blood pressure. A systolic blood pressure (the top number) of greater than 140 mmHg and/or a diastolic blood pressure (the bottom number) of greater than 90 mmHg is higher than the normal range. If the blood pressure is high on at least two separate occasions after the first 20 weeks of pregnancy and the woman has signs of organ dysfunction (e.g. proteinuria), then they meet the criteria for a diagnosis of pre-eclampsia. [33] If the systolic blood pressure is greater than 160 or the diastolic pressure is greater than 110, the hypertension is considered to be severe. [17]

Laboratory testing

Another common feature of pre-eclampsia is proteinuria, which is the presence of excess protein in the urine. To determine if proteinuria is present, the urine can be collected and tested for protein; if there is 0.3 grams of protein or more in the urine of a pregnant woman collected over 24 hours, this is one of the diagnostic criteria for pre-eclampsia and raises the suspicion that a seizure is due to eclampsia. [17]

In cases of severe eclampsia or pre-eclampsia, the woman can have low levels of platelets in the blood, a condition termed thrombocytopenia. [53] [30] A complete blood count, or CBC, is a test of the blood that can be performed to check platelet levels.

Other investigations include: kidney function test, liver function tests (LFT), coagulation screen, 24-hour urine creatinine, and fetal/placental ultrasound.

Differential diagnosis

Convulsions during pregnancy that are unrelated to pre-eclampsia need to be distinguished from eclampsia. Such disorders include seizure disorders as well as brain tumor, aneurysm of the brain, and medication- or drug-related seizures. Usually, the presence of the signs of severe pre-eclampsia precede and accompany eclampsia, facilitating the diagnosis. [36]

Prevention

Detection and management of pre-eclampsia is critical to reduce the risk of eclampsia. The USPSTF recommends regular checking of blood pressure through pregnancy in order to detect preeclampsia. [54] Appropriate management of a woman with pre-eclampsia generally involves the use of magnesium sulfate to prevent eclamptic seizures. [55] In some cases, low-dose aspirin has been shown to decrease the risk of pre-eclampsia in women, especially when taken in the late first trimester. [52]

Treatment

The four goals of the treatment of eclampsia are to stop and prevent further convulsions, to control the elevated blood pressure, to deliver the baby as promptly as possible, and to monitor closely for the onset of multi-organ failure.

Convulsions

Convulsions are prevented and treated using magnesium sulfate. [56] The study demonstrating the effectiveness of magnesium sulfate for the management of eclampsia was first published in 1955. [57] Effective anticonvulsant serum levels range from 2.5 to 7.5 mEq/L, [58] however the ideal dosing regime (dose, route of administration, timing of dosing) to prevent and treat eclampsia is not clear. [59]

With intravenous administration, the onset of anticonvulsant action is fast and lasts about 30 minutes. Following intramuscular administration the onset of action is about one hour and lasts for three to four hours. Magnesium is excreted solely by the kidneys at a rate proportional to the plasma concentration (concentration in the blood) and glomerular filtration (rate at which the blood is filtered through the kidneys). [58] Magnesium sulfate is associated with several minor side effects; serious side effects are uncommon, occurring at elevated magnesium serum concentrations greater than 7.0 mEq/L. Serious toxicity can be counteracted with calcium gluconate. [60]

Even with therapeutic serum magnesium concentrations, recurrent convulsions may occur, and additional magnesium may be needed, but with close monitoring for respiratory, cardiac, and neurological depression. If magnesium administration with resultant high serum concentrations fails to control convulsions, the addition of other intravenous anticonvulsants may be used and intubation and mechanical ventilation may be initiated. It is important to avoid magnesium toxicity, including thoracic muscle paralysis, which could cause respiratory failure and death.

Magnesium sulfate results in better outcomes than diazepam, phenytoin or a combination of chlorpromazine, promethazine, and pethidine. [61] [62] [63]

Blood pressure management

Blood pressure is controlled to prevent stroke, which accounts for 15 to 20 percent of deaths in women with eclampsia. [64] Common drugs used for blood pressure control during eclampsia are hydralazine or labetalol, [30] due to their effectiveness, lack of negative effects on the fetus, and mechanism of action. Blood pressure management is indicated with a diastolic blood pressure above 105–110 mm Hg. [32] Normal blood pressure levels for pregnant women vary between trimesters and as so blood pressure management will be tailored accordingly. [65]

Delivery

If the baby has not yet been delivered, steps need to be taken to stabilize the woman and deliver her speedily. This needs to be done even if the baby is immature, as the eclamptic condition is unsafe for both baby and mother. As eclampsia is a manifestation of a type of non-infectious multiorgan dysfunction or failure, other organs (liver, kidney, lungs, cardiovascular system, and coagulation system) need to be assessed in preparation for a delivery (often a caesarean section), unless the woman is already in advanced labor. Regional anesthesia for caesarean section is contraindicated when a coagulopathy has developed.

There is limited to no evidence in favor of a particular delivery method for women with eclampsia. Therefore, the delivery method of choice is an individualized decision. [31]

Monitoring

Invasive hemodynamic monitoring may be elected in an eclamptic woman at risk for or with heart disease, kidney disease, refractory hypertension, pulmonary edema, or poor urine output. [30]

Etymology

The Greek noun ἐκλαμψία, 'eklampsía', denotes a "light burst"; metaphorically, in this context, "sudden occurrence." The Neo-Latin term first appeared in Johannes Varandaeus’ 1620 treatise on gynaecology Tractatus de affectibus Renum et Vesicae. [66] The term 'toxemia of pregnancy' is no longer recommended: placental toxins are not the cause of eclampsia occurrences, as previously believed. [67]

Notable deaths from eclampsia

Related Research Articles

Obstetrics is the field of study concentrated on pregnancy, childbirth and the postpartum period. As a medical specialty, obstetrics is combined with gynecology under the discipline known as obstetrics and gynecology (OB/GYN), which is a surgical field.

<span class="mw-page-title-main">Pre-eclampsia</span> Hypertension occurring during pregnancy

Pre-eclampsia is a multi-system disorder specific to pregnancy, characterized by the onset of high blood pressure and often a significant amount of protein in the urine. When it arises, the condition begins after 20 weeks of pregnancy. In severe cases of the disease there may be red blood cell breakdown, a low blood platelet count, impaired liver function, kidney dysfunction, swelling, shortness of breath due to fluid in the lungs, or visual disturbances. Pre-eclampsia increases the risk of undesirable as well as lethal outcomes for both the mother and the fetus including preterm labor. If left untreated, it may result in seizures at which point it is known as eclampsia.

Fetal distress, also known as non-reassuring fetal status, is a condition during pregnancy or labor in which the fetus shows signs of inadequate oxygenation. Due to its imprecision, the term "fetal distress" has fallen out of use in American obstetrics. The term "non-reassuring fetal status" has largely replaced it. It is characterized by changes in fetal movement, growth, heart rate, and presence of meconium stained fluid.

HELLP syndrome is a complication of pregnancy; the acronym stands for hemolysis, elevated liver enzymes, and low platelet count. It usually begins during the last three months of pregnancy or shortly after childbirth. Symptoms may include feeling tired, retaining fluid, headache, nausea, upper right abdominal pain, blurry vision, nosebleeds, and seizures. Complications may include disseminated intravascular coagulation, placental abruption, and kidney failure.

<span class="mw-page-title-main">Gestational hypertension</span> Medical condition

Gestational hypertension or pregnancy-induced hypertension (PIH) is the development of new hypertension in a pregnant woman after 20 weeks' gestation without the presence of protein in the urine or other signs of pre-eclampsia. Gestational hypertension is defined as having a blood pressure greater than 140/90 on two occasions at least 6 hours apart.

<span class="mw-page-title-main">Placental abruption</span> Medical condition

Placental abruption is when the placenta separates early from the uterus, in other words separates before childbirth. It occurs most commonly around 25 weeks of pregnancy. Symptoms may include vaginal bleeding, lower abdominal pain, and dangerously low blood pressure. Complications for the mother can include disseminated intravascular coagulopathy and kidney failure. Complications for the baby can include fetal distress, low birthweight, preterm delivery, and stillbirth.

<span class="mw-page-title-main">Complications of pregnancy</span> Medical condition

Complications of pregnancy are health problems that are related to, or arise during pregnancy. Complications that occur primarily during childbirth are termed obstetric labor complications, and problems that occur primarily after childbirth are termed puerperal disorders. While some complications improve or are fully resolved after pregnancy, some may lead to lasting effects, morbidity, or in the most severe cases, maternal or fetal mortality.

Soluble fms-like tyrosine kinase-1 is a tyrosine kinase protein with antiangiogenic properties. A non-membrane associated splice variant of VEGF receptor 1 (Flt-1), sFlt-1 binds the angiogenic factors VEGF and PlGF, reducing blood vessel growth through reduction of free VEGF and PlGF concentrations. In humans, sFlt-1 is important in the regulation of blood vessel formation in diverse tissues, including the kidneys, cornea, and uterus. Abnormally high levels of sFlt-1 have been implicated in the pathogenesis of preeclampsia.

<span class="mw-page-title-main">Intrauterine hypoxia</span> Medical condition when the fetus is deprived of sufficient oxygen

Intrauterine hypoxia occurs when the fetus is deprived of an adequate supply of oxygen. It may be due to a variety of reasons such as prolapse or occlusion of the umbilical cord, placental infarction, maternal diabetes and maternal smoking. Intrauterine growth restriction may cause or be the result of hypoxia. Intrauterine hypoxia can cause cellular damage that occurs within the central nervous system. This results in an increased mortality rate, including an increased risk of sudden infant death syndrome (SIDS). Oxygen deprivation in the fetus and neonate have been implicated as either a primary or as a contributing risk factor in numerous neurological and neuropsychiatric disorders such as epilepsy, attention deficit hyperactivity disorder, eating disorders and cerebral palsy.

<span class="mw-page-title-main">Vasa praevia</span> Condition in which fetal blood vessels cross or run near the internal opening of the uterus

Vasa praevia is a condition in which fetal blood vessels cross or run near the internal opening of the uterus. These vessels are at risk of rupture when the supporting membranes rupture, as they are unsupported by the umbilical cord or placental tissue.

<span class="mw-page-title-main">Posterior reversible encephalopathy syndrome</span> Medical condition

Posterior reversible encephalopathy syndrome (PRES), also known as reversible posterior leukoencephalopathy syndrome (RPLS), is a rare condition in which parts of the brain are affected by swelling, usually as a result of an underlying cause. Someone with PRES may experience headaches, changes in vision, and seizures, with some developing other neurological symptoms such as confusion or weakness of one or more limbs. The name of the condition includes the word "posterior" because it predominantly though not exclusively affects the back of the brain. Common underlying causes are severely elevated blood pressure, kidney failure, severe infections, certain medications, some autoimmune diseases, and pre-eclampsia. The diagnosis is usually made by a brain scan (MRI) on which areas of swelling can be identified.

<span class="mw-page-title-main">Amniotic fluid embolism</span> Potentially fatal complication of pregnancy

An amniotic fluid embolism (AFE) is a life-threatening childbirth (obstetric) emergency in which amniotic fluid enters the blood stream of the mother, triggering a serious reaction which results in cardiorespiratory collapse and massive bleeding (coagulopathy). The rate at which it occurs is 1 instance per 20,000 births and it comprises 10% of all maternal deaths.

<span class="mw-page-title-main">Velamentous cord insertion</span> Velamentous placenta

Velamentous cord insertion is a complication of pregnancy where the umbilical cord is inserted in the fetal membranes. It is a major cause of antepartum hemorrhage that leads to loss of fetal blood and associated with high perinatal mortality. In normal pregnancies, the umbilical cord inserts into the middle of the placental mass and is completely encased by the amniotic sac. The vessels are hence normally protected by Wharton's jelly, which prevents rupture during pregnancy and labor. In velamentous cord insertion, the vessels of the umbilical cord are improperly inserted in the chorioamniotic membrane, and hence the vessels traverse between the amnion and the chorion towards the placenta. Without Wharton's jelly protecting the vessels, the exposed vessels are susceptible to compression and rupture.

<span class="mw-page-title-main">Placental disease</span> Medical condition

A placental disease is any disease, disorder, or pathology of the placenta.

<span class="mw-page-title-main">Circumvallate placenta</span> Medical condition

Circumvallate placenta is a rare condition affecting about 1-2% of pregnancies, in which the amnion and chorion fetal membranes essentially "double back" on the fetal side around the edges of the placenta. After delivery, a circumvallate placenta has a thick ring of membranes on its fetal surface. Circumvallate placenta is a placental morphological abnormality associated with increased fetal morbidity and mortality due to the restricted availability of nutrients and oxygen to the developing fetus.

Magnesium salts are available as a medication in a number of formulations. They are used to treat magnesium deficiency, low blood magnesium, eclampsia, and several other conditions. Magnesium is an essential nutrient.

<span class="mw-page-title-main">High-risk pregnancy</span> Medical condition

A high-risk pregnancy is a pregnancy where the mother or the fetus has an increased risk of adverse outcomes compared to uncomplicated pregnancies. No concrete guidelines currently exist for distinguishing “high-risk” pregnancies from “low-risk” pregnancies; however, there are certain studied conditions that have been shown to put the mother or fetus at a higher risk of poor outcomes. These conditions can be classified into three main categories: health problems in the mother that occur before she becomes pregnant, health problems in the mother that occur during pregnancy, and certain health conditions with the fetus.

A pre-existing disease in pregnancy is a disease that is not directly caused by the pregnancy, in contrast to various complications of pregnancy, but which may become worse or be a potential risk to the pregnancy. A major component of this risk can result from necessary use of drugs in pregnancy to manage the disease.

Hypertensive disease of pregnancy, also known as maternal hypertensive disorder, is a group of high blood pressure disorders that include preeclampsia, preeclampsia superimposed on chronic hypertension, gestational hypertension, and chronic hypertension.

<span class="mw-page-title-main">Pregnancy Outcome Prediction study</span>

The Pregnancy Outcome Prediction (POP) Study is a prospective cohort study of 4,512 women who have never given birth, recruited at the Rosie Hospital between January 2008 and July 2012.

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  19. ↑ Berhan, Yifru; Berhan, Asres (June 2015). "Should magnesium sulfate be administered to women with mild pre-eclampsia? A systematic review of published reports on eclampsia: Systematic review of reports on eclampsia". Journal of Obstetrics and Gynaecology Research. 41 (6): 831–842. doi:10.1111/jog.12697. PMID   25833188. S2CID   41573228.
  20. ↑ Zeeman, Gerda G. (June 2009). "Neurologic Complications of Pre-eclampsia". Seminars in Perinatology. 33 (3): 166–172. doi:10.1053/j.semperi.2009.02.003. ISSN   0146-0005. PMID   19464507.
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  24. ↑ Sanders, T G; Clayman, D A; Sanchez-Ramos, L; Vines, F S; Russo, L (August 1991). "Brain in eclampsia: MR imaging with clinical correlation". Radiology. 180 (2): 475–478. doi:10.1148/radiology.180.2.2068315. ISSN   0033-8419. PMID   2068315.
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  26. ↑ Wichert-Ana, Lauro; Ferruzzi, Emerson Henklain; Alexandre Jr, Veriano; Velasco, Tonicarlo Rodrigues; Bianchin, Marino Muxfeldt; Terra-Bustamante, Vera Cristina; Kato, Mery; Santos, Antonio Carlos; Azevedo-Marques, Paulo Mazzoncini de; Oliveira, Lucas Ferrari de; Sakamoto, Américo Ceiki (December 2006). "Epistaxis during a generalized seizure leading to an atypical ictal SPECT finding at the skull base". Journal of Epilepsy and Clinical Neurophysiology. 12 (4): 225–227. doi: 10.1590/s1676-26492006000700007 . ISSN   1676-2649.
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