Ranko Kutlešić

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

INTRODUCTION Eclampsia is one of the most serious complications of hypertensive disorders of pregnancy, defined as the occurrence of one or more convulsions superimposed on preeclampsia. Besides the ordinary course of the disease, ranging from a mild to a severe form, with culmination in eclamptic seizures, there is a significant percent of cases where eclampsia starts unexpectedly, without typical premonitory symptoms and signs, which makes it difficult to prevent. NEURORADIOLOGICAL CHARACTERISTICS AND PATHOGENESIS OF ECLAMPSIA. Neuroradiological signs of eclampsia are described as posterior reversible encephalopathy syndrome, and are manifested by nausea, vomiting, headache, visual disturbances, altered mental status, convulsions and coma, together with characteristic findings on computed tomography or magnetic resonance imaging scan of the head, indicating the presence of vasogenic brain edema. The topic of this article are possible mechanisms of the development of posterior reversible encephalopathy syndrome in pregnancy and modalities of acute treatment of this emergency state. MANAGEMENT OF ECLAMPSIA: Magnesium sulphate is nowadays the drug of choice for the treatment and prevention of eclamptic seizures. Labetalol is considered to be the agent of choice in the treatment of hypertensive emergencies of pregnancy, followed by hydralazine, nifedipine, nicardipine, urapidil, nitroglycerin and sodium nitroprusside (in most refractory cases). Angiotensin converting enzyme inhibitors and angiotensin blocking drugs are contraindicated in pregnancy. Captopril and enalapril are allowed during lactation. CONCLUSION Posterior reversible encephalopathy syndrome in eclamptic patients is completely reversible if adequate diagnosis is promptly made and intensive treatment immediately administered.

Vaginal birth in breech presentation in morbidly obese woman

The unexpected breech presentation in labour dealing with morbidly obese women places health professionals in a clinical dilemma. Obesity is defined as a body mass index (BMI) 30 kg/m and further categorised as Class I: BMI 30–34.9 kg/m, Class II: 35–39.9 kg/m and Class III: 40 (super-morbid) (Sturm 2003). There is a linear relationship between BMI and caesarean rate: 7.3% for normal, 11.3% for overweight, 15.5% for obese Class I, 20.4% for obese Class II and 27.3% for obese Class III categories, respectively. Morbid obesity seriously impacts on pregnancy and reported risks include an overall increase in caesarean delivery (OR 2.9), five-minute Apgar scores less than 7 (OR 3.0), birth weight more than 4500 g (OR. 8.1) and intrauterine growth restriction (OR 9.3) (Weiss et al. 2004). Extremely obese women are at an increased risk of caesarean delivery, which further increases the risks of maternal morbidity (Alanis et al. 2010). There is little evidence whether an elective caesarean section or normal vaginal birth is the optimal mode of delivery in morbidly obese women. Unlike North America, birth in extremely obese women with a BMI over 50 kg/m is not common in Europe (Alanis et al. 2010). We present a case of vaginal birth in a morbidly obese pregnant woman, with a foetus in breech presentation.

A case of eclampsia complicated by cerebral haemorrhage and iatrogenic hypopharyngeal oedema and haemathoma

Introduction. Eclampsia, serious complication of preeclampsia, can further be complicated by intracranial haemorrhage. Cesarean section under general anesthesia represents an additional risk factor. Case report. We present a case of 22 years old primipara in the 38th gestational week who after a sudden occurrence of a headache, within one hour developed eclampsia. Emergent Caesarean section was undertaken; she was intubated after several attempts. Severe tongue and hypopharyngeal edema and haemathoma made the extubation impossible; she remained intubated, sedated, mechanically ventilated, on antioedematous, anticonvulsive, antihypertensive therapy. On the third postoperative day, tracheostomy was performed. On the sixth day, she complained of a headache and visual disturbances. Neurological examination revealed left-sided hemiparesis. Multislice computed tomography showed intracranial hemorrhage. It was not until the closure of tracheostoma (eleventh day) that her blood pressure normalized and the headache ceased. Four days later she was dismissed from the hospital with improved clinical state. Conclusion. In order to avoid sudden and unexpected, but serious complications of preeclampsia/eclampsia, we emphasize the need of searching for more subtle signs of the disease, of prompt radiologic diagnosis and aggressive blood pressure control, with a prepared strategy for difficult airway management.