Dear Editor
Preeclampsia is a disease unique to human pregnancy characterized by new-onset hypertension and proteinuria after the 20th week of gestation. It affects 6-8% of all pregnancies and is one of the leading causes of maternal and fetal morbidity and mortality worldwide. Voluminous vulvar edema in association with preeclampsia is a rare sign during pregnancy. In our case a primigravida women with acute appearance of massive vulvar edema in ongoing twin pregnancy with severe preeclampsia further developed an acute renal failure. Vulvar edema during pregnancy may characterize the severity of the disease. Because of poorly controlled blood pressure of our patient, deteriorated renal function the following 9 hours from her admission and the non-reassuring recordings of the fetal heart rates a caesarean section (CS) was decided. Because of prematurity, neonates were transferred in the Neonatal Intensive Care Unit (NICU), while mother was transferred to the Intensive Care Unit because of severely deteriorated renal function and of the uncontrolled blood pressure. Forty-eight hours later biochemical blood tests, physical findings improved dramatically, while the vulvar edema almost disappeared. The first infant died 10 days after birth because of intraventricular hemorrhage while the second one remained in NICU for 60 days and was discharged when her body weight was 2880 grams.
Preeclampsia ranges from mild disease to a severe form that endangers the life of both mother and the fetus. Severe edema in preeclamptic patients is very rare. The current evidence encloses only five cases related to this issue 1-4. Preeclampsia associated with acute renal failure presents in 5-10% of severe cases of preeclampsia with a predicted mortality rate of 10% 5. Recovery is usually complete if the acute phase passes without further complications.
Persistent hypertension despite anti-hypertensive therapy, progressive deterioration in renal function and non-reassuring fetal testing were the evidence of disease progression and the reason of our decision to perform CS in the 32 weeks of gestation. Two cases of massive antepartum vulvar edema in patients with preeclampsia were reported who also failed to be managed with medication and delivered by a CS due to fetal distress 3. In another case of severe preeclampsia with vulvar edema whose condition deteriorated despite medical treatment with the development of ascites and signs of impending eclampsia 4. CS again was considered the best choice for a safe termination of the pregnancy.
Severe preeclampsia during pregnancy can be associated with acute appearance of vulvar edema complicated with acute renal failure which usually disappears after delivery. Early recognition of such cases is essential to plan a safe delivery preventing from adverse outcomes both mother and fetus.
References
- 1.Bracero LA, Didomenico A. Massive vulvar edema complicating preeclampsia: a management dilemma. J Perinatol. 1991;11:122–125. [PubMed] [Google Scholar]
- 2.Gerdhzhikov B, Kozovski G. Massive vulvar edema in severe preeclampsia. Akush Ginecol. 2005;44:44. [PubMed] [Google Scholar]
- 3.Morris LF, Rapini RP, Hebert AA, Katz AR. Massive labial edema in pregnancy. South Med J. 1990;83:846–848. doi: 10.1097/00007611-199007000-00030. [DOI] [PubMed] [Google Scholar]
- 4.Daponte A, Skentou H, Dimopoulos KD, Kallitsaris A, Messinis IE. Massive vulvar edema in a patient with preeclampsia. J Reprod Med. 2007;52:1067–1069. [PubMed] [Google Scholar]
- 5.Moulin B, Hertig A, Rondeau E. Kidney and preeclampsia. Ann Fr Anesth Reamin. 2010;29:83–90. doi: 10.1016/j.annfar.2010.02.022. [DOI] [PubMed] [Google Scholar]