Abstract
Introduction
Posterior reversible encephalopathy syndrome (PRES) and the related term reversible posterior leukoencephalopathy syndrome (RPLS) denote a constellation of clinical symptoms paired with key radiological findings. Eclampsia associated with PRES is a rare condition and remains a challenging diagnosis to make. There are only a few studies regarding PRES syndrome with a limited sample size. Our institution is a tertiary referral centre; hence, a good sample size of patients with eclampsia complicated with PRES syndrome is seen in our study. The objective was to identify the maternal and neonatal outcomes in PRES with eclampsia.
Methods
This study is a prospective observational study done in Government Medical College, Aurangabad, India from October 2018 to September 2020. In the present study, we have enrolled 63 cases, who satisfied inclusion and exclusion criteria during two years. All women admitted in the labour room of tertiary health care centre diagnosed with eclampsia with neurological symptoms during the study period were studied. Relevant data were obtained from the case file and compiled by common proforma. Analysis was done by SPSS (Statistical package for social sciences) Version 25th.
Results
In patients with a confirmed diagnosis of PRES with eclampsia(n = 63), the mean age of the patient was 20.74 ± 2.04 years, 23 (36.5%) patients had headache as premonitory symptoms, whereas 13(20.6%)patients had visual disturbances as the premonitory symptom. The mean gestational age at presentation was 34.4 ± 2 weeks. 40(63.5%) patients were showing parieto-occipital region changes, and 24(38.1%) subjects were showing only occipital region involvement in CT brain. 12 (19.04%) subjects were diagnosed with HELLP syndrome as a maternal complication, 07 (11.1%) subjects had Abruptio placentae. 26(41.3%) babies needed NICU admission, and 4 (6.3%) babies had neonatal death.
Conclusion
In pregnant patients presenting with seizure and neurological symptoms, a possibility of PRES should be considered. Proper diagnosis requires careful attention to clinical and radiographic presentation. In eclampsia with PRES patients, a timely intervention with anti-hypertensive, anti-cerebral oedema measures as well as management of other associated symptoms are required.
Supplementary Information
The online version contains supplementary material available at 10.1007/s13224-021-01585-9.
Keywords: PRES, Eclampsia, Cerebral imaging, Vasogenic oedema
Introduction
Posterior reversible encephalopathy syndrome (PRES) was first described in 1996 by Hinchey et al. [1] It is known by many other names including PRES, hyperperfusion encephalopathy, brain capillary leak syndrome, hypertensive encephalopathy and reversible posterior leukoencephalopathy syndrome.
Pathophysiology of PRES has been proposed, suggesting endothelial dysfunction and cerebral vasospasm. One theory is that increased systemic pressure exceeds the cerebral vasculature autoregulatory mechanism [2] leading to fluid extravasation into the brain and resulting in hydrostatic oedema [3]. The selective involvement of the posterior cerebral areas could reflect a watershed zone due to a lesser degree of adrenergic innervations and auto regulation mechanisms in this area [4].
The objective of the study was to identify the obstetric outcomes in mother and the neonates in PRES.
Materials and Methods
This is a prospective observational study done from October 2018 to September 2020, which was approved by the institutional review board at the Government Medical College, Aurangabad, India.
Inclusion criteria was pregnancy or within 6 weeks' postpartum presenting with eclampsia along with persistant neurological symptoms where CT was performed to confirm the diagnosis of PRES.
Exclusion criteria was a past history of neurological disorder, noneclamptic patient, known seizure disorder and later diagnosis of seizure from a source other than eclampsia.
All women diagnosed as eclampsia and presenting with persistant neurological symptoms were selected. Patients having neurological features like headache, altered mental status, irritability, recurrent convulsion,deep coma were subjected to CT scan, and those having diagnosis of PRES were enrolled in study.
The diagnosis of PRES was made by radiologists using the standard radiological criteria for PRES. PRES has a unique CT imaging appearance symmetrical hypodensity as the extent of cerebral oedema increases. The criteria for diagnosis of PRES on CT were hypoattenuation of the occipital and parietal regions [5]. The brain imaging shows oedema of white matter and reversible ischaemic changes predominantly in areas perfused by posterior brain circulation, that is, the parieto-occipital areas [6, 7].
Patient was stabilised and basic treatment was given. After obtaining written informed consent, relevant data were obtained in a common proforma that included sociodemographic characteristics of mothers [Age, parity, residency, socio-economic status according to modified Kuppaswamy Scale], obstetric history and associated other co-morbid condition.
Presenting complaints & signs and symptoms in mother at presentation were noted. BP at the admission was noted. Further, these women were subjected to complete examination [General and systemic examination].
In obstetric examination, gestational age, amount of liquor was assessed, and FHS were noted. Laboratory investigations performed were complete blood count, urine protein, LFT, KFT, blood coagulation profile like PT, INR and fundoscopy. Cervical status was noted. Patients were monitored with intrapartum partogram. Decision regarding mode delivery (vaginal delivery, instrumental (vacuum and forceps) and LSCS) was taken by senior obstetrician.
Patients were monitored for complications like HELLP, Abruptio placenta, PPH, ventilation support and death during labour and post-delivery. (2 weeks).
Their babies were followed upto two weeks post-delivery. Birth weight, APGAR Score at 5 min, preterm birth, LBW, IUGR, IUFD, NICU admission, neonatal complications and early neonatal death were noted.
Treatment Protocol
Treatment of eclampsia with PRES was done with Inj MgSO4 with Pritchard regimen. Inj. Mannitol was administered in cases that did not respond to Inj. MgSO4 alone and had either recurrent convulsions, extreme irritability, visual disturbances, or severe or deep coma. Dose of Inj. Mannitol was administered as 100 cc of 20% IV. 6 hourly for 48 h, and then, it was tapered 8 hourly for next 24 h, 12 hourly for next 24 h and then omitted. Inj labetalol and oral nifedipine were given to control BP.
Statistical Analysis
The data were compiled in master chart, i.e. in MS-EXCEL Sheet and for analysis of this data; SPSS (Statistical package for social sciences) version 25th was used. Frequencies and Percentages were calculated to show the distribution.
Results
In the study period, 34,282 deliveries took place out of which 463(1.35%) were eclampsia patients. Out of 463 eclampsia cases, 63 were diagnosed as PRES cases giving a incidence of PRES as 13.61% (63/463) in eclampsia cases and overall incidence of PRES as 0.18%. (63/34,282) 63 patients of Eclampsia with PRES were enrolled in study and studied for maternal and perinatal outcome. The findings from all 63 patients who underwent neuroimaging are reported in the current study.
Discussion
Hypertensive disorder of pregnancy is a common medical disorders in pregnancy. PRES is one of the dangerous complications associated with eclampsia. The majority of these patients underwent imaging within the first 24 h after admission.
Table 1 shows the sociodemographic profile that the majority of cases were unbooked (42 cases, 66.7%) and belonged to the rural area. Sardesai, S et al. [8] observed that 42.7% subjects were from rural area, and 57.3% subjects were from the urban locality. Prompt and affordable referral services are required to limit the delays and to save maternal lives [9]. In our study, 28 subjects were primigravida, and nine subjects were multigravida. Similarly, 17 subjects were primipara, and nine subjects were multipara. Brewer J et al. reported similar findings in their study in 2013. Among the 63 study subjects, 30(47.6%) women presented with antepartum eclampsia and 26 (41.27%) women with postpartum eclampsia. Antepartum (47.6%) cases with eclampsia with PRES were more than those presenting with postpartum eclampsia with PRES (41.27%) 0.7 women.
Table 1.
Distribution of sociodemographic factors
| Sr.No | Variable | Frequency (n = 63) | % |
|---|---|---|---|
| 1 | Age in yrs | ||
| < 20 | 35 | 55.5 | |
| 21–25 | 14 | 22.2 | |
| 26–30 | 12 | 19.1 | |
| 31–45 | 02 | 3.2 | |
| Mean ± SD | 20.74 ± 2.04 | ||
| 2 | Booked | 21 | 33.3 |
| Unbooked | 42 | 66.7 | |
| 3 | Primigravida | 28 | 75.7 |
| Multigravida | 09 | 24.3 | |
| Primipara | 17 | 65.4 | |
| Multipara | 09 | 34.6 | |
| 4 | Presentation on admission | ||
| Antepartum eclampsia | 30 | 47.6 | |
| Intrapartum eclampsia | 7 | 11.1 | |
| Postpartum eclampsia | 26 | 41.27 |
Table 2 shows the presentation, number of convulsions, BP, gestational age on admission.
Table 2.
Frequency of maternal symptoms at presentation and mode of delivery
| Sr.No | Variable | Frequency (n = 63) | % |
|---|---|---|---|
| 1 | No of convulsion | ||
| 1–2 | 27 | 42.9 | |
| 3–5 | 9 | 46 | |
| ≥ 6 | 7 | 11.1 | |
| 2 | Premonitory symptoms | ||
| Headache | 23 | 36.5 | |
| Visual disturbances | 13 | 20.6 | |
| Altered mental state | 13 | 20.6 | |
| Vomiting | 09 | 14.3 | |
| Epigastric pain | 09 | 14.3 | |
| Deep Coma | 04 | 6.3 | |
| 3 | Blood pressure on admission | ||
| 140/90 to 160/110 | 43 | 68.3 | |
| > 160/110 | 20 | 31.8 | |
| 4 | Gestational age | ||
| < 28 weeks | 05 | 7.9 | |
| 28–33.6 weeks | 21 | 33.3 | |
| 34–36.6 weeks | 08 | 12.7 | |
| 37–40 weeks | 26 | 41.3 | |
| > 40 weeks | 3 | 4.8 | |
| Mean ± SD 34.4 ± 2 weeks | |||
| 5 | Treatment given | ||
| MgSO4 | 37 | 76.19 | |
| MgSO4 + Mannitol | 26 | 23.80 | |
| 6 | Mode of Delivery | ||
| PT Vaginal Delivery | 19 | 30.2 | |
| FT Vaginal Delivery | 12 | 19.4 | |
| Vaccum | 01 | 1.6 | |
| Preterm LSCS | 15 | 23.8 | |
| Term LSCS | 13 | 20.6 | |
| Post Term LSCS | 3 | 4.8 |
The mode of delivery and details of treatment received are also shown. Headache (36.5%) was the most common symptom followed by visual disturbances, and altered mental state was seen in 20.6% cases. 14.3% cases had vomiting and epigastric pain. 6.3% cases had deep coma. In many subjects, two or more symptoms coexisted. Karanth S et al. [10] found common presenting symptoms of PRES as headache (93.3%) and vomiting (53.3%), and visual disturbances were present in very few patients (3.3%) in his study.
Hypertension and eclampsia with PRES are closely associated [11–13]. It is due to endothelial damage in the setting of hypertension and failure of cerebrovascular autoregulation with subsequent vasogenicoedema [14, 15]. In our study, 20 subjects presented with BP of more than 106/110 mm of Hg on admission, whereas 43 subjects presented with a BP less than 160/110 mm of Hg. Sardesai, S et al. [8, 16] found that 50% of cases presented with BP more than 160/110, and 50% of cases presented with BP less than 160/110. Generalised seizures are often the most common clinical manifestation of PRES [17]. In our study, majority of the patients (46%) had 3–5 seizures. However, seven (11.1%) patients had more than 6 seizures at presentation. Whereas 27 subjects had 1 to 2 convulsions only. Increase in the number of convulsion increased the risk of maternal morbidity and mortality significantly [18, 19] Madhu Sinha et al. reported 40.2% subjects had 3 to 5 convulsions and 19.2% subjects with more than 6 convulsions [18]. In our study, 37 patients were treated with inj Mgso4 only (Pritchart regime). And remaining 26 required inj mannitol along with inj Mgso4. Inj mannitol is used in cases of PRES to reduce the raised intracranial pressure, to promote diuresis and minimise the risk of acute renal failure. Mannitol also establishes an osmotic gradient between plasma and brain cells, drawing water from the cerebral extracellular space into the vasculature, thereby reducing cerebral oedema.
In our study, 32/63 (50.79%) patients delivered vaginally. (19 were preterm delivery, 1 was vacuum delivery, and 19 delivered full term). The remaining 31 patients (49.2%) were delivered by LSCS. (15 patients had preterm LSCS, 3 had LSCS for postdatism, and 13 had term LSCS). The most common indication for LSCS was antepartum eclampsia with unfavourable cervix (24 cases), transverse lie (1 case), and previous LSCS (6 cases). The preterm delivery rate is very high as induction of labour was attempted immediately on admission to save the maternal life and reduce complications. Similar findings were noted by Karanth S et al. [10]. He found 43.3% vaginal delivery and 56.7% of LSCS in his study, whereas Fisher N et al. found 55.6% vaginal delivery and 44.4% of LSCS [20]. Table 3 40 (63.5%) subjects were showing parieto-occipital region changes, 24 (38.1%) subjects were showing only occipital region changes, 14(22.2%) subjects were showing temporo-occipital region changes, and 4 (6.3%) subjects were showing changes in cerebellum region.
Table 3.
CT findings according to region of brain
| Region Involved | CT Finding | Frequency (n = 63) | ||||
|---|---|---|---|---|---|---|
| Cerebral oedema (n = 57) | Hypodense Lesion (n = 20) | Cerebral Infarction (n = 2) | Haemorrhage (n = 3) | No | % | |
| Parieto-occipital region | 30 | 7 | 01 | 02 | 40 | 63.5 |
| Temporo-occipital region | 7 | 5 | 01 | 01 | 14 | 22.2 |
| Cerebellum | 3 | 1 | 00 | 00 | 04 | 6.3 |
| Occipital | 17 | 7 | 00 | 00 | 24 | 38.1 |
Focal regions of symmetric hemispheric oedemas are often seen [21]. Haemorrhage, focal haematoma or isolated subarachnoid haemorrhage is seen in some cases [22]. In Sardesai, S et al. study, 62.7% subjects had parieto-occipital region changes, 65.5% subjects had only occipital region changes, 11.8% subjects had temporo-occipital region changes, and 7.27% subjects were showing changes in cerebellum region 8. Table 4 shows maternal outcome in PRES. In this study, 12 (19.04%) subjects had HELLP syndrome, 07 (11.1%) subjects had Abruptio Placentae, Atonic PPH (6.5%). DIC and puerperal sepsis was seen in 6.5% of patients, pulmonary oedema (4.5%) and ARF was seen in 3.2% cases. There were 5 (7.2%) maternal deaths in this study. Causes of maternal death were pulmonary embolism, abruptio placentae, septic shock syndrome, aspiration pneumonitis, intracranial haemorrhage with ARF and ARDS. Haque H et al. [23] found that PRES cases had complications like PPH (15.21%), pulmonary oedema (2.17%) and ARF (4.35%). Table 5 Showing neonatal outcome. Out of 63 patients, 49 (77.8%) were liveborn, 14 (22.2%) were FSB, Out of the 49 live born babies, 23 (46.9%) subject babies had APGAR score 7–10. Babies having APGAR score less than 3 were 6 (12.2%). Birth weight less than 2 kg was seen in 24 babies (38.1%), and 12 (19.1%) babies had a birth wt of 2.1 to 2.5 kg. Only 5 (7.9%) babies were born with a weight of 3.1 to 3.5 kg. Perinatal asphyxia in 26 (41.3%), IUGR (28.6%) and hyperbilirubinemia (6.3%) was noted. All these babies needed NICU admission. 4 babies had neonatal death due to sepsis, RDS, LBW and metabolic acidosis. Deepika Pannu et al. [24] found that in PRES cases, 9.6% had PPH, pulmonary oedema 14.5%, ARF in 12%, HELLP Syndrome in 13.2%, DIC in 2.4% patients and puerperal sepsis in 6%, maternal deaths in 8.2% cases babies with 24 babies (46.9%) with a birth weight of < 2 kg. 26 newborns needed NICU admission, and there were 4 neonatal deaths. Out of 63 patients, only 49 (77.8%) subjects babies were liveborn, and 14 (22.2%) subject babies were FSB. This can be attributed to the associated IUGR, HELLP Syndrome, DIC, Abruptio placentae, status eclampticus and pulmonary oedema [25, 26]. Karanth S et al. [10] observed similar rate (20.0%) of still birth. Birth weight less than 2 kg was seen in 24 babies (38.1%), and 12 (19.1%) babies had a birth wt of 2.1 to 2.5 kg. Only 5 (7.9%) babies were born with a weight of 3.1 to 3.5 kg. Dr Archana Kumari et al. [26, 27] observed that 39.28% of babies had less than equal to 2 kg weight. Perinatal asphyxia in 26 (41.3%), IUGR (28.6%) and hyperbilirubinemia (6.3%) were noted. All these babies needed NICU admission 0.4 babies had neonatal death due to sepsis, RDS, LBW and metabolic acidosis. IUGR alone is known to be associated with severe neonatal mortality and morbidity [28, 29].
Table 4.
Maternal complications in PRES
| Maternal complication | Frequency (n = 63) | % |
|---|---|---|
| DIC | 4 | 6.5 |
| Abruptio placentae | 7 | 11.1 |
| ARF | 2 | 3.2 |
| PPH | 4 | 6.5 |
| HELLP syndrome | 12 | 19.04 |
| Puerperal sepsis | 4 | 6.5 |
| Wound discharge/gape | 3 | 4.8 |
| Pulmonary oedema | 3 | 4.8 |
| Death | 5 | 7.9 |
Table 5.
Neonatal outcomes in PRES
| Sr. No. | Variable | Frequency (n = 63) | % |
|---|---|---|---|
| 1 | Neonatal outcome | ||
| Live birth | 49 | 77.8 | |
| FSB | 14 | 22.2 | |
| 2 | APGAR score | ||
| 7–10 | 24 | 46.9 | |
| 3–6 | 20 | 40.8 | |
| < 3 | 06 | 12.2 | |
| 3 | Birth weight | ||
| ≤ 2 KG | 24 | 38.1 | |
| 2.1–2.5 | 12 | 19.1 | |
| 2.6- 3.0 | 21 | 33.3 | |
| 3.1–3.5 | 05 | 7.9 | |
| 4 | Perinatal complication | ||
| NICU admission | 26 | 41.3 | |
| IUGR | 18 | 28.6 | |
| IUFD | 14 | 22.2 | |
| Neonatal death | 04 | 6.3 | |
| Perinatal asphyxia | 08 | 12.7 | |
| Hyperbilirubinemia | 04 | 6.3 |
Conclusion
Timely diagnosis and treatment are essential to save lives in PRES. It requires careful attention to clinical and radiographic profiles. Multidisciplinary approach in management will help to improve the outcome.
Supplementary Information
Dr Varsha Deshmukh
is working as a Professor, Dept of OBGY, at GMC and cancer hospital, Aurangabad, Maharashtra. She is a recognised undergraduate and postgraduate teacher and has served as a guide to 33 postgraduade students. She was the Past President of Aurangabad OBGY Society (2018-19) and has won the best society award in her tenure. She has many publications in various national and international journals. She is the national corresponding editor of JOGI(2021-23). She is working in the oncology dept at present. She has a fellowship in palliative care. She also has done a certificate course in surgical oncology from Tata Hospital, Mumbai. 
Declarations
Conflict of interest
The authors report no conflict of intrest.
Ethical approval
Ethical comittee approval was obtained from the ethical committee of Govt Medical College, Aurangabad. (Pharma/IEC-GMCA/46/2018).
Footnotes
Varsha Deshmukh is a Professor at the Department of OBGY, GMC and Cancer Hospital, Aurangabad, Maharashtra, India; Vikas R Gangurde is Chief Resident, Department of OBGY, GMC, Aurangabad, Maharashtra, India.
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