and Eclampsia
Demographics, Clinical Course, and Complications
Zain Al-Safi, MD, Anthony N. Imudia, MD, Lusia C. Filetti, MD, Deslyn T. Hobson,
Ray O. Bahado-Singh, MD, MBA, and Awoniyi O. Awonuga, MD
OBJECTIVE: To estimate and evaluate the demographics,
clinical course, and complications of delayed postpartum
preeclampsia in patients with and without eclampsia.
METHODS: We conducted a retrospective cohort study
of patients who were discharged and later readmitted
with the diagnosis of delayed postpartum preeclampsia
more than 2 days to 6 weeks or less after delivery
between January 2003 and August 2009.
RESULTS: One hundred fifty-two patients met criteria
for the diagnosis of delayed postpartum preeclampsia. Of
these, 96 (63.2%) patients had no antecedent diagnosis of
hypertensive disease in the current pregnancy, whereas
seven (4.6%), 14 (9.2%), 28 (18.4%), and seven (4.6%)
patients had gestational hypertension, chronic hypertension, preeclampsia, and preeclampsia superimposed on
chronic hypertension, respectively, during the peripartum period. Twenty-two patients (14.5%) developed
postpartum eclampsia, and more than 90% of these
patients presented within 7 days after discharge from the
hospital. The most common presenting symptom was
headache in 105 (69.1%) patients. Patients who developed
eclampsia were significantly younger than those who did
not (meanstandard deviation, 23.26.2 compared with
28.36.7 years; adjusted odds ratio [OR] 1.13, 95% confidence interval [CI] 1.021.26, P.03), and other demographic variables were no different. A lower readmission
hemoglobin was associated with a lower odds of progresFrom the Department of Obstetrics and Gynecology and the Division of
Reproductive Endocrinology and Infertility, Wayne State University School of
Medicine/Detroit Medical Center, Detroit, Michigan; and the Division of
Reproductive Medicine and Infertility, Massachusetts General Hospital, Boston,
Massachusetts.
Corresponding author: Awoniyi O. Awonuga, MD, Division of Reproductive
Endocrinology and Infertility, Department of Obstetrics and Gynecology, 60
West Hancock, Detroit, MI 48201; e-mail: aawonuga@med.wayne.edu;
niyiawonuga@aol.com.
Financial Disclosure
The authors did not report any potential conflicts of interest.
2011 by The American College of Obstetricians and Gynecologists. Published
by Lippincott Williams & Wilkins.
ISSN: 0029-7844/11
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MD,
Al-Safi et al
RESULTS
During the study period, 48,498 deliveries were recorded, and preeclampsia occurred in 3,072 patients
(6.3%, 95% CI 6.1 6.6). One hundred fifty-two patients (5.0%, 95% CI 4.25.8) were readmitted to the
hospital within 6 weeks of their initial discharge with
the diagnosis of postpartum preeclampsia or eclampsia. The meanstandard deviation and median
(range) maternal age and gestational age at delivery
were 27.66.8 and 28 (15 44) years and 38.22.5
and 39 (28 42) weeks, respectively. Twenty-three
percent (23.3%, 95% CI 17.330.7) of the patients
were primigravid, 32.9% (95% CI 26.3 41.2) were
nulliparous, 78.9% (95% CI 71.8 84.7) were on
Medicaid, and 96.7% (95% CI 92.598.6) were
African American. Information about the gravidity
and parity was missing in two patients. The mode of
delivery was vaginal in 57.9% (95% CI 49.9 65.5),
whereas 42.1% (95% CI 34.6 50.1) underwent cesarean deliveries. Four (2.6%, 95% CI 0.9 7.0)
patients had twin gestations.
Of the 152 patients readmitted with the diagnosis
of delayed postpartum preeclampsia or eclampsia, 96
(63.2%, 95% CI 55.370.4) had no antecedent diag-
1103
nosis of hypertensive disease in the current pregnancy, whereas seven (4.6%, 95% CI 2.39.2) had
gestational hypertension, 14 (9.2%, 95% CI 5.6 14.9)
had chronic hypertension, 28 (18.4%, 95% CI 13.1
25.3) had preeclampsia, and seven (4.6%, 95% CI
2.39.2) were diagnosed with preeclampsia superimposed on chronic hypertension during the peripartum
period. Twenty-seven (17.8%, 95% CI 12.524.6) of
the patients readmitted with the diagnosis of delayed
postpartum preeclampsia were treated with magnesium sulfate during the peripartum period. These
patients were equally distributed across the eclampsia
and noneclampsia groups (Table 1). The mean (range)
number of days postpartum and between discharge
and readmission were 7.6 days (323) and 4.7 days
(0 19), respectively.
The highest systolic blood pressure on readmission was (mean [range]) 176 (116 240) mmHg and
the highest diastolic blood pressure was 101 (72131)
mmHg. Symptoms and signs at presentation were not
mutually exclusive. Headache (n105, 69.1%, 95%
CI 61.375.9) was the most common presenting
symptom. Other symptoms included shortness of
breath (n41, 30.0%, 95% CI 20.6 34.5), blurry
vision (n32, 21.1%, 95% CI 15.328.2), nausea
(n19, 12.5%, 95% CI 8.218.7), vomiting (n17,
11.2%, 95% CI 7.117.2), edema (n16, 10.5%, 95%
CI 6.6 16.4), seizure (n6, 4.0%, 95% CI 1.8 8.4),
other neurological deficit (n8, 5.3%, 95% CI 2.7
10.0), and epigastric pain (n8, 5.3%, 95% CI 2.7
10.0). Six patients were admitted with a history of
eclamptic seizures at home, five seized while in the
emergency department, and another 11 seized during
the readmission period. The overall rate of eclampsia
for patients readmitted with the diagnosis of postpar-
Table 1. Hospital Course and Some Laboratory Data in Patients With Postpartum Eclampsia Compared
With Those Who Did Not Develop Postpartum Eclampsia
No Eclampsia
Eclampsia
130
130
130
130
130
130
130
128
130
128
130
123
127
125
175.219.4
101.711.6
23 (17.7)
108 (83.1)
7.73.8
4.0 (019)
108 (83.1)
11.31.4
10.71.7
236.672.0
323.6145.1
77 (241,044)
0.7 (11)
50 (40.0)
22
22
22
22
22
22
22
20
22
20
22
22
20
21
177.323.7
100.011.4
4 (18.2)
21 (95.5)
6.82.7
3.50 (012)
20 (90.9)
11.01.5
11.62.2
233.675.2
304.1126.2
32 (1945)
0.6 (11)
9 (42.9)
.64
.52
.96
.57
.28
.26
.53
.32
.03
.62
.55
.92
.56
.97
Data are meanstandard deviation, n (%), or median (range) unless otherwise specified.
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Al-Safi et al
No antihypertensive used
Calcium channel blockers
Alpha or -blockers or both
Others
Combination (24 drugs)
No Eclampsia*
Eclampsia*
68 (52.3)
31 (23.8)
9 (6.9)
3 (2.3)
19 (14.6)
10 (45.5)
7 (31.8)
1 (4.5)
1 (4.5)
3 (13.6)
Includes calcium channel blockers, -blockers, -blockers, and -blockers, diuretics, and clonidine.
hemoglobin (P.03). When these variables were entered into a logistic regression model, young age was
associated with greater odds of developing eclampsia
(adjusted OR 1.13, 95% CI 1.021.26, P.03),
whereas a lower readmission hemoglobin was associated with a lower odds of progression to eclampsia
(adjusted OR 0.75, 95% CI 0.57 0.98, P.04). Gravidity was not associated with risk of eclampsia (gravidity less than three compared with three or more;
adjusted OR 1.29, 95% CI 0.37 4.45, P.69). Although patients who developed eclampsia appeared
less likely to have peripartum preeclampsia, chronic
hypertension, and diabetes, these differences were not
statistically significant (Table 3). There were no significant differences between patients with postpartum
preeclampsia with and without seizures with respect to
other demographic variables, medical disorders associated with pregnancy, hospital course, or laboratory
findings (Tables 1 and 3). Of 543 patients diagnosed
with preeclampsia superimposed on chronic hypertension during the study period, only 28 (5.2%, 95% CI
DISCUSSION
In this large series of 152 patients with delayed postpartum preeclampsia who were readmitted after initial
discharge from the hospital, we identified several variables that could help stratify patients who are more
likely to develop the disease. In our study, over 96% of
the patients were African American, 78% were on
Medicaid, and 63.2% had no antecedent diagnosis of
hypertensive disease in the index pregnancy. Similar to
the 78% reported by Chames and colleagues,5 those
with no antecedent diagnosis of hypertensive disease
seem to be particularly at risk, because the highest rate
of eclampsia (77.3%) occurred in this group of patients.
This could be the result of the fact that patients and their
physicians might not be aware that there is still a
measurable risk of preeclampsia even after postpartum
discharge despite an uneventful pregnancy and delivery.
In contrast, of the 543 patients diagnosed with
preeclampsia superimposed on chronic hypertension
during the study period, only 28 (5.2%) were readmitted
to the hospital for postpartum preeclampsia and none
developed eclampsia. However, it is possible that some
of these patients were discharged from the emergency
department after merely increasing the dose of their
antihypertensive(s) if they were asymptomatic and
therefore were not recorded.
Only maternal age and preadmission hemoglobin distinguished between those who did or did not
develop postpartum eclampsia. In contrast, other
maternal demographic variables, history of medical
disorders, symptoms and signs on presentation, hospital course, and laboratory data were not associated
Table 3. Demographic Data and Medical History of Patients With Postpartum Eclampsia Compared
With Those Who Did Not Develop Postpartum Eclampsia
No Eclampsia
Eclampsia
130
128
115
130
130
129
129
105
130
130
130
130
130
28.36.7
4 (113)
35.58.6
126 (96.9)
102 (78.5)
21 (16.3)
38.12.5
3,180.8786.8
6 (4.6)
25 (19.2)
20 (15.4)
18 (13.8)
3 (2.3)
22
22
17
22
22
22
20
14
22
22
22
22
22
23.26.2
2 (16)
34.97.3
21 (95.5)
20 (90.9)
2 (9.1)
38.72.1
3,159.1754.6
1 (4.5)
3 (13.6)
1 (4.5)
1 (4.5)
1 (4.5)
.001
.03
.76
.55
.25
.53
.30
.92
1.0
.77
.31
.31
.47
Data are meanstandard deviation, median (range), or n (%) unless otherwise specified.
Al-Safi et al
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with the development of postpartum eclampsia. Similarly, intrapartum use of magnesium sulfate was not
associated with the development of delayed postpartum eclampsia.
Although more common in the ante- and intrapartum periods, 44% of eclampsia occurred postpartum in one study,13 and nearly one-third of patients
developed eclamptic seizures more than 48 hours
postpartum in another.5 Thus, it is essential that
patients at risk for this condition be identified so that
prompt diagnosis of preeclampsia can be made and
measures to prevent progression instituted.
Headache was the most common presenting
symptom in our study population and was present in
over two-thirds (69.1%) of the patients. Furthermore,
we found that all of our patients (100%) admitted with
postpartum eclampsia presented with prodromal
symptoms, a rate slightly higher than the 91% reported in a previous study.14 This stresses the importance of evaluating postpartum patients carefully for
the signs and symptoms enumerated previously, especially when they are associated with elevated blood
pressures. Given that many patients will be seen in the
emergency department, as most of our patients were,
it is important for emergency department physicians
to have a high index of suspicion for postpartum
preeclampsia including the early involvement of obstetric staff in the care of such patients.
At the present time, there are no data to suggest
that the pathology of preeclampsia in the postpartum
period is different from those that occur in the antepartum and the peripartum periods. In addition,
laboratory values were no different between those
who developed eclampsia and those who did not;
therefore, the findings of normal laboratory values
should not preclude the use magnesium sulfate prophylaxis for seizure prophylaxis. One way to avoid
complications of eclampsia is to continue to educate
all patients and our emergency department colleagues
not to ignore the symptoms, signs, and the possibility
of preeclampsia or its progression. This should take
place before patients are discharged from the hospital
and should include verbal instructions and a printed
instruction sheet.14 Patients should be informed that
they may be at risk for preeclampsia or eclampsia up
to 6 weeks after delivery.
In our study, 90% of those who developed eclampsia presented within 7 days of being discharged in our
study. Two other patients that developed eclampsia did
so on the 11th and 12th days after they were discharged
from the hospital. Whether active postpartum surveillance at home for these eclamptic patients for at least 1
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Al-Safi et al
week after discharge might have prevented the development of eclampsia is an intriguing question.
Several limitations of our study must be acknowledged. First, this was a retrospective cohort study and
some results did not include all of the participants
because of missing data. Although we attempted a
comprehensive review, we may not have identified all
patients with delayed postpartum preeclampsia because mild forms of the disease may have resolved
spontaneously without patients seeking hospital care.
In addition, some of our patients may have sought
care elsewhere rather than at our institution. Furthermore, asymptomatic patients with a history of chronic
hypertension who presented with atypical symptoms
may have been discharged by emergency department
physicians with adjustment of their blood pressure
medication(s) without work-up to determine whether
they had postpartum preeclampsia superimposed on
chronic hypertension. Lastly, the lack of association
between antecedent hypertension, preeclampsia, renal
disease, and diabetes and delayed postpartum eclampsia
may have been the result of a type 2 error. However, the
data for those with history of gestational hypertension
and renal disease show little evidence of trends that
might achieve statistical significance in a larger sample
size. A larger data set may show that patients with
diabetes and chronic hypertension are less likely to
develop delayed postpartum eclampsia.
In summary, we found that younger women are at
a higher risk for eclamptic seizures in the late postpartum period and that the overwhelming majority of
seizures occur within 7 days of postpartum hospital
discharge. Education about the possibility of delayed
postpartum preeclampsia and eclampsia should occur
after delivery whether or not a patient develops hypertensive disease before discharge from the hospital.
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