Importance of considering the possibility of pre-eclampsia/eclampsia even if the woman has not had antepartum or intrapartum pre-eclampsia

• Pre-eclampsia and eclampsia may both present for the first time after delivery [Mathew et al, 2003; Duley et al, 2006].
• In a study of 23 women with late postpartum eclampsia, only five had been previously diagnosed with pre-eclampsia [Chames et al, 2002].
• A prospective descriptive study of every case of eclampsia in the UK in 1992 found that 44% of cases occurred postpartum [Douglas and Redman, 1994].

Possibility of presenting up to 4 weeks after delivery

• A multicentre, retrospective analysis of data involving 89 women with eclampsia found that 29 women had postpartum eclampsia and 23 (79%) of these women had late-onset eclampsia (developing more than 48 hours after delivery) [Chames et al, 2002].
• In a multicentre, retrospective analysis of 3988 women diagnosed with pre-eclampsia, 229 (5.7%) were diagnosed during the postpartum period [Matthys et al, 2004]. Of these, 151 women were studied and 29 (16%) developed eclampsia. The average time from delivery to readmission was 7 days and ranged from 1 day to 24 days.

Importance of considering the possibility of eclampsia in any woman who has a seizure within 4 weeks of delivery

• Symptoms and signs of pre-eclampsia usually precede eclampsia, but not always, which can make diagnosis difficult.
• Case studies of three women report eclampsia developing without preceding hypertension or proteinuria [Dziewas et al, 2002].

Importance of considering pre-eclampsia if the woman develops a headache, vision symptoms, abdominal pain, or typical symptoms

• In a multicentre, retrospective analysis of data involving 89 women with eclampsia, 29 women had postpartum eclampsia, and 21 of these had at least one prodromal symptom that heralded the onset of eclampsia: 20 women had headache, 10 women had vision changes, 5 women had nausea or vomiting, and 2 women had epigastric pain [Chames et al, 2002].
• Case studies have shown that acute severe headache, vision disturbances, and gastrointestinal symptoms may herald impending eclampsia [Veltkamp et al, 2000; Dziewas et al, 2002; Mathew et al, 2003; Graeber et al, 2005; Munjuluri et al, 2005].
• A case-control study of 53 women admitted in the postpartum period found that headache, a blind spot, cortical blindness, malaise, nausea, and vomiting were more likely to occur in women with postpartum severe pre-eclampsia or eclampsia than in women with intrapartum pre-eclampsia [Atterbury et al, 1998].

Immediate referral to hospital

• This is accepted good clinical practice.