Cerebral Manifestations of Preeclampsia

This thesis intends to describe and explain the course of clinical neurophysiological and neuropsychological parameters in patients with hypertensive disorders in pregnancy. We aimed to improve knowledge on cerebral pathophysiological mechanisms of preeclampsia related to signs and symptoms and to explore whether measuring features of these mechanisms with neurophysiological techniques can help to optimize timing of delivery in order to minimize maternal morbidity and maximize neonatal outcome. We compared EEG findings during pregnancy and postpartum in women with normotensive pregnancies and pregnancies complicated by hypertensive disorders. We concluded that women with severe PE show more EEG abnormalities and have impaired mental wellbeing postpartum. We present a study on visual evoked potentials (VEPs). The objective of this study was to compare neurophysiological changes in women with hypertensive disorders of pregnancy using VEPs. We defined reference values for normotensive pregnant women. We concluded in this study that normotensive pregnant women show neurophysiological adaptation to pregnancy of their visual cortex, which seemed to be absent in women with hypertensive disorders of pregnancy. Using Doppler ultrasound we estimated zero flow pressure (ZFP) and cerebral perfusion pressure (CPP) using simultaneously obtained arterial blood pressure and middle cerebral artery blood flow velocity in women with preeclampsia and healthy pregnant controls. Mean ± SD ZFP was lower in patients than in controls whereas CPP was considerably higher, as was the cerebral flow index. In normotensive pregnant women the patellar reflex was cross-sectionally recorded using surface electromyography at four time points during pregnancy and 6-8 weeks postpartum. Latency and amplitude of the compound muscle action potential during normotensive pregnancies showed no changes compared to the non-pregnant state during reproductive age. Latency of the compound muscle action potential was increased in pregnancies with severe preeclampsia compared to normotensive pregnancies. Postpartum these differences had disappeared. Women after PE more often complain of cognitive disturbances compared to women after uncomplicated pregnancies. We performed a study with a neuropsychological test battery in women who have had severe PE and women after uncomplicated normotensive pregnancies. The control group was matched for age, educational level and mode of anesthesia. The formerly pre-eclamptic women had significantly lower scores on most indices of the auditory-verbal memory test. Formerly pre-eclamptic women learned considerably fewer words than controls and recalled less after interference. No persistent differences were observed in tests for attention/concentration and executive functioning. There were no significant differences on depression and anxiety scales. The general discussion reflects on limitations in our studies. It relates findings to clinical perspectives and suggestions for future studies are made

Urodynamic evaluation of hypospadias repair

Purpose: We performed a cross-sectional evaluation of voiding in a population undergoing hypospadias repair to determine whether patients had urinary obstruction at various intervals of followup after the last operation. Materials and Methods: Of approximately 600 patients undergoing hypospadias repair at our department during a 30-year interval 175, 40 months to 66 years old were evaluated. Therefore, we created a cross-sectional study group for evaluation of voiding function. All patients had undergone the final operation for hypospadias at least 1 year previously and were toilet trained. Severity of the initial hypospadias was scored together with the operative technique. Parameters evaluated were medical history, physical examination and uroflowmetry using a rotating disk. Uroflowmetry data (maximum flow rate and voided volume) were plotted in age-related nomograms in 4 different age groups: less than 8 (28 patients), 9 to 14 (18), 15 to 21 (39) and more than 21 (91) years old. All flow charts were evaluated by 2 of us (J. F. A. v. d. W. and E. B.). Results: The severity of initial disease was grade 1 in 30% of the patients, grade 2 in 57%, grade 3 in 10%, grade 4 in 2% and unknown in 2%. The operative technique performed was a van der Meulen repair in 113 patients (65%), a combined Byars-Denis Browne repair in 56 (32%) and miscellaneous in 6 (3%). According to the uroflowmetry nomograms there was a tendency for an increased number of patients to have a normal maximum flow rate with increasing age. A total of 14 patients had a flow curve that suggested distal urethra obstruction and none was symptomatic. There was no difference in uroflowmetry characteristics regarding the operative technique. Conclusions: No difference in uroflowmetry could be established among the operations. There seemed to be a tendency towards improvement in uroflowmetry with increasing followup. There was no direct relationship between low maximum flow rates and clinical apparent obstruction

Electroencephalography in normotensive and hypertensive pregnancies and subsequent quality of life

Objectives: To compare electroencephalography (EEG) findings during pregnancy and postpartum in women with normotensive pregnancies and pregnancies complicated by hypertensive disorders. Also the health related quality of life postpartum was related to these EEG findings. Materials and Methods: An observational case-control study in a university hospital in the Netherlands. Twenty-nine normotensive and 58 hypertensive pregnant women were included. EEG's were recorded on several occasions during pregnancy and 6-8 weeks postpartum. Postpartum, the women filled out health related quality of life questionnaires. Main outcome measures were qualitative and quantitative assessments on EEG, multidimensional fatigue inventory, Short Form (36) Health Survey and EuroQol visual analogue scale. Results: In women with severe preeclampsia significantly lower alpha peak frequency, more delta and theta activity bilaterally and a higher EEG Sum Score were seen. Postpartum, these women showed impaired mental health, mental fatigue and social functioning, which could not be related to the EEG findings. Conclusions: Severe preeclamptic patients show more EEG abnormalities and have impaired mental wellbeing postpartum, but these findings are not correlated

Temporizing management vs immediate delivery in early-onset severe preeclampsia between 28 and 34 weeks of gestation (TOTEM study) : An open-label randomized controlled trial

Peer reviewedPublisher PD

Electroencephalography During Normotensive and Hypertensive Pregnancy: A Systematic Review

The objective of this review was to evaluate the available medical literature concerning the electroencephalogram (EEG) during hypertensive disorders of pregnancy. All articles found during a MEDLINE and Embase database search on the subject of EEG differences associated with hypertensive disorders in pregnancy were screened for eligibility. In all, 22 articles which describe the EEG during preeclampsia (PE)/eclampsia were retrieved. Abnormal EEG findings were observed in the majority of the preeclamptic/eclamptic patients, consisting of slow waves most frequently localized in the occipital lobe, as well as spike discharges. The EEG abnormalities in PE/eclampsia were reversible in the majority of the cases. We conclude that these described abnormalities may be interpreted as a warning sign of deterioration of brain function in PE/eclampsia. However, some caution regarding this conclusion is advised because most of the retrieved articles were published in the 1950s and 1960s, and were not consistent with current clinical guidelines or medical terminology. Further research is needed to establish the clinical value of implementing EEGs in the assessment of the preeclamptic/eclamptic patient. Target Audience: Obstetricians & Gynecologists, Neurologists, Family Physicians Learning Objectives: After completion of this educational activity, the obstetrician, gynecologist and neurologist should be better able to evaluate whether the EEG is normal for pregnancy; distinguish EEG abnormalities in hypertensive disorders in pregnancy, and assess the value of EEG abnormalities in preeclampsia (PE)/eclampsia for the detection of early signs of ischemia

Impaired maternal cognitive functioning after pregnancies complicated by severe pre-eclampsia: a pilot case-control study

Background. Pre-eclampsia is the most significant cause of neurological symptoms in pregnancy. Neurological symptoms may persist even after pregnancy. Somatic symptoms of pre-eclampsia, such as hypertension and proteinuria, generally disappear after delivery. However, formerly pre-eclamptic women more often complain of cognitive disturbances compared to women after uncomplicated pregnancies. Methods. Three to eight months postpartum, a neuropsychological test battery was performed in 10 former severely pre-eclamptic women (according to the guidelines of the American College Obstetricians and Gynecologists) and 10 women after uncomplicated normotensive pregnancies. The control group was matched for age, educational level and mode of anesthesia. All women delivered by cesarean section either under general or regional anesthesia. Tests were performed for premorbid intelligence, short- and long-term memory, attention, concentration, executive functions, visual and spatial abilities. Anxiety and depression levels were measured. Results. The formerly pre-eclamptic women had significantly lower scores on most indices of the auditory-verbal memory test. Formerly pre-eclamptic patients learned considerably fewer words than controls and recalled less after interference. Both case and control group did not differ in age, parity or level of education. There were no differences in the level of intellectual functioning and language tests, such as naming and word fluency. No persistent differences were observed in tests for attention/concentration and executive functioning. There were no significant differences on depression and anxiety scales. Conclusions. Maternal memory seems to be impaired after pregnancies complicated by severe pre-eclampsia. This effect cannot be attributed to depression and/or anxiety or method of anesthesia

Electromyographically recorded patellar reflex in normotensive pregnant women and patients with preeclampsia

ObjectiveTo define reference values of the patellar reflex in normotensive pregnant and postpartum women and to compare these with values in women with preeclampsia. DesignObservational study. SettingUniversity teaching hospital in the Netherlands. PopulationNormotensive non-pregnant women, pregnant women and preeclamptic women. MethodsIn normotensive pregnant women the patellar reflex was cross-sectionally recorded using surface electromyography at four time points during pregnancy and six to eight weeks postpartum. In non-pregnant normotensive women this was recorded once. Preeclamptic women were recorded during pregnancy and postpartum. Main outcome measuresLatency and amplitude of the compound muscle action potential of the patellar reflex. ResultsLatency and amplitude of the compound muscle action potential during normotensive pregnancies showed no changes compared with the non-pregnant state during reproductive age. Latency of the compound muscle action potential was increased in pregnancies with severe preeclampsia compared with normotensive pregnancies. These differences disappeared postpartum. ConclusionsDuring pregnancy, the patellar reflex can be assessed using surface electromyography. Latency and amplitude show no changes during normotensive pregnancies and are no different from the postpartum or non-pregnant values. In severely preeclamptic women, latency is increased. The clinical value of this is limited

Cerebral perfusion pressure in women with preeclampsia is elevated even after treatment of elevated blood pressure

Cerebral perfusion pressure (CPP) is elevated in preeclampsia, and may predispose to cerebrovascular complications and progression to eclampsia. We estimated zero flow pressure (ZFP) and CPP using simultaneously obtained arterial blood pressure and middle cerebral artery blood flow velocity in 10 women with preeclampsia, all treated with methyldopa with or without nifedipine, and 18 healthy pregnant controls. Mean +/- SD ZFP was lower in women with preeclampsia than in controls (16.8 +/- 10.9 vs. 31.7 +/- 15.0mmHg, p=0.01) whereas CPP was considerably higher (82.3 +/- 17.7 vs. 55.0 +/- 11.7mmHg, p<0.001), as was the cerebral flow index (41.9 +/- 18.0 vs. 25.6 +/- 11.2, p=0.02). There was a significant correlation between blood pressure and CPP in women with preeclampsia, but not in controls. Women with preeclampsia may have an increased cerebral perfusion due to a reduced ZFP and increased CPP despite treatment with antihypertensive medication. More rigorous antihypertensive therapy, aimed at reducing CPP, could result in a decrease in cerebral complications in women with preeclampsia

Electroencephalography in Normotensive and Hypertensive Pregnancies and Subsequent Quality of Life

Objectives To compare electroencephalography (EEG) findings during pregnancy and postpartum in women with normotensive pregnancies and pregnancies complicated by hypertensive disorders. Also the health related quality of life postpartum was related to these EEG findings. Materials and Methods An observational case-control study in a university hospital in the Netherlands. Twenty-nine normotensive and 58 hypertensive pregnant women were included. EEG's were recorded on several occasions during pregnancy and 6-8 weeks postpartum. Postpartum, the women filled out health related quality of life questionnaires. Main outcome measures were qualitative and quantitative assessments on EEG, multidimensional fatigue inventory, Short Form (36) Health Survey and EuroQoL visual analogue scale. Results In women with severe preeclampsia significantly lower alpha peak frequency, more delta and theta activity bilaterally and a higher EEG Sum Score were seen. Postpartum, these women showed impaired mental health, mental fatigue and social functioning, which could not be related to the EEG findings. Conclusions Severe preeclamptic patients show more EEG abnormalities and have impaired mental wellbeing postpartum, but these findings are not correlated