TO THE EDITOR: Although preeclampsi...

TO THE EDITOR: Although preeclampsia is typically diagnosed in the prenatal period, we would like to describe an unusual case of late-onset eclampsia presenting postpartum as unlooked for bilateral cortical blindness.

The patient was a healthy, 21-year-old black woman, gravida three para the same with a previous normal pregnancy and no history of hypertension or preeclampsia. She had an unremarkable prenatal course and her life-blood pressure prenatally ranged from 98/62 mm Hg to 130/80 mm Hg undivided week before delivery. Urine protein was naught or trace at all visits. She delivered a healthy 2670 g (5 lb 8 oz) male infant at season Blood pressures immediately postpartum were mainly 120s to 130s/60s to 70 mm Hg with occasional constraining forces of 140 to 150/80 to 90 mm Hg

Eight days after delivery, the patient awoke with a methodical bilateral frontal headache and blurry vision. throughout several hours, this progressed to acute bilateral cortical blindness. Initial evaluation showed children pressure of 169/99 but without proteinuria. after 24-hour urine collection showed 028 grams protein. Comput axial tomography of the brain demonstrated bilateral cheap attenuation lesions in the cerebral hemispheres; magnetic resonance imaging revealed diffuse altered T2 signals in a posterior distribution. Cerebral angiogram was normal. Twenty hours after the first brunt of symptoms the patient evolveed altered mental status and had sum of two units tonic-clonic seizures, at which point she was treated with phenytoin (Dilantin) and magnesium.

The patient's headache and vision quickly improved and according to 48 hours her vision had turn backed to 20/20 acuity. Her children pressure continued to be elevated completely through her hospital stay, at single point reaching 200/110 mm Hg Three days after admission, she was discharged family circle on metoprolol.

Preeclampsia in pregnancy is defined as new-onset elevated descendants pressure (>140/90 mm Hg) along with proteinuria after 20 weeks of gestation. (12) exact cases may progress to eclampsia characterized by dint of seizures. A multicenter review (3) of pre-eclampsia rest up to one third of cases bring to maturityed postpartum with 80 percent of these occurring three to 14 days after delivery. single case report (4) describes attack 26 days after delivery.

Although visual changes as it is as blurry vision or scotoma are customary they may be more typical of late-onset disease. (35) the same study reported visual symptoms in 44 percent of patients with late-onset pre-eclampsia. (3) Acute cortical blindness has been estimated to arise in 1 to 3 percent of patients with eclampsia, although a review of 15 cases noted a prevalence of 15 percent (5) Our patient was similar to patients in that case series including the transient nature of visual los (four hours to eight days in their review) and mental status changes (three of their 15 patients) if it be not that had minimal urine protein and relatively mild hypertension forward initial presentation.

Because 90 percent of women presenting with late postpartum preeclampsia have a headache and bring to a period to one half have a type of visual disturbance, physicians providing obstetric care should be alert for these symptoms as an unusual presentation of this disease. This case demonstrates that preeclampsia is les general in multiparous patients, but it can be inexorable when it develops.

KATHERINE J GOLD MD MSW

Dept of Family Medicine University of Michigan 1500 E Medical Center Dr Rm L2003 receptacle 0239 Ann Arbor, MI 48109-0239

CHRISTOPHER BARNES, DO

Dept of Family Medicine University of Michigan

JESSICA LALLEY, MD

Dept of Obstetrics and Gynecology University of Michigan

THOMAS L SCHWENK, MD

Dept of Family Medicine University of Michigan

REFERENCES

(1) ACOG Committee in succession Obstetric Practice. ACOG practice bulletin. Diagnosis and management of preeclampsia and eclampsia. No. 33 January 2002 American society of Obstetricians and Gynecologists. Obstet Gynecol 2002;99:159-67

(2) Lipstein H to leeward CC, Crupi RS. A existing concept of eclampsia. Am J Emerg M 2003;21:223-6

(3) Chames MC Livingston JC Ivester T Barton JR Sibai BM Late postpartum eclampsia: a preventable disease? Am J Obstet Gynecol 2002;186:1174-7

(4) Delefosse D Samain E Helias A, Regimbeau JM Deval B Farah E et al. Late attack of cortical blindness in a patient with chaste preeclampsia related to retained placental fragments. Anesthesiology 2003;98:261-3

(5) Cunningham FG Fernandez CO Hernandez C Blindness associated with preeclampsia and eclampsia. Am J Obstet Gynecol 1995;172:1291-8

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