An atypical neurological clue in preeclampsia–eclampsia syndrome: A case report

Dear Sir, Preeclampsia is typically characterized by new-onset hypertension and proteinuria in pregnancy. In severe cases, it is associated with the new onset of convulsions that are classically called eclampsia. Eclampsia is characterized by new-onset generalized tonic–clonic seizures in a previously normotensive pregnant woman with no other known neurological causes. 1 Preeclampsia–eclampsia complex is observed in around 1 in 20 pregnancies. 2 Atypical presentations of preeclampsia and eclampsia are rare and can add to the dilemma during management, especially regarding the timing and mode of termination of pregnancy. 3 A 28-year-old G3P0A2 woman with two previous first-trimester spontaneous abortions, previously normotensive and non-epileptic, presented at 34 + 3 weeks gestation with new-onset hypertension (blood pressure BP: 170/110 mmHg), headache, and nausea. She had no previous history of seizures. While receiving intravenous labetalol for blood pressure control, she experienced vomiting and sudden, isolated jerky movements over her abdomen that lasted for 1 min, without any limb involvement, loss of consciousness, or post-ictal confusion Video 1. The patient provided a history of similar abnormal jerky movements of the abdomen that subsided after a few minutes before reaching the hospital. Given her high BP and atypical neurological symptoms, magnesium sulphate (Dhaka regimen) was initiated for seizure prophylaxis. No further abnormal movements occurred thereafter. Blood pressure remained elevated, requiring escalation of antihypertensives (oral labetalol and nifedipine). Magnetic resonance imaging (MRI) brain revealed posterior reversible encephalopathy syndrome (PRES), supporting the diagnosis of atypical eclampsia. In addition, she was a known case of idiopathic thrombocytopenic purpura (ITP) on azathioprine, steroids, and unfractionated heparin. Obstetric history included high uterine artery Doppler pulsatility index in early pregnancy (on aspirin since then). Ultrasound revealed oligohydramnios, fetal growth restriction, and abnormal cerebroplacental ratio (CPR = 1). Given the impending eclampsia and fetal concerns, she underwent emergency cesarean section after steroid cover and withholding heparin appropriately. A healthy baby was delivered with good APGAR scores (standardized assessment using baby’s color, heart rate, reflexes, muscle tone, and respiration). Postoperatively, the patient remained stable with no recurrence of neurological symptoms. She was discharged on antihypertensives without complications such as HELLP (complication of preeclampsia characterised by hemolysis, elevated liver enzymes and low platelets), disseminated intravascular coagulopathy, or organ dysfunction. "href": "Single Video Player", "role": "media-player-id", "content-type": "play-in-place", "position": "float", "orientation": "portrait", "label": "Video 1", "caption": "", "object-id": {"pub-id-type": "doi", "id": "", "pub-id-type": "other", "content-type": "media-stream-id", "id": "1₈52nt03q", "pub-id-type": "other", "content-type": "media-source", "id": "Kaltura"} Atypical presentations of preeclampsia and eclampsia are on the increase, 4 and we hereby report a case of focal seizure observed over the abdomen, detected for the first time during pregnancy in a previously normotensive and non-epileptic patient. There was a sudden onset of high BP and abnormal movement (focal seizure) over the abdomen without any preceding hypertension/preeclampsia/proteinuria. Abnormal abdominal movements were unlike the usual tonic–clonic generalized seizures of the upper or lower limbs described in eclampsia. 5 We could not find any published literature regarding abdominal myoclonic seizures in pregnancy. In addition, abdominal muscle involvement or focal seizures should be observed and may be missed if not observed keenly. In our case, the patient had abdominal myoclonic jerky movements for a minute, during which the upper and lower extremities were normal, and the patient had no signs of uprolling of eyes and deviation of the angle of mouth, which may be typically observed in a case of eclampsia. Early termination of pregnancy and magnesium sulphate seizure prophylaxis helped us to avoid further complications. Atypical preeclampsia–eclampsia complex can be life-threatening to the mother and fetus and warrants early termination of pregnancy to prevent maternal and fetal morbidity and mortality. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. The patient understand that name and initials will not be published and due efforts will be made to conceal identity. Acknowledgment The authors wish to acknowledge the support received from the administration, staff, and residents of the Department of Obstetrics and Gynecology, AIIMS, Mangalagiri. Author’s contribution A. Research project: Conception: Vijayan Sharmila, Kavitha Garkapati Organization: Vijayan Sharmila, Olivia M. Jacob, Kavitha Garkapati Execution: Vijayan Sharmila, Olivia M. Jacob, Kavitha Garkapati B. Statistical analysis: Design: Execution: Review and Critique: C. Manuscript preparation: Writing of the first draft: Olivia M. Jacob Review and Critique: Ethical compliance statement We confirm that we have read the journal’s position on issues involved in ethical publication and affirm that this work is consistent with those guidelines. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.