[Pre-eclampsia-eclampsia: a deferred medical problem].

Pregnancy-associated hypertension is a health problem in Mexico due to its high frequency of morbidity and mortality in mother and fetus as well. Research in this area has been restrained by limitations upon epidemiologic information, unknown etiology and the somewhat easy resolution provided when pregnancy is interrupted. We have reviewed contributions made in our country and up-to-date management concepts.

Complexity and complicity in eclampsia: barriers or bridges?

The aetiology of pre-eclampsia-eclampsia remains largely unclarified, despite over 100 years of systematic study. The assumption that the triggering event is linear and amenable to reductionist techniques has characterized these efforts. The main purpose of this paper is to show that complexity and complicity characterize most pathophysiological processes in pre-eclampsia-eclampsia, a situation suggesting that similar mechanisms must exist at the origin of the disease.

Recurrent eclampsia. Clinical data, morbidity and pathogenic considerations.

The analysis of 24 patients with recurrent eclampsia showed that (i) the first attack complicated the second or later pregnancies in nine cases, (ii) there was one or more apparently normal gestations before the second eclampsia in one-third of the patients, (iii) total maternal and neonatal mortality were twice those of general eclampsia, (iv) four autopsies revealed chronic pyelonephritis and cardiac hypertrophy in addition to the characteristic glomerular and hepatic lesions, (v) all six deaths were due to brain damage, and (vi) chronic hypertension was diagnosed in half of the survivors. The results of this study demonstrate that (i) one or several normal pregnancies after eclampsia do not cancel the possibility of another attack, (ii) recurrent eclampsia is an extremely severe event even though most clinical data are no different from general eclampsia, (iii) underlying diseases seem to play a decisive role, and (iv) some aspects of recurrent eclampsia challenge single cause pathogenic mechanisms.

Main clinical types and subtypes of eclampsia.

Eclampsia has been traditionally divided in three types: antepartum, intrapartum, and postpartum. Several authors consider two more subtypes, early cases and intercurrent eclampsia. The clinical analysis of 990 patients with eclampsia divided according to such classification revealed numerous significant differences that could give grounds for the interpretation of conflicting results in medical research.

Eclampsia and fetal sex.

The study of the possible importance of the sex of the fetus on the frequency and clinical characteristics of 777 singleton pregnancies complicated by antepartum eclampsia showed that; (1) the male to female ratio for the total group was 1.23/1, (2) this figure was 1.27/1 in first pregnancies and 1.

Eclampsia in twin pregnancy.

A clinical analysis of 37 cases of twin pregnancy complicated by eclampsia showed that: (1) the incidence of twins in the total 1,030 cases of eclampsia was three times the figure in the general population, (2) the maternal mortality was slightly higher and perinatal mortality slightly lower than in unselected eclamptic patients, (3) patients with postpartum eclampsia showed significant differences in comparison with antepartum and intrapartum cases, (4) perinatal and maternal mortality were lower in cases delivered by cesarean section, (5) perinatal mortality was significantly higher in male fetuses, and (6) five of the six maternal deaths occurred in cases of male twins. In addition, the data suggest the presence of a reciprocal negative influence between maternal eclampsia and male twins and that this type of eclampsia may be the best example of essential preeclampsia.

Eclampsia and placental abruption: basic patterns, management and morbidity.

The clinical analysis of 46 cases of abruptio placentae complicating eclampsia showed that, (1) the severity of the eclamptic symptoms influenced the extension of the placental separation, (2) older and multiparous women had more complications, larger placental separations and higher mortality, (3) there were ten maternal deaths due to the additive effects of various complications, (4) total perinatal mortality was 44.7% and it was 40.5% for fetuses above 1000 g, (5) optimum timing of delivery by cesarean operation offered slightly better prognosis, even in cases with antepartum fetal death, (6) the dominant factor for morbidity was the stage reached by the combined pathology before receiving qualified medical care, and (7) the wide variability of these cases suggested that the basis for the complete management should be a series of sound and individually tailored decisions to be carried out in a reasonably short time.

Complicated eclampsia: fifteen years' experience in a referral medical center.

The statistical study of a large number of eclamptic patients (n = 704), divided into five successive 3-year periods, was undertaken at the Hospital de Gineco-Obstetricia No. 2 del Centro Médico Nacional in Mexico City in orders to detect significant changes in therapeutic results and/or in the basic character of the disease, as it occurs in a large referral medical complex. The following variables were studied: maternal and perinatal deaths, obstetric profile, main clinical data of the eclamptic episode, frequency of cesarean operation, timing of delivery after admission, main therapeutic changes, frequency of complications in survivors of ante- and intrapartum eclampsia, and cause of death with associated complications.

Uterine and peripheral hematologic profiles in molar pregnancy.

The potential differences in hematologic profiles of blood samples drawn simultaneously from the right utero-ovarian vein and from the upper extremity were investigated in four patients with uncomplicated molar pregnancy in stable obstetric conditions. The patients had undergone no previous chemotherapy and were scheduled for total abdominal hysterectomies. The dominant abnormalities in uterine venous blood were prolongation of thrombin time; shortening of activated partial thromboplastin time; positive protamine sulfate test; and increase in coagulation factors II and VII, with a tendency to low values in factor V.

Coagulation and fibrinolysis in molar pregnancy.

Coagulation and fibrinolysis tests were performed in 14 patients with hydatidiform mole before any significant therapy was given and again, after evacuation of the mole, in eight instances. The results were compared with those found in a group of ten volunteers with normal pregnancies. The most frequent abnormalities in the problem cases were a shortening of the partial thromboplastin time and a prolongation of the thrombin time.

Abnormal coagulation and fibrinolysis in eclampsia. A clinical and laboratory correlation study.

This study evaluated the existence of abnormally increased coagulation and fibrinolysis in 33 severely toxemic and eclamptic women by means of a combined hemotologic profile with clinical and morphologic correlations. The dominant findings were: different degrees of thrombocytopenia, abnormal levels of blood fibrinogen, prolonged thrombin time, and positive protamine sulfate test. Altered activated partial thromboplastin time and positive ethanol gelation test were slightly less frequent, and only few cases showed prolonged prothrombin time or early lysis of euglobulins.

Maternal mortality rates in eclampsia.

This study evaluates the dominant factors that influence the course of eclampsia toward a lethal outcome by means of statistical analysis of various clinical, laboratory, and morphologic data of 365 cases of toxemia with convulsions, that included 49 deaths and 33 autopsies, registered during a 9 year period. This communication suggests that the death of eclamptic patients resulted from a combination of several factors that showed a very wide individual variation. Since advancing age of the mother was associated with a high incidence of coincidental renal and vascular diseases, this was the most clearly influential factor.

Factors that influence maternal mortality in eclampsia.

Three hundred sixty-five cases of eclampsia, including 49 women who died, were analyzed in order to determine factors which led to death. The age of the patient was clearly the most important factor. Older women tended to have coexisting renal and vascular disease and also manifested more hematologic abnormalities, in particular, disseminated intravascular coagulation.