Bergman Lina, Hannsberger Daniel, Schell Sonja, Imberg Henrik, Langenegger Eduard, Moodley Ashley, Pitcher Richard, Griffith-Richards Stephanie, Herrock Owen, Hastie Roxanne, Walker Susan P, Tong Stephen, Wikström Johan, Cluver Catherine
Department of Obstetrics and Gynecology, Stellenbosch University, Cape Town, South Africa; Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden; Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
Department of Surgical Sciences and Neuroradiology Uppsala University, Uppsala, Sweden.
Am J Obstet Gynecol. 2025 Jun;232(6):550.e1-550.e14. doi: 10.1016/j.ajog.2024.10.034. Epub 2024 Oct 30.
Eclampsia is a serious pregnancy complication and is associated with cerebral edema and infarctions. However, the underlying pathophysiology of eclampsia remains poorly explored.
This study aimed to assess the pathophysiology of eclampsia using specialized magnetic resonance imaging to measure diffusion, perfusion, and vasospasm.
This was a cross-sectional study recruiting consecutive pregnant women between April 2018 and November 2021 at Tygerberg Hospital, Cape Town, South Africa. Women with eclampsia, preeclampsia, and normotensive pregnancies who underwent magnetic resonance imaging after birth were recruited. The main outcome measures were cerebral infarcts, edema, and perfusion using intravoxel incoherent motion imaging and vasospasm using magnetic resonance imaging angiography. The imaging protocol was established before inclusion.
Here, 49 women with eclampsia, 20 women with preeclampsia, and 10 normotensive women were included. Cerebral infarcts were identified in 34% of women with eclampsia and 5% of women with preeclampsia (risk difference, 0.29; 95% confidence interval, 0.06-0.52; P=.012). However, no cerebral infarct was identified in normotensive controls. Women with eclampsia were more likely to have vasogenic cerebral edema than women with preeclampsia (80% vs 20%, respectively; risk difference, 0.60; 95% confidence interval, 0.34-0.85; P<.001) and normotensive women (risk difference, 0.80; 95% confidence interval, 0.47-1.00; P<.001). Diffusion was increased in women with eclampsia in the parieto-occipital white matter (mean difference, 0.02 × 10 mm/s; 95% confidence interval, 0.00-0.05; P=.045) and caudate nucleus (mean difference, 0.02 × 10 mm/s; 95% confidence interval, 0.00-0.04; P=.033) compared with women with preeclampsia. In addition, diffusion was increased in women with eclampsia in the frontal white matter (mean difference, 0.07 × 10 mm/s; 95% confidence interval, 0.02-0.12; P=.012), parieto-occipital white matter (mean difference, 0.05 × 10 mm/s; 95% confidence interval, 0.02-0.07; P=.03), and caudate nucleus (mean difference, 0.04 × 10 mm/s; 95% confidence interval, 0.00-0.07; P=.028) compared with normotensive women. Perfusion was decreased in edematous regions. Hypoperfusion was present in the caudate nucleus in eclampsia (mean difference, -0.17 × 10 mm/s; 95% confidence interval, -0.27 to -0.06; P=.003) compared with preeclampsia. There was no sign of hyperperfusion. Vasospasm was present in 18% of women with eclampsia and 6% of women with preeclampsia. However, no vasospasm was present in the controls.
Eclampsia was associated with cerebral infarcts, vasogenic cerebral edema, vasospasm, and decreased perfusion, which are not usually evident on standard clinical imaging. This finding may explain why some patients have cerebral symptoms and signs despite having normal conventional imaging.
子痫是一种严重的妊娠并发症，与脑水肿和梗死有关。然而，子痫的潜在病理生理学仍未得到充分探索。
本研究旨在使用专门的磁共振成像来测量扩散、灌注和血管痉挛，以评估子痫的病理生理学。
这是一项横断面研究，于2018年4月至2021年11月在南非开普敦泰格伯格医院招募连续的孕妇。招募了产后接受磁共振成像的子痫、先兆子痫和血压正常的孕妇。主要结局指标是使用体素内不相干运动成像测量的脑梗死、水肿和灌注，以及使用磁共振血管造影测量的血管痉挛。成像方案在纳入研究前确定。
本研究纳入了49例子痫患者、20例先兆子痫患者和10例血压正常的女性。34%的子痫患者和5%的先兆子痫患者被发现有脑梗死（风险差异为0.29；95%置信区间为0.06 - 0.52；P = 0.012）。然而，血压正常的对照组中未发现脑梗死。与先兆子痫患者相比，子痫患者更易发生血管源性脑水肿（分别为80%和20%；风险差异为0.60；95%置信区间为0.34 - 0.85；P < 0.001），与血压正常的女性相比也是如此（风险差异为0.80；95%置信区间为0.47 - 1.00；P < 0.001）。与先兆子痫患者相比，子痫患者顶枕叶白质（平均差异为0.02×10⁻³mm²/s；95%置信区间为0.00 - 0.05；P = 0.045）和尾状核（平均差异为0.02×10⁻³mm²/s；95%置信区间为0.00 - 0.04；P = 0.033）的扩散增加。此外，与血压正常的女性相比，子痫患者额叶白质（平均差异为0.07×10⁻³mm²/s；95%置信区间为0.02 - 0.12；P = 0.012）、顶枕叶白质（平均差异为0.05×10⁻³mm²/s；9�%置信区间为0.02 - 0.07；P = 0.03）和尾状核（平均差异为0.04×10⁻³mm²/s；95%置信区间为0.00 - 0.07；P = 0.028）的扩散增加。水肿区域的灌注减少。与先兆子痫相比，子痫患者尾状核存在灌注不足（平均差异为 - 0.17×10⁻³mm²/s；9�%置信区间为 - 0.27至 - 0.06；P = 0.003）。没有高灌注的迹象。18%的子痫患者和6%的先兆子痫患者存在血管痉挛。然而，对照组中没有血管痉挛。
子痫与脑梗死、血管源性脑水肿、血管痉挛和灌注减少有关，这些在标准临床成像中通常不明显。这一发现可能解释了为什么一些患者尽管传统成像正常却仍有脑部症状和体征。
