Occasionally, women have an atypical syndrome in which severe preeclampsia-eclampsia persists despite delivery. Martin and colleagues (1995) described 18 such women whom they encountered during a 10-year period. hey advocate single or multiple plasma exchange for these women. In some cases, 3 L of plasma was exchanged three times-a 36-to 45-donor unit exposure for each patient-before a response was forthcoming. Others have described plasma exchange performed in postpartum women with HELLP syndrome (Forster, 2002; Obeidat, 2002). In all of these cases, however, the distinction between HELLP syndrome and thrombotic thrombocytopenic purpura or hemolytic uremic syndrome was not clear (Tsai, 2016).
In our experiences with more than 50,000 women with gestational hypertension among nearly 450,000 pregnancies cared for at Parkland Hospital through 2017, we have encountered very few women with persistent postpartum hypertension, thrombocytopenia, and renal dysfunction who were diagnosed as having a thrombotic micro angiopathy (Dashe, 1998). hese latter syndromes complicating pregnancy were reviewed by Martin (2008) and George (2013) and their colleagues, who conclude that a rapid diagnostic test for ADAMTS-13 enzyme activity might be helpful to diferentiate most of these syndromes.
his is another cause of persistent hypertension, "thunderclap" headaches, seizures, and central nervous system indings. It is a form of postpartum angiopathy. Reversible cerebral vasoconstriction syndrome is characterized by difuse segmental constriction of cerebral arteries and may be associated with ischemic and hemorrhagic strokes. his syndrome has several inciting causes that include pregnancy, and particularly preeclampsia (Ducros, 2012). It is more common in women, and in some cases, vasoconstriction may be so severe as to cause cerebral ischemia and infarction. he appropriate management is not known at this time (Edlow, 2013).
Defective remodeling of the spiral arteries in some placentas is posited as a cause of at least one preeclampsia phenotype. Specifically, lack of deep placentation is linked with preeclampsia, placental abruption, fetal-growth restriction, and preterm birth (Wikstrom, 2011). With this type of "overlap syndrome," hypertensive disorders may serve as markers for subsequent preterm labor and fetal-growth restriction. For example, even in subsequent nonhypertensive pregnancies, women who had preterm preeclampsia are at higher risk for preterm birth and growth-restricted neonates (Bramham, 2011; Connealy, 2014; Palatnik, 2016).
In addition, women who have had either gestational hypertension or preeclampsia risk developing hypertension in future pregnancies (Lykke, 2009b). Generally, the earlier preeclampsia is diagnosed during the index pregnancy, the greater the likelihood of recurrence. And, the recurrence risk for preeclampsia is elevated further in women with the metabolic syndrome (Stekkinger, 2015). Sibai and colleagues (1986, 1991) found that nulliparas diagnosed with preeclampsia before 30 weeks had a recurrence risk as high as 40 percent during a subsequent pregnancy. In a prospective study of 500 women previously delivered for preeclampsia at 37 weeks, the recurrence rate in a subsequent gestation was 23 percent (Bramham, 2011).