Delayed diagnosis of PRES and eclampsia in a concealed pregnancy

Pre-eclampsia and eclampsia are well-known risk factors of posterior reversible encephalopathy syndrome. Early recognition and proper treatment result in complete reversibility of this disease. Concealed pregnancy obstacles a safe prenatal care and a safe planned delivery, because of latency in the diagnosis. We present a case of unrecognized posterior reversible encephalopathy syndrome, eclampsia and premature delivery due to concealed pregnancy.


Introduction
Preeclampsia (PE) remains a leading cause of maternal and perinatal mortality and morbidity. The rate of incidence varies upon the study population but generally ranges from 3% to 7% of all pregnancies [1]. When PE remains untreated, it moves towards a more serious condition known as eclampsia, Eclampsia is defined by the presence of seizures [2]. Pre-eclampsia and eclampsia are both well-known risk factors of posterior reversible encephalopathy syndrome (PRES). Early recognition and proper treatment result in complete reversibility of this disease. The risk of maternal and fetal mortality and morbidity increase in concealed pregnancies due to poor prenatal care [3]. We present a case of unrecognized posterior reversible encephalopathy syndrome, eclampsia and premature delivery due to concealed pregnancy.

Patient and observation
A 25 years old, multiparaous widow female patient with loss of consciousness and generalyzed convulsion was admitted to a hospital. She was hospitalized for the diagnosis and treatment. Her arterial blood pressure was 180/100 mmHg on admission.
Hypoalbunemia and anemia were detected in her laboratory findings and she was given albumin and erythrocyte suspensions.
Amlodipine 10 mg/day was started for hypertension. The patient was referred to us for further examination and treatment. She was concious when admitted to the emergency clinic. The patient was hospitalized by the neurology clinic with a diagnosis of hypertensive encephalopathy. Hyperintensity in bilateral parieto-occipital region and was observed in magnetic resonance imaging that was compatible with PRES ( Figure 1). Initial medical history did not reveal a delayed menstruation or pregnancy. The laboratory findings She stated that she concealed the pregnancy as it was out of wedlock. She was G2P1, and she did not remember the last menstruel period. No seizures took place after hospitalization.
Arterial blood pressure was controlled with antihypertensive (alpha metyl dopa). Magnesium sulphate was started. After 24-hours, urine protein increased to 5791 mg, arterial blood pressure elevated (160/100) and due to the onset of symptoms suggestive of severe preeclampsia such as olyguria, visual symptoms, upper abdominal pain, she was taken to operating room for an emergency cesarean section and one alive female baby in vertex presentation was delivered. With these findings, the patient was diagnosed as having HELLP syndrome and eclampsia. Although latency in the diagnosis due to concealment of pregnancy, she was treated successfully and unfortunately, the fetus died in the third day of delivery. Although she had hypoalbuminemia and hypertension, pregnancy and pre-eclampsia were not considered in the differential dignosis .

Discussion
The patient was treated for hypertension and she received albumin replacement. To investigate the etiology of convulsions and loss of consciousness she was exposed to X-ray. She concealed the pregnancy as her pregnancy was out of wedlock and feared of a possible family violence. Thus the diagnosis was delayed. Finally, during the investigations, pregnancy was realized in the renal ultrasonography. Hide of pregnancy has been implicated in potentially jeopardising prenatal care and subsequent safe planned deliveries. Nirmal et al. have founded that prematurity rates were significantly higher in the concealed pregnancy cohort. Despite the low incidence of maternal morbidity, these women should be regarded as high-risk labour due to the increased perinatal morbidity [3]. There is a maternal and fetal death due to a concealed pregnancy with placenta previa in literature [10].
In clinical practice, it is common that a pregnancy may remain unrecognized up to the end of the first trimester, especially for primiparous women who are unfamiliar with the symptoms of pregnancy [1]. However, from the point of view of obstetric practice, a pregnancy that remains un-booked in the second and third trimester is considered highly unusual and can pose a severe threat to the life and health of the child and mother involved [2].
Newborns following denied pregnancies are delivered after either late onset or total absence of antenatal care, with a presumed subsequently increased risk for neonatal outcome. For this specific group, several characteristic outcome parameters were investigated.
The data underline the elevated fetal outcome risk for newborns after denial of pregnancy. In this group, total absence or late onset of antenatal care results in a manifestation of pregnancy dependent risks. Preterm births and small for gestational age newborns, together with deaths, may be classified as at least potentially avoidable. Eclampsia, the major neurological complication of preeclampsia, is defined as a convulsive episode or any other sign of altered consciousness arising in a setting of PE, and which cannot be attributed to a pre-existing neurological condition. Delivery is the only curative treatment for PE [11].

Conclusion
A concealed pregnancy may lead to both maternal and fetal death.
Hypertension, convulsions, and proteinuria should suggest a diagnosis of eclampsia in a young woman. And in a case of suspected pregnancy, an initial ultrasonographic examination should be performed prior to X-ray.

Competing interests
The authors declare no competing interests.

Authors' contributions
The work presented here was carried out in collaboration between all authors. ZOD, YS and YT analyzed the data and wrote the