///2009 Abstract Details
2009 Abstract Details2018-05-01T17:45:11+00:00

Atypical Eclampsia and Posterior Reversible Encephalopathy Syndrome During Elective Repeat Cesarean Section

Abstract Number: 114
Abstract Type: Case Report/Case Series

Michelle M Kawasaki MD1 ; King Andrea MD2

Due to the high risk of preeclampsia (PRE-E) and eclampsia (ECL), clinicians identify parturients with classical presentations (i.e., hypertension [HTN], proteinuria, edema, > 20 weeks gestation, or < 48 hours postpartum) in order to start magnesium (Mg) and antihypertensive therapy. But what happens to patients who dont have HTN, proteinuria, or edema?

We present the case of a healthy, term, 29 year old Hispanic patient (G4P2) scheduled for elective repeat cesarean section. During the last weeks of gestation, she had mild blood pressure (BP) elevation and 1+ proteinuria, but was not treated for PRE-E. On preoperative evaluation, she had normal BP (113/75) and a negative history for anesthetic complications; review of systems was significant for chronic sinusitis and headache (HA). In the operating room, after placement of standard monitors, her initial BP was 125/71 and heart rate (HR) 98. A spinal (SAB) was easily placed (bupivacaine, fentanyl, morphine) with the patient sitting. She was repositioned supine, in Trendelenberg (TBG), with left uterine displacement. After a T4 level was achieved, she was taken out of TBG. Her BP declined to 90/60s; she was treated with but did not respond to 10 mg IV ephedrine. The BP declined to 70/30s, she was treated with 100 mcg IV phenylephrine. She experienced a profound reaction to phenylephrine; BP increased to 220/125 and HR declined to 30-40. Atropine 1 mg IV was given, resulting in SVT with HR 180s and ST-segment changes. She complained of a headache, became unresponsive, and then seized. The seizure lasted < 1 minute. She was intubated and given IV midazolam. The surgeons were told to proceed. A vigorous baby was delivered with APGARS 9/9 at 1 and 5 minutes.

Postoperatively, an EKG showed prolonged QT and nonspecific S-T wave changes. Head CT was negative for an acute event. The patient was extubated 4 hours post-op. She experienced a second seizure after extubation. A neurologist obtained an MRI suspicious for posterior reversible encephalopathy syndrome (PRES). PRES is a form of hypertensive encephalopathy occasionally seen following the onset of PRE-E or ECL. The treatment of PRES is the same as for ECL, Mag therapy was initiated; the patient made a full recovery.

Review of the literature revealed many case reports of "atypical" ECL, defined as onset before 20 weeks gestation, onset > 48 hours postpartum, or without prodromal symptoms. Review of the patients clinic notes revealed complaints of HA for several weeks, weight gain > 2 lbs in one week, and PRE-E precautions. In hindsight, the patient had subtle PRE-E symptoms (mild BP elevation from baseline, complaint of a HA, and mild proteinuria). In addition, she had extreme response to normal doses of adrenergic agonists. Patients with PRE-E have profound responses and require smaller doses of these drugs. Fortunately, our patient had no permanent sequelae from her ECL and was dischaged home after a few days.

SOAP 2009