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PRES IN AN OBSTETRIC PATIENT: A DEVASTATING OUTCOME
Abstract Number: 71
Abstract Type: Case Report/Case Series
Posterior reversible encephalopathy syndrome (PRES) is an increasingly recognized entity seen most commonly in patients with acute hypertension, renal insufficiency, or immunosuppressive therapy. Maintenance of a high degree of suspicion for PRES is particularly important in parturients, because it may be difficult to distinguish it from severe preeclampsia/eclampsia. Prompt recognition and early initiation of therapy can increase the chances of a successful recovery.
A 35-year-old G5P4 female, at 39 weeks gestation, presented with contractions. Prenatal course was unremarkable. HR 80, BP 127/75. Coagulation parameters were normal. A CSE was done for labor analgesia. During the course of the labor, BP ranged from 130s-160s/70s-90s. Preeclampsia work up was normal. After vaginal delivery patient complained of a mild headache, non-positional, and denied other symptoms. This was treated with Tylenol and she was transferred to the floor.
Eight hours after delivery the patient had a generalized seizure. BP was elevated. Eclampsia work up showed elevated uric acid. Magnesium infusion started. The BP normalized to 120s-130s/70-80s. Patient continued to complain of a non-positional headache in the frontal, temporal, and occipital areas. No signs of meningitis. MRI showed multiple areas of hyperintensity in the cortical and subcortical areas of the cerebellum, frontal, parietal, and temporal lobes. A diagnosis of PRES was made. Magnesium was discontinued and Dilantin was started. Patient had another generalized tonic-clonic seizure. Propofol, diazepam, and labetalol and supplemental oxygen were given. Dilantin 1 gm IV was given as a loading dose and Magnesium was restarted. Patient was transferred to MICU. She got intubated later that night for worsening mental status. She eventually received a tracheostomy and remains ventilator dependent in the hospital.
PRES usually presents with headache, visual changes, seizures, and altered mental status. Because acute increases in blood pressure occur in preeclampsia, these women may be susceptible to PRES. CT or MRI, initially normal, will eventually show edema in the cortex and subcortical white matter of parietal and occipital lobes. Lesions have been reported in cerebellum. Further complicating the picture is the headache with preeclampsia, and the MRI findings in preeclampsia/eclampsia are similar to those of PRES.
Treatment involves taking away the offending stimulus like treating the hypertension and preventing seizures. Usually magnesium will suffice. If anti-hypertensive agents are needed, nitroglycerin should be avoided as it may aggravate PRES. Long term seizure treatment is usually not needed since findings return to normal within a few weeks.
PRES is generally reversible if it is recognized and treated early, but unfortunately this is not always the case, as was evident in our situation.