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Posterior Reversible Encephalopathy Syndrome in a Patient with Previously Unrecognized Postpartum Eclampsia
Abstract Number: S-56
Abstract Type: Case Report/Case Series
Introduction: Posterior Reversible Encephalopathy Syndrome (PRES) involves clinical and radiologic findings including headache, seizure, visual disturbances, and specific MRI findings. It has been associated with eclampsia, severe hypertension, immunosuppresion, distributive shock, renal failure, and has been seen in patients who were exposed to both general anesthesia and regional anesthesia techniques1,2. We report on a parturient who developed generalized seizures two days after labor epidural and general anesthesia for cesarean delivery and who was found to have imaging consistent with PRES.
Case: A 28 year old female with gestational diabetes, gestational hypertension, and asthma presented at 36 2/7 weeks in preterm labor. After a failed labor epidural reactivation she underwent a cesarean section under general anesthesia for arrest of dilation. The patient’s intraoperative and early postoperative course was uncomplicated with systolic blood pressures in the 130-160 range and trace proteinuria. On the third postoperative day she had generalized tonic-clonic seizures that were terminated with lorazepam and propofol and managed with emergent intubation.
Discussion: As recognition of antepartum preeclampsia has improved, late postpartum preeclampsia is becoming increasingly prevelant. Over 90% of patients who present with postpartum eclampsia have at least one prodromal symptom including visual disturbances , epigastric pain, nausea and vomiting, or headache.3, 4 In our case, the patient described persistent headaches and one day of blurry vision. She not only had the classic features of posterior circulation hyperintensity seen on FLAIR but also a small area on DWI suspicious for cytotoxic edema. Thus, parturients may not infrequently possess many of the conditions associated with PRES (ecclampsia, severe hypertension, immunosuppresion, sepsis, exposure to anesthesia) making this relatively new syndrome a diagnosis for which all practicioners should be aware.
1. Post-partum eclampsia: epidemiology and prognosis. J Gynecol Obstet Biol Reprod (Paris). 2007 May;36(3):276-80. Epub 2007 Feb 15.
2. Hinchey J, Chaves C, Appignani B, et al. A Reversible Posterior Leukoencephalopathy Syndrome. NEJM. 1996 February 22; 334:494-500
3. Mark C. Chames MDa, Jeffrey C. Livingston MDb, Thomas S. Ivester MDb, John R. Barton MDc, Baha M. Sibai MD. Late postpartum eclampsia: A preventable disease? American Journal of Obstetrics and Gynecology Volume 186, Issue 6, June 2002, Pages 1174-1177
4. Wagner SJ, Acquah LA, Lindell EP, Craici IM, Wingo MT, Rose C, White W, August P, Garovic V. Posterior Reversible Encephalopathy Syndrome and Eclampsia: Presenting the case for more aggressive blood pressure control. Mayo Clinic Proc Sept. 2011; 86(9): 851-856