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Simultaneous presentation of Post Dural Puncture Headache and Post Partum Eclampsia with Posterior Reversible Encephalopathy Syndrome: A rare and unique case
Abstract Number: S 57
Abstract Type: Case Report/Case Series
Postdural puncture headache (PDPH) has a high differential index of suspicion of a headache following regional anesthesia. Other differentials include, Post Partum Eclampsia (PPE) and Posterior Reversible Encephalopathy Syndrome (PRES). We present a rare case of simultaneous development of PDPH and PPE in a parturient, which then proceeded to PRES.
Case Description & Management
A 26 year old G2 P2 parturient delivered vaginally following an uncomplicated combined spinal epidural but then developed positional headache (no neurological symptoms) on post-partum day 2. Conservative management for PDPH includes IV caffeine/analgesia (Fioricet) with slight improvement. She was discharged home on the post partum day 3 with mild headache. Two days later, the patient was readmitted to neuro ICU with severe headache having had two episodes of tonic and clonic seizures at home. CT-brain showed global cerebral edema. Patient had slightly elevated blood pressure with normal PIH labs with moderately elevated uric acid levels. The patient was diagnosed with post partum eclampsia and treated with IV magnesium and dexamethasone. On the following day, an MRI was suggestive of PRES with mild intracranial hypotension. On the third post readmission day, patient’s condition improved but the positional headache persisted, which necessitated an epidural blood patch. Her headache resolved and she was discharged home in stable condition without any neurological sequelae.
PRES is a rare disorder associated with acute hypertension, immune-suppressive therapy and eclampsia and manifests with headache, seizures, and altered sensorium. Late post partum eclampsia is diagnosed as convulsions occurring greater than 48 hours but less than 4 weeks postpartum, with 40% of the cases without the clinical signs and symptoms of preeclampsia . The case presented here is a unique and rare episode of Post partum eclampsia with PRES, which commenced with subtle signs of a headache, masked with PDPH symptoms, proceeding to seizures. In the same patient, post-partum eclamptic seizure, masked her coincident PDPH later successively treated with epidural blood patch. Simultaneous onset of the two different complications, PDPH and PPE masked each other due to the common symptom of headache.
Headache in post-partum women may not always be simple PDPH on its own. PPE and PRES must always be considered in the differential diagnosis.
1. Hirshfeld-Cytron J, Lam C, Karumanchi SA, Lindheimer M. Late postpartum eclampsia: examples and
review. Obstet Gynecol Surv. 2006 Jul; 61(7):471-80.