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Conversion Disorder in Pregnancy
Abstract Number: F-56
Abstract Type: Case Report/Case Series
Acute neurologic deficits in the obstetric population are relatively rare but carry considerable risk of morbidity and mortality. The broad differential diagnosis mandates precise and expedient diagnostic skills to guide subsequent management and optimize outcomes for mother and child. We discuss the case of a patient who presented with acute onset aphasia and quadriplegia.
A 27-year-old G6P5005 at 32 1/7 with no past medical history and no prenatal care presented after being found minimally responsive and with globally decreased motor function. She had complained of a headache the previous night but woke up normally that morning and returned to bed. Later she was found crying but with her eyes fixed and immobile.
On presentation to the hospital, the patient was lying motionless. Multiple attempts at IV placement were witnessed; however, she did not wince or withdraw to these painful stimuli. The patient was able to make eye contact and began to lacrimate during subsequent IV attempts. A short time later, she was able to communicate by blinking to “yes” or “no” questions. Approximately two hours after arrival, the Neurology service examined the patient and had a working diagnosis of acute basilar stroke – she was flaccid, did not withdraw to pain on all extremities, did not flinch to abrupt scare, and her toes were downgoing bilaterally.
Following a CT scan demonstrating no acute bleeding, the patient was transferred to the neurological ICU, and a tPA bolus was administered for presumed basilar artery thrombus. A CT angiogram was subsequently obtained demonstrating normal cerebral perfusion, and the tPA infusion was stopped. Follow-up examination revealed improving motor function of her upper extremities; however, she continued to have expressive aphasia, consistent with non-neurologic deficits.
The patient began having contractions, and examination revealed dilation to 4 cm and breech presentation. Attempted tocolysis with terbutaline was unsuccessful, and she was taken to the operating room emergently for Cesarean section. The patient was induced and intubated uneventfully. Cryoprecipitate was administered prophylactically for reversal of the tPA. Blood loss was estimated at 800 mL. She was able to be extubated while following commands and revealing good upper body strength.
The next morning the patient had an MRI that was normal. Her differential diagnosis included conversion disorder versus basilar migraine. By PPD #3 the patient had regained all speech and motor function and was discharged home.
Having a thorough differential diagnosis of acute neurologic deficits, while working rapidly in a multidisciplinary setting, is essential to provide excellent care. Conversion disorder, while exceedingly rare and a diagnosis of exclusion, must always be included in this differential diagnosis to improve outcomes by reducing iatrogenic injury. Fortunately we had a good outcome for both mother and baby given the complex presentation.