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A case of Postpartum Hemorrhagic Posterior Reversible Encephalopathy Syndrome (PRES) not associated with Preeclampsia
Abstract Number: F-61
Abstract Type: Case Report/Case Series
Introduction: Postpartum headaches (PPH) are common in the obstetric patient population. Many are benign, though certain signs or symptoms warrant concern of more serious etiologies. We report a case of PPH associated with visual changes, in which MRI revealed a diagnosis of hemorrhagic posterior reversible encephalopathy syndrome (PRES).
Case: A 32-year old healthy G3P2 presented at 40 weeks in active labor and received epidural analgesia prior to vaginal delivery. On PPD 1 she had tubal ligation under spinal anesthesia, and had sustained hypertension postoperatively. After negative preeclampsia workup, she was discharged on nifedipine. On PPD 6, she presented with severe headache, emesis and vision loss. Nicardipine and magnesium infusions were started. Brain MRI showed acute bilateral occipital lobar hematomas with edema and moderate surrounding SAH, supporting a diagnosis of hemorrhagic PRES. MRV and MRA studies were unremarkable and repeat preeclampsia workup was negative. Over the next 7 days she had gradual improvement in her symptoms prior to discharge on nifedipine and enalapril. She has continued to have headache and blurred vision up to 6 months postpartum and follows with neurology and ophthalmology. Head CT 6 months postpartum revealed encephalomalacia in the areas of previous hemorrhage.
Discussion: PRES is an uncommon syndrome found in a number of medical conditions, including malignant hypertension, eclampsia, and immunosuppressive therapy.(1) Signs and symptoms include headache, altered alertness, seizures, and vision changes. Altered cerebrovascular regulation is thought to result in breakdown of the blood-brain barrier causing characteristic imaging findings of bilateral parieto-occipital edema.(2) Treatment is supportive, with reversibility attributed to early diagnosis, anatomic location of PRES, and clinical history of patients.(1)
Our case was atypical due to the presence of ICH on imaging. Studies report a prevalence of ICH with PRES ranging from 6.4% to 19.4%.(3) PRES related to eclampsia has the highest risk of ICH, while PRES related to hypertension alone has a lower risk.(3) Although our patient experienced acute blood pressure elevation postpartum, preeclampsia was ruled out. ICH with PRES may be an indicator of more severe damage,(4) and the persistent symptoms in our patient supports this as well.
1. Radiat Med, 2006; 24:659-68
2. NEJM, 1996; 334:494-500
3. Neurorad, 2010; 52:855-63
4. Neurocrit Care, 2009; 10:306-12