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An interesting case of postpartum seizure and headache – A diagnostic challenge
Abstract Number: SU-66
Abstract Type: Case Report/Case Series
Eclampsia most commonly occurs between 20 weeks of gestation and the first 48 hours postpartum. However, it may be delayed and present 3 to 4 weeks following delivery (1-2). The differential diagnosis of headache and seizure in the parturient should include post dural puncture headache (PDPH), venous sinus thrombosis, lupus cerebritis, meningitis, encephalitis and, rarely pneumocephalus (PC) from neuraxial anesthesia. Most cases of PC during epidural anesthesia have been associated with air loss of resistance (LOR) technique (3-4).
A 33-year-old G3 P2 obese parturient developed severe headache following epidural placement using saline LOR technique for labor analgesia. The epidural placement was challenging due to the patient’s size and required three attempts. Following delivery, the patient was evaluated for a positional headache and received an epidural blood patch with good relief of her headache. On the 5th postpartum day, the patient was re-admitted to the hospital complaining of severe headache, emesis, hypertensive emergency and seizures. The patient was intubated for airway protection. Head CT scan showed a small amount of air in the frontal horn of the right lateral ventricle (Figure 1). Magnetic resonance venogram (MRV) was negative for thrombus and initial laboratory data were not suggestive of eclampsia.
This patient’s presenting symptoms and initial studies posed a diagnostic challenge for both the obstetric and anesthesia teams. The delayed onset of the seizures following this patient’s delivery, as well as the initial negative laboratory data for preeclampsia/eclampsia encouraged the medical teams to look for a diagnosis beyond eclampsia. PC and PDPH following neuraxial anesthesia have also been associated with seizures. The Head CT and MRV of the brain showing PC initially led to PC and PDPH being placed high on the differential diagnosis as the etiology of her seizures and headache. However, repeat laboratory testing revealed elevated liver enzymes and the patient subsequently developed pulmonary edema. Intravenous magnesium therapy was initiated with excellent response and eclampsia became the consensus primary diagnosis. She was discharged on hospital day 4 without complication or sequelae.
1. Am J Obstet Gynecol 2002;186:1174-7.
2. J R Soc Med. 2006 Apr; 99(4): 203–4.
3. Eur J Anaesthesiol. 1999; (6): 413-7.
4. Int J Obstet Anesth. 2006; 15 (3): 237-9.