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Anesthetic Management of a Patient Presenting with Atypical PRES: A Case Report.
Abstract Number: S4C-4
Abstract Type: Case Report/Case Series
A 36-year-old healthy G3P2 female presented at 38 weeks gestation with spontaneous rupture of membranes. She had an uncomplicated vaginal delivery after 5 hours of labor. Immediately postpartum, she had a tonic-clonic seizure. The patient verbalized the sensation of impending doom prior to developing labored respirations and seizing. She was profoundly bradycardic with desaturation to the 80’s. Blood pressure was not detectable by NIBP, but she had a palpable pulse. A magnesium bolus and intravenous midazolam were administered for presumed eclamptic seizure. Amniotic fluid embolism was considered as a possible cause of her hypotension and hypoxemia. After several minutes, the patient remained hypotensive and obtunded. She was intubated and stabilized.
MRI demonstrated multiple foci of restricted diffusion involving the frontal, parietal, and occipital lobes bilaterally, congruent with the diagnosis of posterior reversible encephalopathy syndrome (PRES). Despite the diagnosis of PRES on imaging, she did not require any anti-hypertensive agents. She was continued on a magnesium infusion. Of note, she had inferior and septal ST segment abnormalities on EKG and elevated serum troponin. Echocardiography showed inferoseptal hypokinesis. Ultimately, the patient’s acute coronary event was of undetermined etiology.
PRES is a neurologic syndrome associated with preeclampsia/eclampsia, severe hypertension, renal failure, lupus and immunosuppressive agents (1). In the parturient, PRES typically occurs postpartum with a rapid onset of symptoms including seizures, headache, visual changes/loss, high blood pressure, and mental status changes (2). Seizure is the most common presentation (3). PRES is typically diagnosed via MRI, although the underlying pathophysiology is uncertain (1). Prompt treatment, including anti-hypertensives, magnesium infusion, and delivery of fetus, will often result in resolution of symptoms (3). Based on literature review, cardiac issues are not strongly associated with PRES. Ultimately, our patient’s postpartum course was complicated by an eclamptic seizure and PRES without any degree of hypertension. She also exhibited evidence of myocardial injury (troponinemia and wall motion abnormalities), which is not a typical feature seen with PRES.
1. Case Reports in Obstetrics and Gynecology. 2014;Article ID 928079, 6 pages
2. Lancet Neurol. 2013;12:175-85.
3. Journal of Clinical Anesthesia. 2007;19:145-148.