///2019 Abstract Details
2019 Abstract Details2019-07-13T07:45:15-05:00

Posterior Reversible Encephalopathy Syndrome Causing Catatonia in a Complex Parturient

Abstract Number: RF3AC-365
Abstract Type: Case Report Case Series

Etty Sims M.D.1 ; John T. Wenzel M.D.2; H. Jane Huffnagle D.O.3; Suzanne L. Huffnagle D.O.4

Introduction

Posterior reversible encephalopathy syndrome (PRES) is a reversible neurologic syndrome associated with hypertension, preeclampsia, eclampsia, and renal failure. MRI shows cortical and subcortical edema in posterior cerebral regions. Treatment is aimed at the underlying trigger.

Case

A 24 y/o G2P0 with h/o sickle cell disease, DVT/PE (anticoagulated), and opioid abuse was admitted at 31 wks for sickle cell crisis and anemia (Hgb 5.4 g/dl) requiring transfusion. She developed fever, hypoxia, and bacteremia from a PICC.

Pregnancy was complicated by pre-eclampsia with severe features, transaminitis, nephrotic range proteinuria, and direct bilirubinemia. Blood pressure was controlled with labetalol; magnesium was administered.

The patient became progressively non-cooperative, non-verbal, stopped following commands and ceased interactions. Psychiatry and neurology were consulted for catatonia. Her mother assumed decision making. CT was negative for CVA. MRI revealed edema in bilateral parieto-occipital and fronto-parietal lobes and cerebellar hemispheres. PRES was diagnosed and multidisciplinary delivery planning began.

Concerns for performing cesarean section (c/s) included hemorrhage, anticoagulation, DVT/PE, positive antibody screen, and acute chest syndrome. Concerns for inducing labor included inability to participate or convey pain and need for operative vaginal delivery. Induction of labor with epidural analgesia was recommended and anticoagulants held. Despite catatonia, epidural was placed with mother’s consent. Pain was difficult to assess, but no signs of uncontrolled pain were seen.

Mental status improved quickly postpartum and returned to baseline by 48 hours. Abnormal lab values resolved and enoxaparin was restarted. She was discharged home with her newborn, satisfied with her care.

Discussion

Pathophysiology of PRES is not well understood, and theories include endothelial dysfunction or cerebral vessel spasm. Though PRES is usually reversible when diagnosed and treated, irreversible damage has been described with delayed or missed diagnosis.

PRES in pregnancy is usually diagnosed postpartum, with treatment aimed at blood pressure and seizure control. In our patient, delivery was seen as definitive treatment. The team felt induction of labor carried less risk than c/s.

Multidisciplinary care was beneficial to manage her co-morbidities. We considered vaginal delivery without epidural, but were concerned for uncontrolled pain and its hemodynamic effects, inability to communicate, and further exacerbation of sickle cell crisis. Placing an elective epidural in a patient who could no longer give consent or participate in the procedure raised an ethical concern and required agreement of the family. With the cooperative teamwork of several specialties and the family, our patient had a favorable outcome.

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2. Arch Gynecol Obstet 2015;292:1217–23

3. J Radiology 2007;189:904–912

4. IJOA 2008;17:88–89

SOAP 2019