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Postpartum Subarachnoid Hemorrhage in a Patient with History of Migraines and Seizures
Abstract Number: RF5AH-200
Abstract Type: Case Report Case Series
An 18-year-old G1P0 at 38 weeks gestation with history of migraines and epilepsy was admitted for category II fetal heart tracing and planned induction. She soon developed an unrelenting headache with elevated blood pressures and a magnesium infusion was started for seizure prophylaxis. An epidural was placed after multiple attempts without immediate complication for labor analgesia. The headache persisted with minimal improvement despite pharmacological intervention and she had one episode of emesis. After vaginal delivery she developed postpartum hemorrhage treated with oxytocin, misoprostol and carboprost. Her headache suddenly worsened and developed right-sided facial droop, ptosis and blood pressure of 180/110 controlled with IV boluses of labetalol and hydralazine as well as nicardipine infusion. A CT scan showed a small subarachnoid hemorrhage over the left parietal area. Angiography showed no evidence of aneurysms or arterio-venous malformations. Repeat CT showed stable SAH and magnetic resonance venogram negative for venous sinus thrombosis. She was discharged the fourth day postpartum after resolution of symptoms. The patient denied severe headaches at her three-month follow-up with neurology but reported word-finding difficulty, new-onset stuttering and forgetfulness. The neurologist noted slight right-arm pronator drift and scheduled no further follow-up, expecting self-resolution. Her symptoms completely resolved with no evidence of hypertensive disease at 8 months.
The incidence of subarachnoid hemorrhage (SAH) is estimated at 4-10/100,000 pregnancies with a 10-fold increase in pre-eclampsia and accounts for roughly 15% of maternal deaths(1–3) Patients typically present with a sudden onset “thunderclap” headache that must be immediately recognized. Prompt neurosurgical, hemodynamic and obstetric interventions are necessary to reduce the risk of maternal death and permanent neurological injury. We use this case to highlight the key feature of malignant headaches and to educate providers on the evidence suggesting history pre-eclampsia as an independent risk factor for future hypertension, cerebrovascular accidents, and ischemic heart disease (1-4).
1. Khan M, Wasay M. Haemorrhagic strokes in pregnancy and puerperium. 2012. doi:10.1111/j.1747-4949.2012.00853.x.
2. Brown MC, Best KE, Pearce MS, Waugh J, Robson SC, Bell R. Cardiovascular disease risk in women with pre-eclampsia: systematic review and meta-analysis. Eur J Epidemiol. 2013;28(1):1-19. doi:10.1007/s10654-013-9762-6.
3. Chen CW, Jaffe IZ, Ananth Karumanchi S. Pre-eclampsia and cardiovascular disease. doi:10.1093/cvr/cvu018.
4. Brouwers L, van der Meiden-van Roest AJ, Savelkoul C, et al. Recurrence of pre-eclampsia and the risk of future hypertension and cardiovascular disease: a systematic review and meta-analysis. BJOG. 2018;125(13):1642-1654. doi:10.1111/1471-0528.15394.