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An uncommon case of post partum seizures

Published:February 16, 2015DOI:https://doi.org/10.1016/j.ejim.2015.02.004

      1. Indication

      A 30-year-old woman was admitted for headaches and altered somnolence and agitation few days after uncomplicated vaginal delivery. No complications occurred during this first pregnancy. Four days after delivery, she complained with headache and decreased level of consciousness. Seizures responding to benzodiazepin treatment were observed when she arrived at the emergency department. On admission, she was confused with visual abnormalities (blurred vision and scotomata). Temperature was 36.6 °C. Blood pressure was measured at 150/90 mm Hg. Urinary dipstick confirmed mild proteinuria of >2+. Elevated liver enzymes were confirmed on laboratory values (twice the upper limit of normal). Cerebral magnetic resonance imaging (MRI) showed white matter edema in the posterior cerebral hemispheres, particularly the parieto-occipital regions and the cerebellum and cortical symmetrical punctate areas of increased signal on proton density and T2-weighted images in the fronto-parietal regions. Magnetic resonance angiography (MRA) documented vascular irregular narrowing of the posterior cerebral arteries.
      What is the diagnosis?
      Posterior reversible encephalopathy associated with post-partum eclampsia.

      2. Diagnosis

      Posterior reversible encephalopathy has been associated with many conditions including eclampsia, severe hypertension, autoimmune diseases, treatment with cytotoxic medications, infections and post transplantation immunosuppression. Late eclampsia, usually defined when the onset of seizures is >48 h after delivery, is not always preceded by pre-eclampsia before delivery (1). The pathogenesis of PRES complicated eclampsia remains unclear. Neuroimaging (MRI) is essential to the diagnosis. Typical findings of PRES are symmetrical white matter edema in the posterior cerebral hemispheres, and involvement of the cerebellum and brainstem is common [
      • Bartynski W.S.
      Posterior reversible encephalopathy syndrome, part 1: fundamental imaging and clinical features.
      ]. The distribution of abnormalities is usually not confined to a single vascular territory. Diffusion-weighted (DWI) imaging aids in the distinction of PRES syndrome from stroke.
      Most case series and case reports suggest that PRES is usually benign and with treatment, most patients with PRES have complete reversibility of clinical and neuroradiographic syndromes. Prompt treatment is important in preventing the permanent damage as posterior cerebral artery infarctions (ischemic stroke) and seizure recurrence or epilepsy [
      • Sabiri B.
      • Moussalit A.
      • Salmi S.
      • El Youssoufi S.
      • Miguil M.
      Post-partum eclampsia: epidemiology and prognosis.
      ]. Our patient was treated with magnesium for seizures and calcic inhibitor for hypertension. The day after, the patient's medical condition was close to normal.
      Treating clinicians should have a high clinical suspicion especially in the setting of recent post-partum, even without high blood pressure and proteinuria, recognize the neurologic syndrome, and evaluate for PRES with brain MRI.

      Conflict of interests

      No conflict of interest.

      References

        • Bartynski W.S.
        Posterior reversible encephalopathy syndrome, part 1: fundamental imaging and clinical features.
        AJNR Am J Neuroradiol. 2008; 29: 1036-1042
        • Sabiri B.
        • Moussalit A.
        • Salmi S.
        • El Youssoufi S.
        • Miguil M.
        Post-partum eclampsia: epidemiology and prognosis.
        J Gynecol Obstet Biol Reprod. 2007; 36: 276-280