Abducens nerve palsy as a sign of pre-eclampsia with severe
A 36-year old primigravid woman presented at a gestational age of 33 weeks and 2 days with abrupt reduced vision and headache. Past medical history was negative, except for migraine. At admission, blood pressure readings reached 169/100 mmHg.

A urine dipstick indicated significant proteinuria, confirmed with a 24 hours urine collection revealing 971 mg of protein. On clinical examination, hyperreflexia and unilateral abducens nerve palsy was apparent.

The patient was admitted for fetal lung maturation and observation. Labetalol 600mg daily and magnesium sulfate intravenously were administered, however diastolic hypertension persisted. Due to the persisted severe hypertension, a caesarean section was performed 48 hours after admission and with completion of the fetal lung maturation.

The neonate was admitted to the neonatal unit since the birth weight was only 1470 grams. Apgar of the neonate were 7/5/10, after 1, 5 and 10 minute(s) respectively. No neonatal problems were observed during the 1-month hospitalization. Magnesium sulfate was continued for 48 hours after delivery.

A cerebral MRI was performed to rule out ischemia or hemorrhage, no abnormalities were observed. Within 3 days after delivery, a reduction of the palsy and normalization blood pressure was detected. Full recovery of the palsy was observed within 5 months.

Key takeaways:-
• Although this feature is uncommon, the obstetrician should be aware of the clinical significance

• The true etiology of this sign is yet to be determined, but nerve compression due to intracranial hypertension and vasospasm of the nerve vessels due to hypertension, have been hypothesized

• Regardless, all neurologic symptoms, including palsy, should be regarded as a sign of severe preeclampsia

• Before 34 weeks of gestational age, British and American guidelines propose to first administer corticosteroids for fetal lung maturation for 48 hours and then initiate delivery if severe hypertension remains or the clinical condition of the patient or fetus deteriorates

• In this case, a caesarean section was selected as the route of delivery, mainly due to the low estimated fetal weight. According to the guidelines, caesarean section should not be the de facto route of delivery and should be determined by other obstetrical, fetal or maternal factors

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