Postpartum posterior reversible encephalopathy syndrome
Posterior reversible encephalopathy syndrome (PRES), also known as posterior reversible cerebral oedema syndrome, is a condition characterised by the acute onset of varied non-specific neurological symptoms often associated with a high blood pressure.

Published in the Journal of Obstetrics and Gynaecology, the authors present an unusual case of a pregnant paraplegic patient developing postpartum preeclampsia and PRES requiring a differential diagnosis with an autonomic hyperreflexia, a potentially life-threatening complication of spinal cord injury, usually involving patients with spinal cord lesions at or above the T6 level.

A 31-year-old woman primigravida affected by a complete leg and lower trunk paralysis due to a T3–T4 spinal cord injury, undergoing an uncomplicated Caesarean section (CS) under a general anaesthesia for paraplegia at 38 weeks of gestation. The patient received sodium thiopental and rocuronium for the induction of general anaesthesia, and sevoflurane with opioid for the maintenance.

Three hours after the delivery, she presented with an elevated blood pressure (176/95 mmHg), a mild thrombocytopenia (99,000 platelets/lL) and a mild increase of transaminases (AST 42 U/L; ALT 66 U/L). She was fully alert and oriented, and her general physical examination was normal. Nifedipine was administered orally and her blood pressure had normalised. Twelve hours after the CS, she developed vomiting, a headache, diplopia and perioral paraesthesias.

A brain CT scan revealed a pons hypodensity and excluded an intracranial bleeding. After a neurologic consultation, LMWH was continued and acetylsalicylic acid 500 mg was administered intravenously. After eight hours, she had emesis, a headache and a blurred vision; her blood pressure was 170/110 mmHg despite the nifedipine, and a neurological examination revealed a strength loss and a poor movement coordination in the right arm. There was a decrease in platelet count (68,000/lL) and a further rise of the liver enzymes (AST 571 U/L; ALT 437 U/L), with no evidence of haemolysis.

A brain MRI revealed there was a vasogenic oedema involving the pons, superior and middle cerebellar peduncles, pyramidal tract, cerebral peduncles, posterior limbs of internal capsule and the bulbar pyramids. The radiology findings, clinical presentation and blood tests lead to a diagnosis of atypical PRES associated with postpartum pre-eclampsia.

A continuous intravenous infusion of magnesium sulphate and urapidil was started, leading to an improvement of the blood pressure, of the symptoms and of the laboratory parameters.
The following day, an oral nifedipine treatment was reinstated, and the woman was discharged home on the 11th day after her delivery, with a controlled blood pressure, a negative neurological examination, improvement of brain lesions on MRI, and normalised blood tests.

The hypotensive treatment was withdrawn 10 days later. A repeat clinical examination and MRI two months after delivery documented that there had been a full recovery.

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PRES - Rare but known complication of hypertensive patient.
Sep 24, 2018Like1