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Rare but critical: Postpartum eclampsia presenting as hemorrhagic stroke
To cite this article: Touzani S, et al. Rare but critical: Postpartum eclampsia presenting as hemorrhagic stroke. Presse Med. (2017), http://dx.doi.org/10.1016/j.lpm.2017.05.003 Presse Med. 2017; //: ///
Rare but critical: Postpartum eclampsia presenting as hemorrhagic stroke L'accident vasculaire cérébral hémorragique : une présentation rare mais grave de l'éclampsie du postpartum Stroke is a rare event during pregnancy and the puerperium. Nevertheless, the 6 weeks of postpartum and, particularly, the few days around delivery are times of increased risk for ischemic or hemorrhagic stroke and cerebral venous thrombosis. Eclampsia is the leading cause of pregnancy-specific stroke [1]. In fact, hypertensive disorders of pregnancy (HDP) can trigger some severe forms of maternal complications such as cardiovascular and cerebrovascular diseases. The prevalence of HDP is 8–10% of all pregnancies in the population worldwide and these disorders are a major cause of maternal and neonatal mortality and morbidity [2]. A previously healthy 38-year-old woman, gravid 3 para 3, developed generalized tonic-clonic seizures 6 hours after a
repeat cesarean delivery of a full-term baby under epidural anesthesia. The seizure ceased after intravenous administration of midazolam. Her family medical history was unremarkable and her medications included paracetamol and nefopam. On examination, we found an unconscious patient in a postcritical state with a blood pressure at 170/100 mmHg and a pulse rate at 72 beats per minute. She was afebrile and her respiratory rate was 15/min. Capillary blood glucose was 1.3 g/dL. Review of systems was unremarkable except for pitting edema in the lower extremities. Bedside urinalysis was interpreted as having protein. The patient was diagnosed with eclampsia. An IV magnesium sulfate protocol was started (4 g loading dose followed by 2 g per hour). Intubation and mechanical ventilation were performed after a second seizure. Her serum chemistry, blood cell counts and coagulation profiles were normal. An unenhanced computed tomography (CT) of the brain (figure 1A) disclosed subarachnoid hemorrhage and intracranial hematoma in the right parieto occipital region without evidence of mass effect. Therapeutic management in the intensive care unit involved elevated blood pressure control (nicardipine 5 mg/ h) and neuroprotection physiological measures. CT angiography and angiography (figure 1B, C) were not suggestive of intracerebral aneurysm, arteriovenous malformation, sinus thrombosis or angiopathy. Examination after extubation revealed vision and
Letter to the editor
en ligne sur / on line on www.em-consulte.com/revue/lpm www.sciencedirect.com
Figure 1 Neuroimaging of ICH. A. An unenhanced CT scan. B. CT angiography. C. Angiography
1
tome xx > n8x > xx 2017
LPM-3325
To cite this article: Touzani S, et al. Rare but critical: Postpartum eclampsia presenting as hemorrhagic stroke. Presse Med. (2017), http://dx.doi.org/10.1016/j.lpm.2017.05.003
2
Letter to the editor
S. Touzani, M.A. Berdai, S. Labib, M. Harandou
attention disorders. She was placed on antihypertensive therapy and successfully discharged after one week with close follow up. Positive 24 hour proteinuria confirmed the diagnosis of intracerebral hemorrhage complicating eclampsia. Discussion and conclusion The puerperium is associated with physiological changes that increase the risk of vascular events. Puerperal stroke is a rare event (9 to 34 per 100,000 deliveries worldwide). However, the 6 weeks of postpartum is a high-risk time. Intracerebral hemorrhage (ICH) carries the highest relative risk (28.3), morbidity and mortality, with an in-hospital mortality of 20% [1]. Risk factors for postpartum ICH include African American race, age over 35 years, preexisting hypertension or preeclampsia/ eclampsia/gestational hypertension, cesarean delivery, use of cocaine or tobacco, migraine, coagulopathy, postpartum hemorrhage, transfusion, fluid, electrolyte and acid-base disorders [1]. Although it remains a controversial issue, pregnancy does not seem to increase the risk of first cerebral hemorrhage from an arteriovenous malformation or a cerebral aneurysm. The most common pregnancy-specific etiology for hemorrhagic stroke is preeclampsia/eclampsia [3]; which is potentially of interest to neurologists because it shares common pathophysiology and risk factors with stroke, including endothelial dysfunction, dyslipidemia, hypertension, hypercoagulability and abnormal cerebral vasomotor reactivity. Therefore, a history of puerperal preeclampsia/eclampsia would lead to an increased risk of stroke later in life, as well [4]. Brain imaging is essential to determine the diagnosis. The most common neuroradiologic findings in eclampsia are cerebral edema, ischemia and hemorrhage; and the likelihood of seizures increases commensurately with the amount of subcortical and cortical fluid, as in hypertensive encephalopathy. The brain MRI is the gold standard to distinguish between stroke and other neurological conditions and to characterize the origin of cerebral oedema (cytotoxic versus vasogenic) [5]. However, MRI may present a considerable delay and a noncontrast head CT may be preferable as a first line imaging investigation while facing a puerperium neurocritical emergency. Intracranial vessel imaging can be performed with transcranial Doppler to identify a reversible vasoconstriction syndrome [6]. Management includes the use of magnesium sulfate and aggressive control of elevated blood pressure as well as
emergent delivery of the fetus. Medicosurgical measures should be considered in cases of elevation of intracranial pressure. Comprehensive and multidisciplinary approach based on pathophysiology of eclampsia and hemorrhagic stroke may help to establish guidelines for this specific condition. A long follow-up should be established for these patients at high risk of future vascular events [6,7]. Disclosure of interest: the authors declare that they have no competing interest.
References [1]
[2] [3] [4] [5]
[6] [7]
James AH, Bushnell CD, Jamison MG, Myers ER. Incidence and risk factors for stroke in pregnancy and the puerperium. Obstet Gynecol 2005;106 (3):509–16. Ghulmiyyah L, Sibai B. Maternal mortality from preeclampsia/eclampsia. Semin Perinatol 2012;36:56–9. Tettenborn B. Stroke and pregnancy. Neurol Clin 2012;30(3):913–24. Bushnell C, Chireau M. Preeclampsia and stroke: risks during and after pregnancy. Stroke Res Treat 2011;2011:858134. Hacein-Bey L, Varelas PN, Ulmer JL, Mark LP, Raghavan K, Provenzale JM. Imaging of cerebrovascular disease in pregnancy and the puerperium. AJR Am J Roentgenol 2016;206(1):26–38. Frontera JA, Ahmed W. Neurocritical care complications of pregnancy and puerperum. J Crit Care 2014;29(6):1069–81. Ohno Y, Kawai M, Morikawa S, Sakakibara K, Tanaka K, Ishikawa K, et al. Management of eclampsia and stroke during pregnancy. Neurol Med Chir (Tokyo) 2013;53(8):513–9.
Soumaya Touzani, Mohamed Adnane Berdai, Smael Labib, Mustapha Harandou University Hospital Hassan II, Department of Obstetric and Pediatric Anesthesiology and Intensive Care, Sidi Hrazem Road, 1835 Fez, Morocco Correspondence: Soumaya Touzani, University Hospital Hassan II, Department of Obstetric and Pediatric Anesthesiology and Intensive Care, Sidi Hrazem Road, 1835 Fez, Morocco [email protected] Received 3 December 2016 Accepted 3 May 2017 Available online: http://dx.doi.org/10.1016/j.lpm.2017.05.003 © 2017 Elsevier Masson SAS. All rights reserved.
tome xx > n8x > xx 2017
Rare but critical: Postpartum eclampsia presenting as hemorrhagic stroke L'accident vasculaire cérébral hémorragique : une présentation rare mais grave de l'éclampsie du postpartum Stroke is a rare event during pregnancy and the puerperium. Nevertheless, the 6 weeks of postpartum and, particularly, the few days around delivery are times of increased risk for ischemic or hemorrhagic stroke and cerebral venous thrombosis. Eclampsia is the leading cause of pregnancy-specific stroke [1]. In fact, hypertensive disorders of pregnancy (HDP) can trigger some severe forms of maternal complications such as cardiovascular and cerebrovascular diseases. The prevalence of HDP is 8–10% of all pregnancies in the population worldwide and these disorders are a major cause of maternal and neonatal mortality and morbidity [2]. A previously healthy 38-year-old woman, gravid 3 para 3, developed generalized tonic-clonic seizures 6 hours after a
repeat cesarean delivery of a full-term baby under epidural anesthesia. The seizure ceased after intravenous administration of midazolam. Her family medical history was unremarkable and her medications included paracetamol and nefopam. On examination, we found an unconscious patient in a postcritical state with a blood pressure at 170/100 mmHg and a pulse rate at 72 beats per minute. She was afebrile and her respiratory rate was 15/min. Capillary blood glucose was 1.3 g/dL. Review of systems was unremarkable except for pitting edema in the lower extremities. Bedside urinalysis was interpreted as having protein. The patient was diagnosed with eclampsia. An IV magnesium sulfate protocol was started (4 g loading dose followed by 2 g per hour). Intubation and mechanical ventilation were performed after a second seizure. Her serum chemistry, blood cell counts and coagulation profiles were normal. An unenhanced computed tomography (CT) of the brain (figure 1A) disclosed subarachnoid hemorrhage and intracranial hematoma in the right parieto occipital region without evidence of mass effect. Therapeutic management in the intensive care unit involved elevated blood pressure control (nicardipine 5 mg/ h) and neuroprotection physiological measures. CT angiography and angiography (figure 1B, C) were not suggestive of intracerebral aneurysm, arteriovenous malformation, sinus thrombosis or angiopathy. Examination after extubation revealed vision and
Letter to the editor
en ligne sur / on line on www.em-consulte.com/revue/lpm www.sciencedirect.com
Figure 1 Neuroimaging of ICH. A. An unenhanced CT scan. B. CT angiography. C. Angiography
1
tome xx > n8x > xx 2017
LPM-3325
To cite this article: Touzani S, et al. Rare but critical: Postpartum eclampsia presenting as hemorrhagic stroke. Presse Med. (2017), http://dx.doi.org/10.1016/j.lpm.2017.05.003
2
Letter to the editor
S. Touzani, M.A. Berdai, S. Labib, M. Harandou
attention disorders. She was placed on antihypertensive therapy and successfully discharged after one week with close follow up. Positive 24 hour proteinuria confirmed the diagnosis of intracerebral hemorrhage complicating eclampsia. Discussion and conclusion The puerperium is associated with physiological changes that increase the risk of vascular events. Puerperal stroke is a rare event (9 to 34 per 100,000 deliveries worldwide). However, the 6 weeks of postpartum is a high-risk time. Intracerebral hemorrhage (ICH) carries the highest relative risk (28.3), morbidity and mortality, with an in-hospital mortality of 20% [1]. Risk factors for postpartum ICH include African American race, age over 35 years, preexisting hypertension or preeclampsia/ eclampsia/gestational hypertension, cesarean delivery, use of cocaine or tobacco, migraine, coagulopathy, postpartum hemorrhage, transfusion, fluid, electrolyte and acid-base disorders [1]. Although it remains a controversial issue, pregnancy does not seem to increase the risk of first cerebral hemorrhage from an arteriovenous malformation or a cerebral aneurysm. The most common pregnancy-specific etiology for hemorrhagic stroke is preeclampsia/eclampsia [3]; which is potentially of interest to neurologists because it shares common pathophysiology and risk factors with stroke, including endothelial dysfunction, dyslipidemia, hypertension, hypercoagulability and abnormal cerebral vasomotor reactivity. Therefore, a history of puerperal preeclampsia/eclampsia would lead to an increased risk of stroke later in life, as well [4]. Brain imaging is essential to determine the diagnosis. The most common neuroradiologic findings in eclampsia are cerebral edema, ischemia and hemorrhage; and the likelihood of seizures increases commensurately with the amount of subcortical and cortical fluid, as in hypertensive encephalopathy. The brain MRI is the gold standard to distinguish between stroke and other neurological conditions and to characterize the origin of cerebral oedema (cytotoxic versus vasogenic) [5]. However, MRI may present a considerable delay and a noncontrast head CT may be preferable as a first line imaging investigation while facing a puerperium neurocritical emergency. Intracranial vessel imaging can be performed with transcranial Doppler to identify a reversible vasoconstriction syndrome [6]. Management includes the use of magnesium sulfate and aggressive control of elevated blood pressure as well as
emergent delivery of the fetus. Medicosurgical measures should be considered in cases of elevation of intracranial pressure. Comprehensive and multidisciplinary approach based on pathophysiology of eclampsia and hemorrhagic stroke may help to establish guidelines for this specific condition. A long follow-up should be established for these patients at high risk of future vascular events [6,7]. Disclosure of interest: the authors declare that they have no competing interest.
References [1]
[2] [3] [4] [5]
[6] [7]
James AH, Bushnell CD, Jamison MG, Myers ER. Incidence and risk factors for stroke in pregnancy and the puerperium. Obstet Gynecol 2005;106 (3):509–16. Ghulmiyyah L, Sibai B. Maternal mortality from preeclampsia/eclampsia. Semin Perinatol 2012;36:56–9. Tettenborn B. Stroke and pregnancy. Neurol Clin 2012;30(3):913–24. Bushnell C, Chireau M. Preeclampsia and stroke: risks during and after pregnancy. Stroke Res Treat 2011;2011:858134. Hacein-Bey L, Varelas PN, Ulmer JL, Mark LP, Raghavan K, Provenzale JM. Imaging of cerebrovascular disease in pregnancy and the puerperium. AJR Am J Roentgenol 2016;206(1):26–38. Frontera JA, Ahmed W. Neurocritical care complications of pregnancy and puerperum. J Crit Care 2014;29(6):1069–81. Ohno Y, Kawai M, Morikawa S, Sakakibara K, Tanaka K, Ishikawa K, et al. Management of eclampsia and stroke during pregnancy. Neurol Med Chir (Tokyo) 2013;53(8):513–9.
Soumaya Touzani, Mohamed Adnane Berdai, Smael Labib, Mustapha Harandou University Hospital Hassan II, Department of Obstetric and Pediatric Anesthesiology and Intensive Care, Sidi Hrazem Road, 1835 Fez, Morocco Correspondence: Soumaya Touzani, University Hospital Hassan II, Department of Obstetric and Pediatric Anesthesiology and Intensive Care, Sidi Hrazem Road, 1835 Fez, Morocco [email protected] Received 3 December 2016 Accepted 3 May 2017 Available online: http://dx.doi.org/10.1016/j.lpm.2017.05.003 © 2017 Elsevier Masson SAS. All rights reserved.
tome xx > n8x > xx 2017