Posterior Reversible Encephalopathy Syndrome During Pregnancy: Seizures in a Previously Healthy Parturient
Timothy R. Long, Barry D. Hein, Michael J. Brown, Charlotte H. Rydberg, and C. Thomas Wass
(J Clin Anesth, 19:145-148, 2007)
Department of Anesthesiology, Mayo Clinic, Rochester, MN
Posterior reversible encephalopathy syndrome (PRES) is a disorder defined neuroradiologically that commonly presents with multiple seizures. In the case reviewed here, a previously healthy woman was taken to the hospital after experiencing a generalized tonic-clonic seizure during the 28th week of pregnancy.
The patient had 4 additional seizures on her way to the hospital and another generalized clonic-tonic seizure after admission to the labor and delivery ward. Blood pressure at this time was 160/80 mm Hg, and heart rate was 120 bpm. Perioperative laboratory studies revealed the following findings: urine protein >300 mg/dL, aspartate aminotransferase 296 U/L, d-dimer >2000 ng/mL, creatinine 1.2 mg/dL, and platelet count 210,000 × 109/L. The patient's trachea was intubated for emergent cesarean delivery, and an intravenous infusion of magnesium sulfate was started for seizure prophylaxis. She remained hemodynamically stable during surgery, and a 1050-g baby girl was delivered with 1- and 5-minute Apgar scores of 1 and 4, respectively. Imaging with computed tomography and magnetic resonance imaging yielded findings consistent with PRES. The patient was discharged on postoperative day 3 with oral labetalol, nifedipine, and a 6-week course of warfarin sulfate. A follow-up magnetic resonance imaging study was normal at 6 months.
Posterior fossa structures are most often affected in PRES, and the hallmark feature is bilateral symmetrical vasogenic edema in the occipital and posterior parietal lobes. Although preeclampsia and eclampsia seem to be common causes of PRES, a cause-and-effect relationship has not been confirmed. Prompt treatment with antihypertensive and antiepileptic medications plus delivery offers a complete resolution of symptoms and neurologic recovery, but unrecognized PRES can result in permanent brain injury or even death.