Posterior leukoencephalopathy syndrome: Postpartum focal neurologic deficits: A report of three cases and review of the literature
A 29-year-old woman, G2 P1, at the 35th week of gestation with a history of pregnancy-induced hypertension, was admitted to the emergency department due to two generalized seizures episodes at home without prodromal symptoms. According to the patient's husband, the patient has presented malaise and headache during the past week.\nThe patient's blood pressure was 180/100 mmHg at admission. Obstetric ultrasound was normal. The laboratory test concerning renal and liver function was normal, except for the presence of 2 + proteinuria. The electrocardiogram showed sinus tachycardia. Emergency cesarean delivery was indicated due to eclampsia. Rapid sequence induction with 200 mg of propofol and 100 mg of succinylcholine was administered and anesthesia was maintained with oxygen and nitrous oxide at a concentration of 50%. 1.5% of sevofluorane and 150 mcg of fentanyl were administered after the umbilical cord was clamped. After induction and during surgery, systolic blood pressure was between 140 mmHg and 130 mmHg. A 2000 g male infant with Apgar scores of 7 at 10 min was delivered. The scalp pH was 7.17 and appropriate resuscitation was performed. The patient was admitted extubated at the Post Anesthesia Care Unit (PACU) with blood pressure over 170/110 mmHg, conscious, hemodynamically stable and disoriented, with a coherent conversation but with blurred vision. No focal neurological symptoms were seen at this time. Her blood pressure decreased from 170/110 mmHg to 140/100 mmHg after an intravenous administration of magnesium sulfate first bolus of 4 gr followed by an infusion of 1 g/24 h associated with intravenous infusion of labetalol and nitroglycerin according to our protocol. The laboratory test in the Intensive Care Unit (ICU) was normal. After surgery, a cranial computerized tomography (CT) and magnetic resonance imaging (MRI) scans were performed because the patient was still Hypertensive and had headache and confusion. The CT scan showed findings consistent with posterior reversible encephalopathy in the context of eclampsia, and brain MRI confirmed these findings []. Ophthalmological examination was requested showing moderate hypertensive retinopathy. An echocardiogram was also performed showing slight pericardial effusion, normal left ventricular size and normal systolic function, moderate functional mitral regurgitation and pulmonary artery pressure slightly elevated. Three days after the seizures, her neurologic examination became normal. Her blood pressure gradually normalized but laboratory values still showed slight anemia and mild proteinuria. She was treated orally with amlodipino 10 mg/day and labetalol 200 mg bid from the second day of stay at the ICU. One week later, the MRI was repeated and results were normal. Nine days later, the patient was discharged home without any neurological sequel.