Case Report

Postpartum intracranial hemorrhage disguised as preeclampsia

Abstract

A 35-year-old woman, gravida 5 para 3, presented to the emergency department 9 days after a cesarean delivery with a new-onset headache, hypertension, and hyperreflexia. Formal urinalysis did not demonstrate proteinuria. Comput- ed tomography of the brain demonstrated bilateral parietal subarachnoid hemorrhages. The patient was subsequently transferred to a tertiary care hospital where she underwent magnetic resonance imaging and computed tomographic angiography that were not suggestive of intracerebral aneurysm, arteriovenous malformation, sinus thrombosis, or angiopathy. The patient was treated with nimodipine and was successfully discharged without any neurologic sequel- ae or continued hypertension. This case illustrates the potential for presumed postpartum preeclampsia to mask other serious entities, such as intracranial hemorrhage.

postpartum headache is a Diagnostic dilemma for the emergency physician. Although the etiologies of postpartum headache are broad and may include migraine, meningitis, eclampsia, spinal headache, intracerebral hemorrhage (ICH), stroke, and hypertensive encephalopathy, there is much overlap in their respective symptoms. The classic presenta- tion of postpartum preeclampsia includes headache, visual disturbance, hypertension, hyperreflexia, and proteinuria. Postpartum ICH could easily be confused with presumed preeclampsia. We present the case of a Postpartum woman who presented with ICH that mimicked preeclampsia.

A previously healthy 35-year-old African American woman, gravida 5 para 3, presented to the emergency department (ED) with a new-onset, severe, left-sided headache of 4 days’ duration. Nine days before presentation, she delivered a full-term baby via repeat cesarean delivery under Epidural anesthesia. The visit to the ED was ultimately precipitated by the development of photophobia and phonophobia. Review of systems was remarkable for Leg swelling and unremarkable for any neurologic deficits, loss of consciousness, nausea, vomiting, or fever. Her family medical history included an aunt who died from a ruptured intracerebral aneurysm. Her medications included ibuprofen, acetaminophen, and vitamins. She denied any use of Illicit substances, alcohol, or tobacco.

On examination, she appeared in mild discomfort although alert and appropriate. Her vital signs were the following: temperature, 378C; blood pressure, 185/88 mm Hg; pulse rate, 49 beats per minute; respiration rate, 18breaths per minute. There was a mild photophobia that precluded funduscopic examination. Findings from her neurologic examination were normal except for symmetrical brisk reflexes in both upper and lower extremities without clonus. Pitting edema was noted in the lower extremities. Findings from the remainder of her examination were normal, including her abdominal wound and epidural access site, which were healing.

Bedside urinalysis was subjectively interpreted as having protein, and thus the patient was immediately treated with intravenous magnesium sulfate for presumed postpartum preeclampsia. The remainder of her serum chemistry, blood cell counts, and coagulation profiles were normal. Computed tomography (CT) of the brain revealed small bilateral subarachnoid hemorrhages in the parietal lobes without evidence of mass effect. Interestingly, the formal urinalysis failed to detect any urinary protein excretion. The magne- sium infusion was terminated prematurely in light of this and the CT findings, as this was most likely not preeclampsia. Her blood pressure did, however, normalize.

The patient was then transferred to a neurosurgical intensive care unit where nimodipine was started. Magnetic resonance imaging, angiography, and CT angiography of the brain were negative for aneurysm or any sign of cerebral angiopathy. The patient’s headache and hypertension re- solved spontaneously, and she was discharged without further event 9 days after presentation with a sole diagnosis of ICH. Intracranial hemorrhage is a dangerous albeit rare entity that poses a diagnostic dilemma to emergency physicians in that it may resemble several other entities, especially postpartum preeclampsia. Indeed, approximately 15% of postpartum patients with ICH have proteinuria [1]. Analo- gously, the diagnosis of ICH was delayed in one study because of this presumption [2]. The estimated rate of ICH is 6 to 8 cases per 100000 deliveries and that of stroke (all causes) is 26 to 34 cases per 100000 deliveries [3-5]. Risk factors for postpartum ICH include African American race, preexisting hypertension, gestational hypertension, cesarean delivery, preeclampsia, use of cocaine or tobacco, Sickle cell disease, migraine, and coagulopathy [1,3-6]. Moreover, most events-ICH or infarction-occurred within 6 weeks of delivery [1,3-5]. Mortality rates ranged from 20% to 30%

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of women with ICH, and permanent neurologic deficit was noted in 40% [2,3].

The causes of ICH in the postpartum period are similar to those in the general population with 1 addition: postpartum angiopathy (PPA) [2,7,8]. Postpartum angiopathy that is refractory to the measure may require more aggressive immunosuppressive agents. Hemorrhage in this setting may result from direct vessel rupture or from Hemorrhagic transformation of an ischemic region. The pathophysiology of this condition is not fully understood, but may involve postpartum-associated Fluid shifts, drastic hormonal shifts, or embryonic fluid emboli [2,7]. Drug-related PPA has also been noted in cases involving the use of lactation suppressants (bromocriptine and ergot alkaloids) and sympathomimetics [9-11]. Diagnosis involves cerebral angiography once other entities such as eclampsia and venous thrombosis have been excluded. The treatment of PPA includes nimodipine and high-dose steroids. Postpar- tum angiopathy refractory measures may require more aggressive immunosuppressive agents.

In light of these data, the patient with postpartum headache deserves prompt and focused evaluation. Any patient with evidence of infarction or hemorrhage should be referred for angiography, magnetic resonance imaging, and CT angiography of the brain. This case was unique in that the patient presented with ICH manifested by headache and hypertension without preeclampsia.

Jason J. Tanguay DO Department of Emergency Medicine Midwestern University/Chicago College of Osteopathic Medicine

Downers Grove Chicago, IL 60610, USA

E-mail address: [email protected]

Paul J. Allegretti DO Department of Emergency Medicine Midwestern University/Chicago College of Osteopathic Medicine Provident Hospital of Cook County Chicago, IL 60615, USA

doi:10.1016/j.ajem.2007.04.006

References

1. Kittner SJ, Stern BJ, Feeser BR, et al. Pregnancy and the risk of stroke. N Engl J Med 1996;355:768 - 74.
2. Witlin AG, Friedman SA, Egerman RS, et al. Cerebrovascular disorders complicating pregnancy-beyond eclampsia. Am J Obstet Gynecol 1997;176:1139 - 48.
3. Bateman BT, Schumacher HC, Bushnell CD, et al. Intracerebral hemorrhage in pregnancy: frequency, risk factors, and outcome. Neurology 2006;67:424 - 9.
4. James AH, Bushnell CD, Jamison MG, et al. Incidence and risk factors for stroke in pregnancy and the puerperium. Obstet Gynecol 2005;106:509 - 16.
5. Jaigobin C, Silver FL. Stroke and pregnancy. Stroke 2000;31: 2948 - 51.
6. Witlin AG, Mattar F, Sibai BM. Postpartum stroke: a twenty-year experience. Am J Obstet Gynecol 2000;183:83 - 8.
7. Geocadin RG, Razumovsky AY, Wityk RJ, Ulatowski JA, et al. Intracerebral hemorrhage and postpartum cerebral vasculopathy. J Neurol Sci 2002;205:29 - 34.
8. Konstantinopoulos PA, Mousa S, Khairallah R, et al. Postpartum cerebral angiopathy: an important diagnostic consideration in the postpartum period. Am J Obstet Gynecol 2004;191:375 - 7.
9. Roh JK, Park KS. Postpartum cerebral angiopathy with intracerebral hemorrhage in a patient receiving lisuride. Neurology 1998;50:1152 - 4.
10. Comabella M, Alvarez-Sabin J, Rovia A, et al. Bromocriptine and postpartum cerebral angiopathy: a causal relationship? Neurology 1996;46:1754 - 6.
11. Maher LM. Postpartum intracranial hemorrhage and phenylpropanol- amine use. Neurology 1987;37:1686.