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A Dreadful Trilogy Complicating a Normal Vaginal Delivery FREE TO VIEW

Geurys Rojas-Marte, MD; Anand Rai, MBBS; On Chen, MD; Sameer Chadha, MD; Vijay Shetty, MD; Jacob Shani, MD
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Maimonides Medical Center, Brooklyn, NY

Chest. 2014;146(4_MeetingAbstracts):288A. doi:10.1378/chest.1992413
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SESSION TITLE: Critical Care Student/Resident Case Report Posters I

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM

INTRODUCTION: Complications in the postpartum are not rare. However, the occurrence of three major ones is extremely uncommon. We report the case of a 22 year-old female, who developed Eclampsia along with Peripartum Cardiomyopathy(PPCM) and Cerebral Reversible Vasoconstriction Syndrome(RCVS)

CASE PRESENTATION: A 22 year-old female became hypertensive and delirious 24 hours after a normal vaginal delivery. Soon after, she had an episode of generalized, tonic-clonic seizure. She was intubated and transferred to medical intensive care unit(MICU). On physical examination she was tachycardic, obtunded, without signs of focal neurologic deficit. The remainder of the physical examination was noncontributory. Complete blood count, basic metabolic panel and liver function tests were normal, troponin I was 1.25 ng/ml, analysis of cerebrospinal fluid and serology for herpes simplex types 1 and 2 were negative. An X-ray of the chest and electrocardiogram were normal. Computed tomography of the head was unrevealing. A transthoracic echocardiogram showed ejection fraction of 40 percent with mild left ventricular enlargement. Cardiac magnetic resonance image was consistent with non-ischemic cardiomyopathy. While in MICU, patient became hypotensive, requiring use of norepinephrine drip to maintain adequate blood pressure. A magnesium drip was started and the patient was loaded with phenytoin. 12 hours later the norepinephrine was discontinued and the patient was liberated from the ventilator. Next day, she was transferred to a medical floor; neurologic examination and vital signs were normal. One day later, the patient began complaining of severe, frontal headache. Physical exam was negative for papilledema or nystamus. MRA-head showed moderate narrowing in several arteries, including the temporal branch of the right middle cerebral artery and left anterior cerebral artery. Treatment with nimodipine was started for suspicion of RCVS. Two days later a repeat MRA-head showed improvement of the previously described narrowing; the headache had subsided. Two days later the patient was discharged home.

DISCUSSION: Eclampsia is a common cause of maternal mortality. Its association with RCVS has been described in some series. Moreover, it has been proposed that they share a similar underlying pathophysiologic mechanism1. However, other conditions, including the use of vasopressors, could cause this disorder. On the other hand, PPCM is seen in 1 per 3200 deliveries, with a mortality that can be as high as 18%2. Ocurrence of these conditions simultaneously has not been reported.

CONCLUSIONS: It is important to recognize certain conditions that, as in this patient, can complicate a normal vaginal delivery.

Reference #1: Elkayam U. Clinical characteristics of Peripartum Cardiomyopathy in the United States, Diagnosis, Prognosis and Management. JACC. 2011;58:660-664.

Reference #2: Fugate JE, Ameriso SF, Ortiz G et al. Variable presentations of postpartum angiopathy. Stroke. 2012;43:670-6.

DISCLOSURE: The following authors have nothing to disclose: Geurys Rojas-Marte, Anand Rai, On Chen, Sameer Chadha, Vijay Shetty, Jacob Shani

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