Worldwide, the incidence of postpartum eclampsia is on increasing trend at 16-18% of all eclamptic seizures.
A 28-year-old woman, G3P3, was brought in by an ambulance to the emergency department 11 days postpartum with loss of consciousness and seizure like activity at home. She had an uncomplicated pregnancy and elective repeat caesarean delivery with no evidence of pre-eclampsia throughout the antenatal and immediate postnatal period. She had a family history of tubular interstitial renal disease; brother with kidney transplantation and sister with advance chronic kidney disease. Sister also had pre-eclampsia. Collateral history from the family revealed that she was tired and sleep deprived since the time of delivery. On the day of presentation, she was feeling unwell, collapsed and became unresponsive for 45 minutes with associated urinary incontinence. On emergency triage, she was unconscious with GCS 3 but was maintaining airway, hypertensive 185/110 mmHg and hyper reflexic both upper and lower limbs bilaterally symmetrically. There were no other focal neurological deficits. She had an extensive work up in form of blood tests, CT brain/ angiogram, lumbar puncture and EEG which were unremarkable. MRI brain did not reveal any infarct or venous sinus thrombosis. There was no proteinuria. After excluding all other causes, the impression was made of post-partum eclampsia. She was resuscitated with loading dose of MgSO4 and two bolus IV Hydralazine and Labetolol for hypertension. After 30 minutes, GCS came back to 15 with occasional confusion.
She then was admitted to ICU under multi-disciplinary team care; Intensivist, obstetrician, renal physician, and neurologist. She had aggressive blood pressure management with Nitroprusside Sodium, Hydralazine, Labetolol and Amlodipine and was commenced on anti-epileptics; Levetiracetam and Lacosamide with ongoing MgSO4 infusion for 48 hours. Despite adequate blood pressure control and no further seizure episodes during the one week of stay in ICU, she remained confused and delirious with fluctuating sensorium for a prolonged period of 2 weeks. This, was attributed to cerebral irritation and dysfunction, and possibly due to large dose of Levetiracetam. Subsequently, she also developed behavioural disorders and agitation. The differential diagnoses by psychiatric team were post-partum psychosis or depression. She was commenced on Olanzapine and the Levetiracetam dose was reduced. This resulted in a significant improvement in her behavioural and mental status. She was ultimately discharged home after a total of 2 weeks hospitalization on anti-hypertensive agents and anti-epileptics with regular follow up at renal and neurology outpatient clinics.