To cite this article: Touzani S, et al. Rare but critical: Postpartum eclampsia presenting as hemorrhagic stroke. Presse Med. (2017),
http://dx.doi.org/10.1016/j.lpm.2017.05.003
Presse Med. 2017; //: ///

Rare but critical:
Postpartum eclampsia
presenting as
hemorrhagic stroke
L'accident vasculaire cérébral hémorragique :
une présentation rare mais grave de
l'éclampsie du postpartum
Stroke is a rare event during pregnancy and the puerperium.
Nevertheless, the 6 weeks of postpartum and, particularly, the
few days around delivery are times of increased risk for ischemic
or hemorrhagic stroke and cerebral venous thrombosis. Eclampsia is the leading cause of pregnancy-specific stroke [1]. In fact,
hypertensive disorders of pregnancy (HDP) can trigger some
severe forms of maternal complications such as cardiovascular
and cerebrovascular diseases. The prevalence of HDP is 8–10% of
all pregnancies in the population worldwide and these disorders
are a major cause of maternal and neonatal mortality and
morbidity [2].
A previously healthy 38-year-old woman, gravid 3 para 3,
developed generalized tonic-clonic seizures 6 hours after a

repeat cesarean delivery of a full-term baby under epidural
anesthesia. The seizure ceased after intravenous administration
of midazolam. Her family medical history was unremarkable and
her medications included paracetamol and nefopam. On examination, we found an unconscious patient in a postcritical state
with a blood pressure at 170/100 mmHg and a pulse rate at
72 beats per minute. She was afebrile and her respiratory rate
was 15/min. Capillary blood glucose was 1.3 g/dL. Review of
systems was unremarkable except for pitting edema in the
lower extremities. Bedside urinalysis was interpreted as having
protein. The patient was diagnosed with eclampsia. An IV magnesium sulfate protocol was started (4 g loading dose followed
by 2 g per hour). Intubation and mechanical ventilation were
performed after a second seizure. Her serum chemistry, blood
cell counts and coagulation profiles were normal. An unenhanced computed tomography (CT) of the brain (figure 1A)
disclosed subarachnoid hemorrhage and intracranial hematoma
in the right parieto occipital region without evidence of mass
effect. Therapeutic management in the intensive care unit
involved elevated blood pressure control (nicardipine 5 mg/
h) and neuroprotection physiological measures. CT angiography
and angiography (figure 1B, C) were not suggestive of intracerebral aneurysm, arteriovenous malformation, sinus thrombosis
or angiopathy. Examination after extubation revealed vision and

Letter to the editor

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Figure 1
Neuroimaging of ICH. A. An unenhanced CT scan. B. CT angiography. C. Angiography

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LPM-3325

To cite this article: Touzani S, et al. Rare but critical: Postpartum eclampsia presenting as hemorrhagic stroke. Presse Med. (2017),
http://dx.doi.org/10.1016/j.lpm.2017.05.003

2

Letter to the editor

S. Touzani, M.A. Berdai, S. Labib, M. Harandou

attention disorders. She was placed on antihypertensive therapy
and successfully discharged after one week with close follow up.
Positive 24 hour proteinuria confirmed the diagnosis of intracerebral hemorrhage complicating eclampsia.
Discussion and conclusion
The puerperium is associated with physiological changes that
increase the risk of vascular events. Puerperal stroke is a rare
event (9 to 34 per 100,000 deliveries worldwide). However, the
6 weeks of postpartum is a high-risk time. Intracerebral hemorrhage (ICH) carries the highest relative risk (28.3), morbidity
and mortality, with an in-hospital mortality of 20% [1]. Risk
factors for postpartum ICH include African American race, age
over 35 years, preexisting hypertension or preeclampsia/
eclampsia/gestational hypertension, cesarean delivery, use of
cocaine or tobacco, migraine, coagulopathy, postpartum hemorrhage, transfusion, fluid, electrolyte and acid-base disorders
[1]. Although it remains a controversial issue, pregnancy does
not seem to increase the risk of first cerebral hemorrhage from
an arteriovenous malformation or a cerebral aneurysm. The
most common pregnancy-specific etiology for hemorrhagic
stroke is preeclampsia/eclampsia [3]; which is potentially of
interest to neurologists because it shares common pathophysiology and risk factors with stroke, including endothelial dysfunction, dyslipidemia, hypertension, hypercoagulability and
abnormal cerebral vasomotor reactivity. Therefore, a history
of puerperal preeclampsia/eclampsia would lead to an
increased risk of stroke later in life, as well [4]. Brain imaging
is essential to determine the diagnosis. The most common
neuroradiologic findings in eclampsia are cerebral edema, ischemia and hemorrhage; and the likelihood of seizures increases
commensurately with the amount of subcortical and cortical
fluid, as in hypertensive encephalopathy. The brain MRI is the
gold standard to distinguish between stroke and other neurological conditions and to characterize the origin of cerebral
oedema (cytotoxic versus vasogenic) [5]. However, MRI may
present a considerable delay and a noncontrast head CT may be
preferable as a first line imaging investigation while facing a
puerperium neurocritical emergency. Intracranial vessel imaging
can be performed with transcranial Doppler to identify a reversible vasoconstriction syndrome [6].
Management includes the use of magnesium sulfate and
aggressive control of elevated blood pressure as well as

emergent delivery of the fetus. Medicosurgical measures should
be considered in cases of elevation of intracranial pressure.
Comprehensive and multidisciplinary approach based on pathophysiology of eclampsia and hemorrhagic stroke may help to
establish guidelines for this specific condition. A long follow-up
should be established for these patients at high risk of future
vascular events [6,7].
Disclosure of interest: the authors declare that they have no competing
interest.

References
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[2]
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James AH, Bushnell CD, Jamison MG, Myers ER. Incidence and risk factors
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Ghulmiyyah L, Sibai B. Maternal mortality from preeclampsia/eclampsia.
Semin Perinatol 2012;36:56–9.
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Soumaya Touzani, Mohamed Adnane Berdai, Smael Labib,
Mustapha Harandou
University Hospital Hassan II, Department of Obstetric and Pediatric
Anesthesiology and Intensive Care, Sidi Hrazem Road, 1835 Fez,
Morocco
Correspondence: Soumaya Touzani, University Hospital Hassan II,
Department of Obstetric and Pediatric Anesthesiology and Intensive
Care, Sidi Hrazem Road, 1835 Fez, Morocco
touzani.soumaya@gmail.com
Received 3 December 2016
Accepted 3 May 2017
Available online:
http://dx.doi.org/10.1016/j.lpm.2017.05.003
© 2017 Elsevier Masson SAS. All rights reserved.

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