PRES-A rare disease during puerperium, difficult to diagnose

Dr. Mala Banik
Shohana Sultana Mou
Khandaker Nusrat Jahan

Objective: PRES (Posterior reversible encephalopathy syndrome) is defined as a clinico- radiological syndrome characterized by headache, convulsion, altered mental condition visual disturbance and characterized by white matter vasogenic edema affecting the posterior occipital and parietal lobes of brain. Diagnosis is difficult, and clinical context and clinical judgment are essential.

Case Report: This is a case report of 24 years old lady P2(LUCS), 1st abortion, ALC 10 days admitted at evening in Labour emergency of Sir Salimullah Medical College Mitford Hospital, Dhaka on 10th day of puerperium following LUCS with history of headache for 2 days, several episodes of convulsions from morning, blurring of vision and altered level of consciousness. She was normotensive, Only there was documentation of sudden high rise of blood pressure (160/120) during LUCS operation. Her postnatal period was uneventful and discharged on 5th POD. On 10th POD morning when she developed one episode of convulsion and altered mental status, she was taken to a local private hospital and diagnosed as Puerperal Psychosis. But when her condition deteriorated and several episodes of convulsions occurred, she was then admitted to HDU of our Tertiary level hospital. Then she was consulted with the Multidisciplinary approach, MRI and MRV of Brain showing altered signal intensity areas in both Parieto-Occipital lobes, Frontal lobes:features consistent with PRES. She was managed with anticonvulsant drugs, steroids and intravenous fluid. Her symptoms subsided and discharged after 9 days.

Discussion: Convulsion during puerperium, in the aspect of Bangladesh, is mostly considered due to Postpartum eclampsia or meningoencephalitis. Incidence of maternal mortality due to eclampsia is around 20% treated early, the clinical globally, whereas it's reported to be 24% in Bangladesh. Incidence of PRES, on the other hand, is not well researched and therefore unknown. A study published in PubMed which shown 3 case reports on PRES. PRES is only diagnosed by MRI. So, in our mind we have to be suspicious about the diagnosis being PRES.

Conclusion: Early diagnosis and prompt management can resolve the symptoms of PRES and reduce the mortality. Improved knowledge and research about factors influencing the outcome of PRES will result in better early management, less morbidity and mortality. Delayed diagnosis and treatment may lead to mortality or irreversible neurological deficit. If recognized and syndrome commonly resolves within a week.

Reference:
1.www.ncbi.nlm.nih.gov/pmc/articles/PMC6360475/