key: cord-319382-97iwwsfg
authors: Sripadma, Dr. P.V.; Rai, Dr. Ashish; Wadhwa, Dr. Chetan
title: Postpartum Atypical Posterior Reversible Encephalopathy Syndrome in a COVID-19 patient- An Obstetric Emergency
date: 2020-09-26
journal: J Stroke Cerebrovasc Dis
DOI: 10.1016/j.jstrokecerebrovasdis.2020.105357
sha: 
doc_id: 319382
cord_uid: 97iwwsfg

Encephalopathy in COVID-19 has been widely reported with several reports of posterior reversible encephalopathy syndrome (PRES) speculated to be due to an abrupt surge in blood pressure caused by coronavirus disease. Though peripartum posterior reversible encephalopathy syndrome is well recognized, its atypical variant with hemorrhage is uncommon. Peripartum atypical posterior reversible encephalopathy syndrome with COVID-19 requires early recognition and warrants dedicated inter-disciplinary management. We present a case of postpartum atypical posterior reversible encephalopathy syndrome with good maternal and fetal outcome. Our clinical and treatment approach with differential diagnosis are discussed in this hitherto unreported obstetric emergency with COVID-19.

Encephalopathy in COVID-19 has been widely reported with several reports of posterior reversible encephalopathy syndrome (PRES) speculated to be due to an abrupt surge in blood pressure caused by coronavirus disease. Though peripartum posterior reversible encephalopathy syndrome is well recognized, its atypical variant with hemorrhage is uncommon. Peripartum atypical posterior reversible encephalopathy syndrome with COVID-19 requires early recognition and warrants dedicated inter-disciplinary management. We present a case of postpartum atypical posterior reversible encephalopathy syndrome with good maternal and fetal outcome. Our clinical and treatment approach with differential diagnosis are discussed in this hitherto unreported obstetric emergency with COVID-19.

Postpartum, Atypical, PRES, seizures,COVID-19

A 25 year old primigravida with unremarkable antenatal period went into spontaneous labour at term and delivered a healthy baby weighing 3.2 kilogram. She had an unremarkable hemogram (hemoglobin: 12.4g/dL, total leucocyte count : 5,500/cu.mm with 65% neutrophils and 35% lymphocytes, platelets: 2.7 lacs/cu.mm), renal(urea 23mg/dL, creatinine 0.7mg/dL), liver 

This sudden surge of blood pressure was unexpected as our patient was normotensive during pregnancy, had an uneventful normal delivery and had no suggestion of preeclampsia 1 . SARS CoV-2 can bind directly to angiotensin-converting enzyme 2 receptors causing endothelial disruption, an abrupt rise in blood pressure and failure of cerebral blood flow autoregulation 2 .We speculate a peripartum infection with COVID-19 could have triggered cerebral autoregulatory dysfunction leading to blood-brain barrier breakdown and consequent vasogenic edema 3 . Presence of hemorrhage, diffusion restriction and contrast enhancement with symmetrical or asymmetrical posterior predominant vasogenic edema constitute atypical PRES, these findings are known to be uncommon in postpartum PRES 4, 5 .While there are several reports of PRES with COVID-19, the atypical variant has only been rarely reported and none in pregnancy 6 . To our knowledge this is the first case report on postpartum atypical PRES with COVID-19. 

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Posterior reversible encephalopathy syndrome: a truly treatable neurologic illness

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The many faces of posterior reversible encephalopathy syndrome

Posterior Reversible Encephalopathy Syndrome in Patients with Coronavirus Disease 2019: Two Cases and a Review of the Literature