Poster Presentation Society of Obstetric Medicine of Australia and New Zealand ASM 2018

Severe pre-eclampsia causing acute cortical blindness in the antepartum; posterior reversible encephalopathy syndrome (PRES) and cortical infarction (#60)

Melissa Katz 1 , Leah Watkins 2 , Nirjhar Nandi 1
  1. Obstetric Medicine, Endocrinology and General Medicine , Cairns Hospital, Cairns , Queensland , Australia
  2. Obstetrics and Gynaecology, Cairns Hospital, Cairns, Queensland, Australia

Posterior reversible encephalopathy syndrome (PRES) is a clinco-radiological entity characterized by headache, altered consciousness, visual disturbances and seizures..1 Magnetic resonance imaging (MRI) shows extensive bilateral white-matter T2/FLAIR abnormalities suggestive of vasogenic oedema in the posterior cerebral hemispheres, particularly the parieto-occipital regions.2  It is well known that PRES occurs commonly in eclampsia but it is less commonly identified and reported in pre-eclampsia.3  Here we present a case of PRES with subsequent cortical infarction in the setting of pre-eclampsia.

A 26 year old G3P1 presented at 35+5 weeks gestation with a one day history of severe headache and photopsia. She was hypertensive with a blood pressure of 240/120mmHg and had a positive dipstick for proteinuria. She was diagnosed with pre-eclampsia and aggressive management was commenced. While being stabilized she complained of sudden and complete loss of vision. Our patient underwent definitive treatment with emergency lower uterine segment caesarean section (LCSCS). Her vision began to return around 4 hours post operatively, when she was able to make out some shadows.

MRI on day 1 post LUSCS revealed marked subcortical high T2 signal in the occipital lobes bilaterally, to a lesser degree surrounding the left trigone of the lateral ventricle and within the periventricular white matter, head of the caudate nucleus and posterior aspect of the external capsule bilaterally.  There were some subtle areas of restricted diffusion within the occipital lobes bilaterally consistent with early infarct. On ophthalmology review 20 hours post delivery she had visual acuity of 6/12 (6/9 with pin hole) bilaterally with normal fundoscopy.

  1. Neill TA. Reversible posterior leukoencephalopathy syndrome. UpToDate.
  2. Legriel S, Pico F, Azoulay E. Understanding posterior reversible encephalopathy syndrome. In: Vincent J-L, editor. Annual Update in Intensive Care and Emergency Medicine 2011: Springer Berlin Heidelberg. 631–653
  3. Mayama M, Uno K, Tano S, Yoshihara M, Ukai M, Kishigami Y, et al. Incidence of posterior reversible encephalopathy syndrome in eclamptic and patients with preeclampsia with neurologic symptoms. Am J Obstet Gynecol. 2016; 215(2): 239. e1-5