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A previously fit and well 17-year-old primiparous woman presented 5 days following the uncomplicated delivery of her first child with a gradual onset, severe, throbbing, predominantly left sided headache. There was no nausea, vomiting, neck stiffness or photophobia. Her past medical history was unremarkable, apart from heterozygosity for factor V Leiden, for which she was screened because of a history of thrombophilia in her mother. On initial assessment, no abnormality was detected other than an elevated blood pressure of 180/100 mm Hg. There was no evidence of oedema or proteinuria. Two days later, her visual acuity deteriorated over 12 h from 6/6 to perception of hand movements bilaterally, precipitating referral to the medical team. She then had a generalised tonic–clonic seizure, which was terminated within 5 min using intravenous magnesium and diazepam. She was subsequently loaded with phenytoin with no further seizures. On examination by the medical team, blood pressure remained elevated at 180/110 mm Hg. Visual acuity was reduced to perception of hand movements, pupillary responses were normal and there was no papilloedema. Tone, power, coordination and sensation were normal throughout. Reflexes were brisk, particularly in the left arm, and the plantars were extensor bilaterally. Other than mildly elevated inflammatory markers compatible with recent parturition, her blood tests and urine dipstick were unremarkable.
QUESTION 1: WHAT IS THE DIFFERENTIAL DIAGNOSIS?
At this stage, the differentials that need to be considered in a peripartum woman with headache, neurological deficits, seizures and a family history of thrombophilia include:
dural venous sinus thrombosis
posterior reversible encephalopathy syndrome (PRES).
QUESTION 2: HOW SHOULD THE PATIENT BE FURTHER INVESTIGATED TO RESOLVE THE DIFFERENTIAL DIAGNOSIS?
The patient’s primiparity, young age, and family history of thrombophilia are significant risk factors for pre-eclampsia.1 Eclampsia—characterised by hypertension, proteinuria and neurological symptoms including visual disturbance and seizures—usually occurs in the last trimester or within a few days of delivery, but may occur up to …