Postpartum headache and seizure from subarachnoid haemorrhage.

Stage 1: Fitting patient with prior history of headache immediately after delivery 3 days ago (negative septic screen/normal CT scan/negative lumbar puncture).

Stage 2: Fit stops with appropriate dose anticonvulsant therapy, proceeds to have respiratory compromise and no improvement in conscious level.

Stage 3: Sedation, intubation, ventilation, neuroprotective strategies and plan to transfer for CT scan.

34-year-old, now P1 patient, who is 3 days post normal vaginal delivery following induction of labour for post dates (term +11days).

Initial history relates to her delivery 3 days ago.

During labour, she had a lumbar epidural (uneventful insertion and provided good analgesia). There was no postpartum bleeding or ongoing obstetric concerns.

She commenced breastfeeding immediately after delivery, but developed a severe frontal headache in the hour after delivery. It was constant with no postural element or photophobia.

There were no neurological signs identified at this time, she had mildly raised blood pressure (140/80) with no proteinuria. Antenatal BP had been stable at 118/75 mmHg, with no proteinuria. All bloods, including PET bloods, were normal.

Due to the ongoing headache, she was discussed with the neurology team who suggested a septic screen (although CNS infection was felt to be unlikely). A CT brain was also performed two hours after onset, which showed no intracranial pathology (see Figure 35.1). The lumbar puncture was normal with no organisms on Gram stain, 5 red cells and no xanthochromia.

Figure 35.1 Normal CT head (image link https://radiopaedia.org/cases/normal-brain-ct).

The headache improved significantly, she was mobilising well and she was due to be discharged later in the afternoon of day 3.

Current presenting complaint – on the afternoon of day 3, when the scenario starts.

The patient is being discharged from the ward by the midwife when she complains of headache and then collapses, becomes unresponsive then has a seizure.

The seizure terminates when appropriate anticonvulsant agents are administered. She remains unresponsive and becomes increasingly hypertensive and bradycardic with unequal pupils. She requires sedation, intubation, ventilation and institution of neuroprotective strategies while arranging for a CT scan and referral to neurosurgery. During the scenario differential diagnosis for the headache and seizure to be considered include:

1. 
   

   1. eclampsia,

   
   
2. 
   

   2. post dural puncture headache and acute subdural haematoma,

   
   
3. 
   

   3. cerebral sinus thrombosis,

   
   
4. 
   

   4. meningitis,

   
   
5. 
   

   5. de novo epilepsy,

   
   
6. 
   

   6. pituitary apoplexy,

   
   
7. 
   

   7. acute intraparenchymal haemorrhage.

The actual pathology is a large subarachnoid haemorrhage resulting in acute interference with cerebral perfusion, seizure and loss of consciousness. She then develops acute hydrocephalus as a result of the blood load.

Her reduced GCS is a combination of:

1. 
   

   1. acute disturbance of cerebral blood flow,

   
   
2. 
   

   2. the resulting seizure,

   
   
3. 
   

   3. the acute hydrocephalus causing potentially lethal rise in intracranial pressure (ICP), and

   
   
4. 
   

   4. the mass effect generated by the intracranial blood load.