Fatal Spontaneous Intracranial Hemorrhage in a Low Risk Parturient: A Case Report with Review of Literature

Abstract

Intracerebral hemorrhage is uncommon during pregnancy when compared to puerperium and associated with devastating outcomes. This is a case of fatal intracerebral and subarachnoid hemorrhage in a 25 years woman who had supervised antenatal care in her second pregnancy. She had one transient diastolic blood pressure (BP) recording of 92mmHg at 35 weeks of gestation and home BP charting and subsequent recordings were normal. She presented at 39 weeks to emergency room in labour with signs of concealed abruption. There was history of transient headache on the day of admission but no other imminent symptoms. She had a seizure-like activity soon after arrival followed by which she lost her consciousness, and Dhaka’s regimen [Magnesium sulfate (MgSO4)] was started. She progressed spontaneously and delivered a 2800 grams fresh stillborn. Investigations suggested features of microangiopathic hemolytic anemia and acute kidney injury. Atonic postpartum hemorrhage was managed aggressively with oxytocics and blood products. There were two consecutive episodes of generalized tonic-clonic seizures (GTCS) despite MgSo4. Neuroimaging revealed diffuse subarachnoid hemorrhage (SAH) with multiple petechial bleeds in bilateral hemispheres. Despite worsening neurological symptoms with increased intracranial pressure, timely neurosurgical intervention was not possible due to associated coagulopathy. Subsequently, she became comatose and condition worsened on postnatal day 6. A retrospective history revealed antepartum eclampsia in her sister. Routine screening for preeclampsia in some form using either phenotypic or biomarkers will be lifesaving and unusual headaches in a pregnant woman warrant through evaluation as time is golden in cerebrovascular accidents.